Baz Ratner / Reuters A health worker walks past a woman holding a baby at the maternity ward in the government hospital in Koidu, Kono district in eastern Sierra Leone, December 20, 2014. 

When Exceptions Become the Norm

HIV Exceptionalism Does More Harm than Good

In 2006, sub-Saharan Africa finally began to see effective antiretroviral therapies for HIV take hold. For years, the region had been deemed “too complex” for these life-saving drugs, with former U.S. Agency for International Development (USAID) head Andrew Natsios suggesting that Africans lacked the conception of Western time required to take the drugs on the prescribed schedule. But activists had finally succeeded at getting pharmaceutical companies to lower the price of HIV drugs and to make the drugs available for free or at low cost to the world’s poor. This was no small feat. The conventional public health wisdom was that HIV drug regimens were too costly for the poor to afford and too complicated for the uneducated to comprehend, and, further, that health systems were too weak to effectively diagnose and deliver drugs to those who needed them the most. Only a decade later, though treatment is provided free of charge or at low cost in most African countries, a sizable number of people who need the drugs cannot access them. In 2013, UNAIDS estimated that 80 percent or more of those eligible for treatment in 14 African countries were not receiving antiretroviral therapy.

The activism also challenged a paradigm of public health that prioritized prevention over treatment, containment over therapeutics, and cost and efficiency over equity. Activists’ hard work to organize around access to antiretroviral therapy—even when couched in a broader health and social justice agenda —had inadvertently buttressed claims that HIV was exceptional. By the middle of the first decade of the twenty-first century, HIV exceptionalism—the idea that HIV/AIDS was an exceptional disease that requires an exceptional response—had become a global health mantra.

At the heart of HIV exceptionalism was an attempt to respond to a disease that poses a unique threat through unique techniques. To fight the spread of HIV, health-care organizations advocated treating the disease differently than other epidemics—with a siloed set of resources and approaches. This led to the creation of separate

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