Kevin de Cock writing in his comment in The Lancet in 2002, entitled ‘Shadow on the continent’ said that how an issue is defined strongly affects how it is addressed. Portrayal of HIV/AIDS against a background of either human rights, poverty, gender or public health elicits different responses, but the measure of each response must be its ability to curtail the epidemic, and at what social cost. In essence this is what this Review is about. How do we best understand what works, how do we estimate and measure the social cost, quite apart from the economic and political costs, and how do we strike the balance between the imperatives of public health on the one hand and the imperatives of human rights on the other?
This tension between public health and human rights arises from the ways in which HIV and AIDS have been and still are defined. As the epidemic unfolds and evolves the limits of previous and existing interventions and philosophies become clearer and the dangers of new ones become more acute. Thinking about the epidemic has to change and has to adapt as the circumstances of those who are grappling with living with HIV, or trying to remain uninfected, change. While human rights operate globally, public health – while being discussed in sweeping global assertions about, for example, testing or circumcision – has to be implemented and understood locally. The sweeping global assumptions of public health – the emphasis on rationality, on measurement, on numbers, on infrastructure and on results, sit uneasily with the irrationality that drives people’s lives, their understandings of their own autonomy and agency and their ability to understand and act on the public health messages. It is this tension between what makes sense as a ‘neutral’ public health intervention, and the failure of success, that suggests that an emphasis on human rights is inappropriate (and that in cases of crisis and emergency they can be reduced or even ignored).