Intended for healthcare professionals


Combating HIV/AIDS in developing countries

BMJ 2004; 329 doi: (Published 15 July 2004) Cite this as: BMJ 2004;329:121
  1. Jennifer Prah Ruger (jruger{at}, research assistant professor
  1. Washington University School of Medicine, Department of Medicine, Division of General Medical Sciences, 660 South Euclid Avenue, Campus Box 8005, St Louis, MO 63110 USA

    Requires empowering people to act on their own terms

    In July 2004 the international community will convene in Bangkok, Thailand, for the 15th international AIDS conference. The gathering occurs at an opportune time in global health as just months earlier, the World Health Organization and UNAIDS launched the “3 by 5” programme—a global initiative to provide antiretroviral therapy to 3 million with HIV/AIDS in developing countries by the end of 2005.1 Additionally in the past few years the Global Fund to Fight AIDS, Tuberculosis, and Malaria was created, to finance a scaling up of resources for interventions against all three diseases ( These initiatives are augmented by increases in funding from private, national, and international sources. Together these efforts represent one of the most important trends in global health over the past five years. The movement for increased funding for HIV/AIDS in developing countries has brought attention to the issue and initiated a process of responding to it.

    Focusing on prevention of HIV and on expanding access to antiretroviral treatment for people living with AIDS is critically important to the fight against HIV/AIDS, but alone this strategy is not enough to tackle the problem. Combating HIV/AIDS in low and middle income countries requires more than prevention and treatment—important as this two pronged strategy is. It requires improving the conditions under which people are free to choose safer life strategies and conditions for themselves and future generations. An alternative view of the HIV/AIDS problem recognises the inter-relatedness of health and other valuable social ends (for example, education, employment, or civil rights) and also emphasises the importance of individual agency or freedom—that is, people's ability to act and bring about change in terms of their own values and objectives and thus to live a life they value—for the prevention and treatment of disease.26 Freedom is essential for both individual and collective action and is critical for changing policy, norms, and social commitments.2 These key elements are part of an alternative way of thinking about HIV/AIDS policy and several points are relevant to this view.

    Firstly, this alternative viewpoint appeals to a particular vision of the good life that is derived from Aristotelian political philosophy79 and Amartya Sen's capability approach.2 10 11 According to Aristotle, society's obligation to maintain and improve health is grounded in the ethical principle of human flourishing, which holds that society is obliged to enable human beings to live flourishing and thus healthy lives. This view sees development as expansion of individual freedom instead of judging development by gross national product or personal income.2 10 11 Similarly it sees health policy as expansion of individuals' choices or opportunities for a healthy life, instead of judging health policy by health spending or defined benefits, important as these are.46 This perspective stems not only from moral and political philosophy, but from empirical evidence synthesised by the scientific community on the effectiveness of HIV prevention and AIDS treatment strategies.12

    Secondly, sustainable prevention and treatment of HIV/AIDS requires empowering people to act and bring about change in their own terms—at the individual as well as the collective level. Combating HIV/AIDS in developing countries thus requires more than disease specific interventions, it must also include a country's broader development strategies. At the individual level, for example, better education, especially for women, makes individuals more likely to protect themselves from contracting HIV.12 Moreover, improved economic, cultural, political, and social conditions for women improve the effectiveness of HIV/AIDS prevention and treatment programmes because women can choose safer life strategies and conditions for themselves and their children. Such conditions can be created through employment and cultural values, ownership of assets, and political and civil opportunities that empower them in the family and in their relationships with men.w1 w2

    Women in developing countries are affected disproportionately by HIV/AIDS. Nearly 60% of individuals living with HIV/AIDS in sub-Saharan Africa are women,w2 thus efforts to reduce gender inequalities in social, economic, and political opportunities is critical.

    In north America, western Europe, Australia, Thailand, Senegal, Uganda, and Brazil the spread of HIV/AIDS has been slowed through multiple prevention strategies. These include health education, behaviour modification, social, economic, and political environments that allow individuals to protect themselves against infection, promotion of condoms, HIV testing and counselling, reducing mother to child transmission, needle exchange and blood safety programmes, and treatments for sexually transmitted diseases.12 In Zimbabwe, USAID and Development Alternatives have pilot projects employing micro-enterprise and microfinance programmes to respond to areas with high prevalence of HIV/AIDS.w3 Although these programmes require evaluation, they recognise that gender inequalities exacerbate women's vulnerability to HIV infection. The response focuses on enhancing women's educational and economic opportunities.w2 w3 Individual freedom is at the core of each of these strategies, and public policies that create conditions in which individuals can exercise their ability to live the life they value are essential.

    Finally, at the collective level, human freedom is essential to policy change and political action and must be enabled through guaranteed human rights and democratic institutions. Collective action—a group's ability to advance and effectuate change—in the political process and public sphere is important for shaping public policy about HIV/AIDS. In the United States, for example, AIDS activists collaborated through numerous organisations to influence values about HIV/AIDS (namely, reducing stigma and discrimination and increasing prioritisation) and to advocate for their own interests (namely, treatment of AIDS) in public decisions.13 Many argue that such advocacy has been so effective in the United States that AIDS assumes a priority that is beyond what its prevalence would warrant. The HIV/AIDS problem in developing countries is surmountable—and the scientific community has identified many of the necessary components to the solution.12 Many of the remaining barriers to success—political will, social commitment, vision, and action—however, relate to problems of collective action. National and global institutions must be reoriented to function more democratically and inclusively and be driven by the interests of individuals and groups they serve. This transition will require more than raising funds and targeting benefits. It calls for expanding the voice and power of all people, especially those with HIV/AIDS in developing countries, to advocate for their interests, shape their destiny, and help themselves and each other.2


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    • Competing interests JPR is supported by a career development award (grant K01DA01635801) from the US National Institutes of Health.


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