If measured on nature's terms, HIV is a spectacularly successful virus. On a human scale, however, it's a global disaster. Now, years after it was recognised, this disease is devastating the lives of the poorest across the globe. In the words of Ugandan President Yoweri Musevini, "HIV/AIDS is the worst misfortune that befell Africa in the 20th Century."
Last week, the Joint United Nations Programme on HIV/AIDS (UNAIDS) secretariat and the World Health Organisation (WHO) presented an updated overview of the HIV/AIDS epidemic. This data indicates that in December 2001, over 40 million men, women and children around the world are living with the HIV virus or have developed full-blown AIDS. This year alone over 5 million people were infected and over 3 million died of the disease.
The virus spreads through unprotected sex, unscreened blood and blood products, contaminated needles, mother to child transmission and breast-feeding. In developing countries the principal form of transmission is through unprotected heterosexual sex. More fundamental causes include poverty, gender inequalities, and lack of political interest in its control.
These factors render some groups more vulnerable than others and influence the way in which the epidemic develops in different regions.
The Global Spread
Over the past 20 years, HIV has generated an AIDS epidemic that has spread to every part of the world. Although Africa has been hardest hit, it is becoming clear that Asia, home to 60 per cent of the world's population, is next in line. According to the International AIDS Society, "Asia is potentially facing a devastating spread of the epidemic." New infections in China have rocketed in the past two years and the most conservative estimates predict 20 million infections in India by 2004.
In the former Soviet republics of Central Asia, socio-economic instability is fuelling drug use and commercial sex and thus increasing the spread of HIV. In 2000, for example, Russia saw more new infections than in all the previous years put together- over 80 per cent of cases were young drug users who have contracted the virus by sharing needles.
In Latin America and the Caribbean, almost 1.8 million people are living with HIV/AIDS. Brazil has demonstrated some successes in controlling HIV, but at 5 per cent Haiti has the world's highest adult prevelence rate outside Sub-Saharan Africa.
In industrialised countries where many of the 1.5 million living with HIV benefit from antiretroviral medications, it is disturbing to note that previous gains in prevention are, in many cases, being eroded. It here is now evidence of climbing rates among underprivileged groups or ethnic minorities. An apparent complacency about risk is leading to higher rates of HIV among some susceptible groups.
Africa's Tragedy
Sub-Saharan Africa remains by far the worst affected, but most poorly resourced region in the world. More than 28 million Africans are living with AIDS - three times the number of AIDS deaths in the rest of the world. In 2001 alone 2.3 million Africans have died of the disease. Over 11,000 new infections occur each day on the continent.
In many African countries, teachers are dying at a faster rate than replacements can be trained. Life expectancy is falling to levels not seen since the early 1960s and, in countries from Zambia to Kenya, child mortality rates are expected to double.
A tragic aspect of the epidemic is the growing population of orphaned children: of the world's 14 million children orphaned by AIDS, over 12 million are living in Africa.
Under normal circumstances adults between 18 and 45 years are the least likely to fall ill and die. However in highly affected countries in Africa , HIV/AIDS is now responsible for the deaths of seven out of 10 people in this age group. The disease also particularly affects women, directly by their increased susceptibility to infection and indirectly in their role as principal carers. In addition many grandparents and other relatives have to assume the role of absent and deceased parents.
There is a clear link between HIV/AIDS, poverty and under-development. HIV/AIDS is both symptom and cause, of poverty - poor people are more likely to be infected with HIV. Once infected - the poor and the malnourished whose immune systems are already weak, will succumb more easily. AIDS attacks fragile societies also - undermining their capacity to mount an effective response.
It is now evident that AIDS is reversing a generation of progress in human development and poverty reduction efforts. According to UNDP Administrator Mark Malloch Brown: "Current trends of the disease risks completely derailing many of the key global development targets that world leaders endorsed at the Millennium Summit in 2000.
The response
Governments, donor and non-profit organisations have invested considerable funds in prevention and control. Despite some sucesses, efforts to control the spread of this disease have been far from satisfactory. Now, 20 years into the epidemic, some lessons have been learnt about what programmmes are effective in addressing AIDS in highly affected countries.
Uganda is one of only a small number of countries to have turned the epidemic around. There the adult HIV prevelance rate has decreased from around 14 per cent in the early 1990s to 8 per cent in 2000.
Sustained political leadership, early intervention, a strong focus on prevention and adopting a multi-sectoral approach are all key ingredients of success.
Many countries, however, have not pursued this approach and prevelance rates remain stubbornly high. In countries such as South Africa, Zimbabwe and Botswana the epidemic is still spinning out of control despite belated efforts to contain it.
It is now recognised that prevention has to be the mainstay of control. Many programmes which have targeted prevention, particularly to high risk groups, have been shown to be effective. This, however, needs to be balanced with efforts to provide comprehensive care including physical, psychological and medical support.
In low-income countries the issue of what treatment options can be afforded is the subject of a major international debate.
The Need For More resources
There is a growing realisation that the volume of resources that have been mobilised in the fight against HIV/AIDS has been grossly inadequate. Last year, UN Secretary General Kofi Annan pointed out that progress in facing up to the AIDS catastrophe has been "unconscionably slow". Addressing African leaders in December he stated: "I stand before you as a fellow African. We know that we came too late to this tragedy. Far too many graves accumulated in Africa as the years passed and energies were not yet fully mobilised."
It has taken over 60 million people with HIV and 22 million deaths for the international community to initiate a global response to the pandemic. Over the past two years, health and HIV/AIDS have been prioritised in G8 discussions and there have been three debates on HIV/AIDS at the UN Security Council. In June 2001, a UN General Assembly Special Session on HIV/AIDS, the first UNGASS ever devoted to a health issue, was held.
An important objective in mobilising the international community is to generate adequate financial resources to arrest the spread of HIV/AIDS. UNAIDS estimates that a minimum of $3-to-4 billion is required a year - or 10 times that currently being spent. Other commentators believe $7 to 10 billion is a more realistic estimate.
To this end, Kofi Annan launched a new Global Fund for Health and HIV/AIDS at the UNGASS in June. To date contributions amounting to $ 1.6 billion have been committed. It was expected that the fund will be operational from January 2002 and that it would lead to substantial increases in the volume of financial resources being directed at the control of HIV/AIDS malaria and tuberculosis in developing countries.
Commentators agree that, with low absolute levels of development aid, funds committted to this Global Fund have to be additional and not a reallocation from existing aid budgets. There are now concerns that the events of recent months, coupled with fears of a global recession, will compromise the commitment demonstrated by political leaders to commit these necessary resources.
Sustaining The Commitment
While the challenges remain formidable there is some room for optimism. In 2000 there was a small decrease in the number of new infections reported in Sub-Saharan Africa. Some 60 per cent of the adult population even in the worst affected countries are not infected. Most young people do not have the virus. Prevention programmes can work - the experience of Uganda has demonstrated that, given political commitment and adequate resources, the progress of the epidemic can be reversed.
And after 20 years there is evidence of a greater interest by the international community in arresting this disease. There is a recognition also that any attempt to control HIV/AIDS must address underlying poverty and disadvantage.
At a time when there is a perception of more compelling international concerns, it is clearly a collective responsibility to ensure that the conquest of HIV/AIDS remains a key priority on the international political agenda
In his address to the UNGASS, Kofi Annan, while attempting to secure a global commitment to combat the epidemic, stated: "I believe this year will go down in history as the year we turned the tide."
For those vulnerable to infection, those already infected and the wider community affected by this disease, let us earnestly hope that Kofi Annan is right.