The state of AIDS

BRUSSELS — The latest antiretroviral drugs have changed an HIV/AIDS diagnosis from a guaranteed death sentence to a manageable, chronic disease. So are we winning the battle? Not yet.

For years, the world employed ad hoc measures in hopes that an effective vaccine would soon solve the crisis. Now some humanitarian aid organizations say that rather than waiting for future medical breakthroughs, there needs to be a comprehensive global strategy for preventing the disease from spreading.

Medicine alone seems unable to stem the epidemic and efforts at prevention are only reaching 10 percent of the people at risk, according to experts. The number of people undergoing treatment has increased tenfold in the last four years, but at least five new people are coming down with HIV/AIDS for every two being treated.

It is worth looking at where HIV/AIDS has come in the last 25 years — and where the remaining hurdles lie.

Until now, the world’s reaction to the epidemic has been too little too late. The disease first surfaced in a 1981 alert to the Center for Disease Control in Atlanta that five gay men in California had died from pneumonia after their immune systems collapsed. By the end of the year, cases from drug addicts using infected needles had begun appearing in England.

By 1985, 17,000 cases in 71 countries were reported to the World Health Organization.

Today, the cumulative total of people infected with HIV/AIDS is nearly 60 million. At least 25 million have died. Anywhere from 2 million to 5 million cases are reported a year. The United States is still recording from 10,000 to 50,000 new cases annually despite widespread education programs.

“Initially, the big problem was across-the-board denial about the disease itself,” said Peter Piot, who until recently was the executive director of UNAIDS. “Particularly in the United States, Europe and Western countries, it was seen as a disease of shame and homosexuals.”

The hesitancy of political leaders to get involved with the illness and its potentially explosive social issues provided the time and space that AIDS needed to gain a worldwide foothold. “When I look back at how we handled AIDS, it is not that some things failed, and others worked,” Piot said. “It is that we began acting on a massive scale far too late.”

While countries dragged their feet in confronting the crisis, the disease spread across continents and beyond the marginal groups it first afflicted. In sub-Saharan Africa, AIDS is unraveling 50 years of development efforts. Some companies are hiring two executives for the same job, because they are afraid that one of the two is certain to come down with AIDS. China, which for a long time tried to deny that it had a problem, is now reporting 50,000 to 100,000 new cases a year.

There are already concerns over political instability in China, India and Russia resulting from the economic impact of AIDS.

As far back as 2000, the year the UN Security Council held its first debate on AIDS, political analysts and security experts began looking into the epidemic and the political destabilization likely to result from the associated economic costs.

In 2003 then-director of the CIA, George Tenet, when briefing Congress, drew attention to the national security implications of the disease, saying: “The intelligence community recently projected that by 2010, we may see as many as 100 million HIV-infected people outside of Africa.” Tenet said that with rising incidences in China, India and Russia, the national security dimension of the virus was plain: "It can undermine economic growth, exacerbate social tensions, diminish military preparedness, create huge social welfare costs, and further weaken beleaguered states. And the virus respects no border."

Piot, who will become director of a worldwide global health center at London’s Imperial College in a few months, has been one of the driving forces behind AIDS 2031, a partnership of leading AIDS specialists, sociologists and economists who are trying to develop a comprehensive strategy for the next 25 years in the fight against AIDS.

A major concern of AIDS 2031 is that the worldwide economic crisis, as well as competition for funding from other global threats like climate change, will reduce the financing for the fight against AIDS at the precise moment when more money is needed.

Piot is convinced that the main advances against AIDS are now likely to come from prevention strategies and changing behavior and cultural attitudes, rather than from breakthrough advances in medicine. “There needs to be a global brand for AIDS prevention," Piot said, "but one that can be customized to be understood locally.”

Changing customs and attitudes, however, is never easy. Recent studies indicate that if 70 percent of males in sub-Saharan Africa were circumcised, 700,000 AIDS infections could be avoided by 2015. But getting men—even in the United States—to go along with that is not easy.

Expanding prevention strategies to include everyone at risk could save $24 billion in medical costs, according to a 2007 report by the Seattle-based Global HIV Prevention Working Group. But governments need convincing that the investment is worth it. Currently health expenditures on AIDS by low- and middle-income countries amount to between 1 and 4 percent of their health budgets, according to The Lancet.

Debates over strategy have weakened and slowed prevention efforts. For example, the pope on his recent trip to Africa suggested that using condoms actually increases the spread of AIDS. The highly respected British medical publication The Lancet denounced the remarks as “outrageous and wildly distorted,” but Africans were left to wonder who was right.

Another tricky area for behavior modification involves injected drug use, which underlies much of the spread of AIDS in Asia.

Both prostitutes and addicts who use infected needles spread AIDS in many parts of Eastern Europe, Russia and Asia. In many cases, the prostitutes are addicts who use commercial sex to finance their addiction. Most governments understandably want to stamp out the use of drugs, but in reducing the quantity of drugs on the market, they drive the price up, and that encourages the use of injected drugs, which give more of a rush. By making drugs more expensive, female addicts are driven even more deeply into prostitution to keep paying for more drugs. Providing access to clean needles can be an interim step, but it runs the risk of providing an easier path to direct injection drug use.

One of the goals of the AIDS 2031 project is to encourage evidence-based research on the effectiveness of prevention strategies, rather than relying on speculation. What the first 25 years has taught us is that the problem won’t go away by itself, and the longer we ignore it the more difficult it is to deal with.

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