Special Focus: A Pandemic That Knows No Borders
Since AIDS was first described in 1981, well over 20 million lives have been lost, and tens of millions more people, increasingly women and young people, are now living with the disease. Most of those afflicted face the almost certain prospect of sickness, destitution, and premature death.
Of the 42 million adults and children who are estimated to be living with HIV/AIDS, 95% live in the developing world. HIV/AIDS has hit the developing world hard, reducing life expectancy and economic potential. The pandemic has increased the vulnerability of future generations by creating millions of orphans and has greatly diminished the capacity of both the public and private sectors.
While sub-Saharan Africa has been hardest hit (with close to 30 million living with HIV/AIDS) the virus is also spreading to some of the world's most populous countries, to include China, India, Indonesia, and Russia. Experts believe that by 2005 the rate of new HIV infections could escalate by as much as 25% or more!
Recently, the U.S. Secretary of State, Colin Powell, put this pandemic in perspective by emphasizing that, "the worldwide AIDS epidemic is more devastating than any terrorist attack, any conflict, or any weapon of mass destruction".
To better understand the pandemic and what needs to be done to win the war against AIDS, WER interviewed Ambassador Anwarul K. Chowdhury, the UN Under-Secretary-General and High Representative for the Least Developed Countries, Landlocked Developing Countries and Small Island Developing States (designated as OHRLLS…see www.un.org/ohrlls). Ambassador Chowdhury (see his biography in the call out box on page 2) has been recognized in many ways for his diplomatic work on behalf of women's rights, children's rights, and the culture of peace. As part of his advocacy work for the most vulnerable countries of the world and to draw attention of the international community to the plight of these countries facing the HIV/AIDS pandemic, Ambassador Chowdhury recently convened a UN symposium on "Population and HIV/AIDS" which focused on the social and political dimensions of the pandemic and its destructive effect upon the poorest and least developed countries.
What follows are the highlights of an extensive interview the Ambassador was kind enough to grant WER.
WER: What are the major causal factors contributing to the spread of HIV, in the least developed countries (LDCs)?
AKC: There are four. First, is the differential access to healthcare in the developing world. Second, is the persistence of certain cultural patterns which increase risk. Third, public health information in most LDCs is limited and there are enormous amounts of "misinformation". Fourth, and most importantly, the financial resources to fight HIV/AIDS are entirely inadequate to the task.
WER: Can you give us a sense of the severity of the HIV/AIDS situation in the LDCs?
AKC: Unfortunately, HIV infection rates in most LDCs in sub-Saharan Africa, for example, continue to increase. In some cases, the HIV/AIDS epidemic is literally threatening the entire nation. For example, a recent report on Botswana, a tiny and desperately poor African nation of 1.6 million, estimated that almost 39% of the adult population is infected! A decade ago, life expectancy in Botswana was 65. Today, because of AIDS, a baby born in Botswana has a life expectancy of 32 years.
WER: Is the HIV/AIDS epidemic largely limited to the LDCs?
AKC: No, this is not the case although this may be the perception of many. HIV/AIDS is a multifaceted, worldwide threat. To address the global nature of HIV/AIDS a number of United Nations agencies have combined to establish the Joint United Nations Programme on HIV/AIDS. This new interagency entity, called UNAIDS (see www.unaids.org), is now the main advocate for global action against the epidemic. Every year UNAIDS and the World Health Organization (WHO) release a report on the status of this global plague.
WER: And what does the most recent UNAIDS/WHO report suggest about the scope of HIV/AIDS infection?
AKC: The report, available at the UNAIDS website, documents that 30% of those living with HIV/AIDS worldwide live in southern Africa, an area that is home to just 2% of the world's population.
In southern Africa the epidemic is particularly devastating for women. A young woman aged 15 to 24 is 2.5 times more likely to be infected than a young man of comparable age.
The report also emphasizes that a new wave of HIV epidemics is threatening the more populous nations of China, India, Indonesia and Russia, mostly due to HIV transmission through injecting drug use and unsafe sex.
The new UNAIDS/WHO report presents many clear warning signs that Eastern Europe and Central Asia could become home to serious new HIV epidemics. Prevalence rates in these regions continue to grow and show no signs of abating.
Young people are among the hardest hit by HIV/AIDS in this part of the world. While young men still bear the brunt of the epidemic, 33% of those infected at the end of 2002 were woman, up from 24% the year earlier. Despite the growing prevalence of HIV infection, too little prevention outreach, such as safe sex education or adoption of safer injection techniques, is being employed in these areas.
The epidemic is also growing in areas where, until recently, there was little or no HIV present, including many areas in Asia and the Pacific. Recent rapid increases in HIV infections in China, Indonesia, and Vietnam show how suddenly an epidemic can erupt wherever significant levels of drug injecting occur and, as seen in Eastern Europe, illustrate the urgent need to increase prevention efforts before the epidemic expands beyond high-risk groups.
WER: You present very disconcerting information. Are there any nations in the LDC category that are effectively combating the spread of HIV/AIDS?
AKC: Yes, encouragingly, there are. Let's look, for example, at Uganda where HIV/AIDS first appeared in 1981. By 1992, the infection rate had reached as high as 18.5% in urban areas. Tragically, the most productive people in Ugandan society were dying off leaving childrearing to other, mostly older and less productive relatives.
