The 10% left behind
Guest post from the Quebec collective The Warning on the ethics of biomedical prevention in the age of 90-90-90 that asks “What about the 10-10-10 left in the shadows?”
Based on the untapped potential of bio-medical prevention, UNAIDS has recently devised a strategy known as 90-90-90: 90% of all infected people tested, 90% of diagnosed people undergoing treatment, and 90% of people treated reaching an undetectable viral load. Now echoed by many involved in the fight against HIV/AIDS, UNAIDS is loudly contending that this is how we will halt the epidemic. There is even talk of an outright “end of AIDS” by 2030.
In a sector that is often lacking in direction and oversight, plans and strategies are definitely welcome. Still, we should not forget that in all of modern infectious disease history, only smallpox has been completely wiped off the face of the earth.
Doesn’t it sound arrogant to say that we will be able to so straightforwardly achieve such an epidemiological outcome using biomedical prevention methods?
What is the overall effect of these strategies? What would we make of those (presumably very, very few) people who contract HIV in 2030? What kind of consideration might we give to consent to testing or consent to treatment?
These questions have hung in the air for several years now. For instance, as early as 2010, The Warning was ringing the ethical alarm bells on the consequences of “Test & Treat”, from which 90-90-90 evolved.
At the end of the day, will the overarching aim of the “all biomedical” approach be to the detriment of other approaches, namely those which address social and structural determinants? How do we come to terms with the difficulty of accessing these prohibitively expensive treatments which highlight financial, social, and geographical differences?
In Quebec, Dr. Cécile Tremblay contends that with this strategy, we could “manage to eliminate HIV transmission in Quebec within five years.” Five years? Let’s not fool ourselves. We at The Warning are asking for restraint and caution. Making grand announcements in order to curry more favour and government funding is a tune we’ve heard before. Seeing doctors make totally specious claims is also not new to us.
Saying that we must all take part in this valiant fight in whatever ways we can is not enough. After 30 years of a global epidemic, platitudes have become politically irresponsible. Is it rational to instill these kinds of optimistic expectations among our politicians as well as in communities affected by and dealing with HIV?
We know that the objective of this strategy is not so bold as to expect 100% of people living with HIV to become undetectable. Rather, the strategy aims to set a new “optimal” level for testing, treatment, and treatment effectiveness that would allow the virus’s reach to diminish. But the question remains: what will we make of the ethical and social impact of policies that are ineffective in reaching the people inevitably excluded from 90-90-90? This is a very serious question, because with it we ask: are we accidentally constructing an HIV underclass (the aberrant 10%) when we are imagining a future with a marginalized and/or underserved minority?
Will these 10% of untested individuals become criminals? Will the 10% of untreated poz people be profiled for control by the State? And in turn, will the 10% of people who supposedly never reach undetectable be deemed biologically defective bodies by “HIV Science”? Will our current social welfare and health insurance policies still support the “choices” that these “statistical deviants” make, and will the agencies that implement those policies respect people’s individual autonomy? Medical practitioners rarely address such questions.
There is something uncanny about positing, ideologically, the future existence of good and bad “neo-poz” people – those who have become part of the “biomedical revolution” and those left astray – when still today so few members of the general population even know that a person living with HIV whose viral load is undetectable cannot transmit the virus. In other words, 90-90-90 may not be bridging the social or educational gaps whose closure has been a long-time goal of the HIV movement.
In a country like Canada – the world leader for criminalizing people living with HIV – the risk of allowing this gap to widen is even greater. Instead don’t you think, as we do, that it might be time to come up with more realistic strategies that are based, fundamentally, on the needs of those most affected by the issues?
We predict that certain major players will find themselves going back to the drawing board before long.
Translated from the French by Jordan A. for the SéroSyndicat
About the authors: The Warning is a 10 year old think tank with members in Paris and Montreal. The group aims to be a critical trouble maker and an incubator of new ideas and concepts to challenge the established AIDS Inc. The Warning celebrates self freedom and shared pleasures and defends the idea that "our bodies belong to us".
An archive of their English contributions is available here.