Roger England

The creation of UNAIDS, the joint United Nations programme on HIV and AIDS, was justified by the proposition that HIV is exceptional. The foundations of exceptionalism were laid when the “rights” arguments of gay men succeeded in making HIV a special case that demanded confidentiality and informed consent and discouraged routine testing and tracing of contacts, contrary to proved experience in public health.1 But exceptionalism grew—to encompass HIV as a disease of poverty, a developmental catastrophe, and an emergency demanding special measures, requiring multisectoral interventions beyond the leadership of the World Health Organization. The exceptionality argument was used to raise international political commitment and large sums of money for the fight against HIV from, among others, the World Bank, through its multi-country AIDS programme, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the US Presidents’ Emergency Plan for AIDS Relief. With its own UN agency, HIV has been treated like an economic sector rather than a disease. The proposition of exceptionality is now under stress. The poverty argument has been exposed as baseless. The country surveys carried out by Measure DHS (Demographic and Health Surveys) of, for example, Ethiopia, Kenya, and Tanzania show that prevalence is highest among the middle classes and more educated people.2 Although HIV can tip households into poverty and constrain national …

Billions of pounds are being spent on the fight against AIDS in developing countries. Roger England believes that much of the money could be better used elsewhere, whereas Paul de Lay and colleagues argue that current spending is not enough