No subject

forward, implicitly or explicitly, as the main explanatory concept for
understanding the epidemiology of HIV infection and in particular for the
rapid spread and high prevalence in sub-Saharan Africa. This has had
enormous implications for the international response to AIDS and has heavily
influenced public health policy and strategy and the design of prevention
and care interventions at national, community and individual level.

It is argued that individual behaviour alone cannot possibly account for the
enormous variation in HIV prevalence between population groups, countries
and regions and that the unexplained remaining variation has been neglected
by the international AIDS community.

Biological vulnerability to HIV due to seriously deficient immune systems
has been ignored as a determinant of the high levels of infection in certain
populations. This is in sharp contrast to well proven public health
approaches to other infectious diseases.

In particular, it is argued that poor nutrition and coinfection with the
myriad of other diseases of poverty including tuberculosis, malaria,
leishmaniasis and parasitic infections, have been neglected as root causes
of susceptibility, infectiousness and high rates of transmission of HIV at
the level of populations.

Vulnerability in terms of non biological factors such as labour migration,
prostitution, exchange of sex for survival, population movements due to war
and violence, has received some attention but the solutions proposed to
these problems are also inappropriately focused on individual behaviour and
suffer from the same neglect of economic and political root causes.

As the foundation for the international community's response to the AIDS
pandemic, explanations of HIV/AIDS epidemiology in terms of individual
behaviour are not only grossly inadequate, they are highly stigmatizing and
may in some cases, be racist. They have diverted attention from poverty and
powerlessness as root causes of vulnerability to infection and as such they
are a waste of scarce resources.

A return to a basic needs approach to all the diseases of poverty is nothing
more than proven public health wisdom and experience. A sustainable and
meaningful response to AIDS is simultaneously a sustainable and meaningful
response to all the diseases of poverty.

The obstacles to the adoption of this approach are economic and political
and must be confronted at the level of international financial institutions,
the globalization of neoliberal economic systems, the growing power
imbalances between and within nations and the undermining of democracy and
national sovereignty.

An alternative strategy for AIDS and the other diseases of poverty would
build on macroeconomic reforms for a fair, rational and sustainable
international economic order so that democratically elected governments may
meet their people's basic needs, including health, without external
interference.