Remedicalizing an epidemic: from HIV treatment as prevention to HIV treatment is prevention.

Bold claims of a ‘paradigm shift’ at the recentWorld AIDS Conference signal a striking remedicalization of our approach to the HIV epidemic and a return to the early 1980s view of the epidemic as a medical problem best addressed by purely technical, biomedical solutions whose management should be left to biomedical professionals and scientists [1]. This is reflected in the assertion by the outgoing President of the International AIDS Society that aggressive diagnosis and treatment of HIV should emerge as the most significant theme of the conference, ‘over and above the human rights issue’ [2]. Studies were presented to demonstrate that antiretroviral drugs and microbicides should now be included alongside male circumcision in the biomedical armamentarium of ‘new HIV prevention technologies’ (NPTs). ‘NPTs’ were even touted as potentially more effective than ‘old’ prevention technologies of condoms [3] based on misleading comparisons between data from randomized controlled trials of simple interventions and observational studies – even though other studies have demonstrated that combined prevention (NPTsþ condoms) were more effective than NPTs only. Despite impressive evidence that ‘old’ prevention has resulted in declining incidence in youth in the most affected countries [4], the enthusiasm for NPTs made it seem as though more classical approaches do not work. Concerns that prevention efforts might be undermined by such biomedical triumphalism cannot be dismissed in light of evidence that prevention efforts are already compromised by the growing emphasis on treatment. Increased investment in treatment is welcomed, but it is profoundly disturbing that prevention remains grossly underfunded even as treatment budgets explode [5]. Nowhere are the dangers of this remedicalization clearer than in the case of ‘treatment-as-prevention’ (TASP), widely trumpeted as a ‘game-changer’ and a ‘paradigm shift’ in the battle against HIV/AIDS.