ethics
THE GLOBAL COMMUNITY:
Creating Models for HIV/AIDS
Prevention, Care, and Treatment
By Kaylin Pennington
Can Community-Driven Treatment Programs Break Down Stigma and Fight HIV/AIDS?
I
n dozens of sub-Saharan African nations, the need
for HIV/AIDS treatment greatly exceeds available
resources. The World Health Organization (WHO)
estimated in a December 2004 report that 1.8 million
Zimbabweans have HIV—the virus that causes AIDS—and
less than 3% of the 300,000 people who need antiretroviral
treatment have access to immediate care. With an estimated
6,000 people dying of HIV/AIDS in Africa each day, the
“Our community-driven model [has] not received a lot
of publicity because it’s flying against conventional
wisdom.” -Israelski
most pressing question is how to best distribute a limited
amount of antiretroviral medicine to the people who need it
the most.
Dennis Israelski, MD, Clinical Professor of Medicine in
Infectious Diseases and Geographic Medicine at the Stanford
University School of Medicine and Medical Director of AIDS
Empowerment and Treatment International (AIDSETI),
has dedicated most of his career to addressing this problem.
He has developed a solution known as “community-driven
development”, an approach that gives control of planning
layout design: Jason Shen
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Children of HIV positive
parents play in a yard
outside an orphanage.
decisions and investment resources to community groups
and local governments. The community-driven development
model demonstrates that a more sustainable system of HIV/
AIDS prevention, care, and treatment can be created.
The Impact of HIV/AIDS
AIDSETI arose from the 2000 International AIDS
Conference in Durban, South Africa, and has since become
an international network of twenty-six community-based
associations of People Living With HIV/AIDS (PLWHA).
Through AIDSETI, Israelski and his colleagues have
given nutritional support, psychological counseling, legal
assistance, and financial aid by starting income-generating
activities to severely impacted communities. Ultimately, this
approach affects the distribution of limited antiretroviral
medicine by giving priority to people in the community who
actively promote HIV/AIDS prevention and treatment.
Dr. Seble Kassaye, a postdoctoral fellow in infectious dis-
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ethics
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policy “Community-driven development leads to an
empowered community. Through empowerment,
vibrant communities are created that can
overcome stigma and discrimination.” –Israelski
eases and member of Israelski’s research team, believes this
model is effective because it works with the political, social,
and economic structures already in place now, and that it
would be a mistake to “wait until Africa becomes like the
West.” The short-term solution of handing out medicine
(the “top-down” approach, as Israelski has termed it) does
not address the crucial social and psychological issues that
underlie the HIV/AIDS epidemic. Although the stigma that
accompanies the disease is not as prevalent as it once was,
it remains a barrier that must be overcome. As an example,
Kassaye explains that it is not uncommon for a daughter to
be relegated to the maids’ quarters if her family discovers
that she is HIV positive.
The Effectiveness of Community Empowerment
“Our community-driven model [has] not received a lot of
publicity because it’s flying against conventional wisdom,”
says Israelski. By giving members of a community the
responsibility to make their own decisions, international
healthcare organizations must relinquish some of their
control. It will take time to break down this inherently
paternalistic relationship, since Israelski believes that the
world system defaults into a top-down approach to health
care.
Kassaye believes that a country in which the government
welcomes the community-driven model will be more
prosperous than a country that questions the model and
continues to rely on distribution of antiretrovirals by various
institutions. One of the best examples of this is in Burundi:
despite more than ten years of civil unrest, there is nearly
universal access to antiretroviral treatment due to the nation’s
transition to the community-driven method. “Empowered
communities can
more effectively hold
their governments
accountable,” says
The Biology of HIV/AIDS
Is there a difference between HIV and AIDS? Yes. In
simple terms, AIDS is the disease and HIV is the cause of
the disease. HIV—or human immunodeficiency virus—is
the retrovirus (or “slow virus”) that attacks the immune
system, gradually compromising overall health. AIDS is
the term used for the final stage of HIV infection. An HIV
positive patient is usually diagnosed with AIDS if the level
of crucial white blood cells (CD-4 cells) drops below 200;
other symptoms include severe weight loss (known as
“AIDS wasting syndrome”).
How does HIV cause illness? HIV spreads through blood,
semen, vaginal fluids, and breast milk from the infected to
the uninfected. Unprotected sexual intercourse and sharing
drug needles are among the highest-risk behaviors. The
virus attacks specific lymphocytes called T-helper cells (also
“T-cells” or “CD-4 cells”), takes them over, and multiplies.
Like all viruses, HIV can replicate only inside cells; however
HIV and other retroviruses use an enzyme called reverse
transcriptase to convert their RNA into DNA, which can
then be incorporated into the host cell’s genes. T-helper
cells play the central role in normal immune response, and
as they are destroyed other parts of the immune system fail
to function. Most individuals who “die from AIDS” actually
die from pneumonia, tuberculosis, or some other disease
that took hold because the HIV-infected immune system
could not adequately combat it.
Below: This map displays the prevalance of AIDS in various parts of the world:
Africa is most heavily affected.
Photo Credit: http://en.wikipedia.org/wiki/AIDS_pandemic

Israelski.
Some opponents
of the community-
driven model say
that strict regulation
of HIV/AIDS drugs
is imporant in
helping to control
the rapid mutation
of the virus to drug-
resistant forms. The
biggest problem with
dispensing HIV/AIDS

58 stanford scientific
 ethics
drugs to communities is that A false-color photograph of +
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the treatment regiment is not a T-cell infected with HIV.
strictly controlled to ensure
that no doses are skipped and there are enough
drugs to consistently last an infected person a lifetime.
Otherwise, the virus will mutate more quickly, creating
a bigger problem for the HIV/AIDS challenge of drug-
resistance.
However, Israelski believes that the community-
driven model is not as haphazard as other models and
organizations that simply try to get the drugs to Africa
and then deal with how to distribute them and potential
problems later. Many other models and organizations
prioritize saving lives, but at what cost for the future?
Israelski’s model has a focus that intends to make sure
the community understands why they are being given
these drugs, what the drugs mean, and why they need
Photo Credit: http://www.lbl.gov/Science-Articles/Archive/sb/July-2004/1_HIV.html
to be responsible for making sure they are administered
correctly. Israelski believes that communities will environment.”
be empowered when they are given the resources to help At the forefront of his future research is an evaluation
themselves solve their own problems. of the impact of coupling community-driven programs
“Community-driven development leads to an empowered with corporate initiatives focused on social responsibility.
community,” he explains. “Through empowerment, vibrant Other groups and organizations advocate community-based
communities are created that can overcome stigma and work, but none of their strategies are as rigorously defined
discrimination.” From his perspective, a few individuals who as the community-driven model. Israelski believes that a

The most pressing question is how to best distribute

a limited amount of antiretroviral medicine to the
people who need it the most.
are committed to bringing a community out of silence can
serve as a tipping point for the creation of sustainable HIV/
AIDS health care.
Prevention, Care, and Treatment of HIV/AIDS
The central goal that continues to drive Israelski’s research
is determining the most cost-effective method of prevention,
care, and treatment of HIV/AIDS and other diseases. Israelski
was one of the founding members of the Worldwide AIDS
Coalition, a nonprofit group that, while not synonymous
with AIDSETI, hopes to function similarly as a mechanism
to provide more service and resources to communities
severely impacted by HIV/AIDS. Israelski calls it a “push-
pull” mechanism: “We will push [the necessary] resources
to groups in the field that are most effective at health service
delivery. In turn, these groups will pull the resources to where
they can do the most good.”
The challenge, Israelski says, is getting funding for
something so original. He points out an ironic paradox:
“There is an international agenda to combat HIV/AIDS and
other communicable diseases in the developing world, but
the profits that accrue from such activities have generally
returned to the North and West. There is an economy
being generated to find a solution to these great microbial
killers of our time, but little economic benefit from these
efforts has been observed in the most resource-constrained
community-driven model fits into a niche that could not
otherwise be filled. S
KAYLIN PENNINGTON is a sophomore majoring in Human Biology with
a possible concentration in International Health, Psychology, or
Human Development/Performance. She hopes to eventually work
as a doctor overseas. She enjoys listening to music, running track,
and spending time with friends and family.
To Learn More:
Visit the AIDS Empowerment and Treatment International
(AIDSETI) website: http://www.aidseti.org/
-Mission statement: To expand access to HIV/AIDS
treatment in resource-poor countries and work to empower
associations of People Living With HIV/AIDS (PLWHA with
the knowledge, financial and pharmaceutical resources to
run their own holistic HIV treatment programs.
Visit the Worldwide AIDS Coalition (WWAC) website:
http://fightaidsnow.org/home.html
-Mission statement: To facilitate consilience in global
efforts to scale up HIV/AIDS prevention, care, and treatment
in resource-poor communities and serve as a vehicle for
donors to channel support to organizations in the fight
against HIV/AIDS and related diseases.

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