In 1992 the government took action. With leadership provided by Uganda's President, an AIDS commission was established and religious leaders were enlisted to help essential outreach efforts. Policies and programs were drawn up for all key ministries, including the military, education, and agriculture. The major AIDS control campaign was tagged "ABC" and called for "A" - Abstinence; "B" - Being faithful; and "C" - Condom use. By 2002 AIDS prevalence in Uganda has decreased to 6.1%.
The Ugandan experience highlights certain key features that must be part of any program intended to combat the scourge of AIDS. These key features include:
AKC: Any effective global strategy to combat HIV/AIDS must involve information; social reform; the development of public health infrastructures; and the mobilization of resources.
WER: Can you please elaborate on what is required in each of these initiatives?
AKC: Yes. Let's look at each to better understand what needs to be done.
Knowledge, Information and Education
Medical research continues to increase our knowledge of the disease, but we need to continue to properly fund ongoing research, analysis and clinical application. As knowledge increases it needs to be properly packaged to optimize education and training. Such education needs to target young people in schools and in sports and social clubs. The media can also have a powerful impact. Support for parents, caregivers, policy makers and teachers is vital for community-based outreach programs designed to increase awareness. Publicity campaigns, such as those in Brazil, Thailand, and Uganda have increased awareness that has led to behavioral change and reduced rates of infection.
Building gender equality and equity is key in the fight against AIDS. To make this happen changes are necessary in both male and female knowledge, attitudes and behavior. Women need to develop greater self esteem and knowledge in order to take more responsibility for their sexual and reproductive health, free from discrimination, coercion and violence. Men need to take greater responsibly for their own conduct and recognize the importance of women's health needs and well being. We need to support female involvement in health planning and implementation.
We must, in each nation, build a public health infrastructure that provides health care that is affordable, convenient and of good quality. Developing countries clearly need enhanced health care services including access to diagnosis and counseling; better information and education; as well as increased research, promotion, supply and distribution of condoms, pharmaceuticals, vaccines, and safe blood transfusions… all of which requires a massive mobilization of resources.
UNAIDS estimates that disbursements from private, national, and international sources for 2003 will total about $4.7 billion in low and middle-income countries… a very substantial increase in the last five years.
Unfortunately, the latest estimates by UNAIDS on the cost of effective prevention, treatment, care and support programs in such countries will be $10 billion annually by 2005. This dollar requirement is expected to increase to $15 billion annually by 2007, an annual level of support that will be required for at least another decade.
While many LDCs are committing as much as 15% of their national budgets to health spending, this level of funding falls far short of the need. It is estimated, for example, that 80% of the total resources to effectively combat AIDS in sub-Sahara Africa and in parts of Asia will have to come from international sources.
AKC: Quite a lot. Since January of 2002, the Global Fund to Fight AIDS, Tuberculosis and Malaria has been operating. This fund represents a new financing mechanism that promotes national ownership and country led activities as well as simplified procedures for identifying need and then delivering assistance. Designed to complement other funding initiatives, the Fund has already approved $2.1 billion in assistance to 224 programs in 121 countries.
WER: What else is occurring in public and private initiatives that offers encouragement?
AKC: There are many new initiatives that will contribute to fighting the scourge of HIV/AIDS. The American Congress, for example, is expected to approve $2.4 billion to be spent in 2004 in fourteen countries to fight AIDS in Africa and in the Caribbean.
Major pharmaceutical companies are now operating extensive programs to improve health in the developing world. These initiatives include major research programs to develop new medicines and vaccines for tackling major killers such as HIV/AIDS, malaria, and tuberculosis. These global pharmaceutical corporations are also helping create community health partnerships that are self-sustaining and replicable as well as creating preferential pricing for medicines (particularly antiretrovirals) and vaccines that are needed most.
WER: Speaking of antiretrovirals, what actions are the governments in China and South Africa doing in this area?
AKC: Both governments announced that they will endeavor to supply antiretroviral drugs to every citizen who needs them. South Africa, for example, will be spending $680 million annually by 2007 to buy drugs, set up clinics, and train thousands of health workers.
Similarly, the World Health Organization has launched the so-called "3 by 5 program", a plan to get 3 million people on antiretroviral treatment by the end of 2005. If WHO achieves this goal it will represent a ten-fold increase in the number of people in LDCs taking antiretroviral medications.
WER: So where do we stand today in the battle against this global disease?
AKC: We are at a turning point. Anti-AIDS programs are growing larger, more coherent, and better funded. There is also a growing political commitment, in both the developed and developing worlds, to ensure that more money is spent, and importantly, new methods are pursued to getting AIDS drugs to the poor in the LDCs.
WER: Are you encouraged?
AKC: Yes. New political commitments, better programs and more funding should not, however, lead to complacency. In 2003, three million died of AIDS. HIV/AIDS is arguably the single biggest threat to life and prosperity in the developing world. The epidemic continues to tear across Africa, Asia, and Latin America. In Botswana, most teachers and farmers will die of AIDS. Almost 11 million children in sub-Saharan Africa have lost at least one parent to the disease. In Zambia, 12% of all children are AIDS orphans. Now that the disease is taking hold in Eastern Europe, India and China, the AIDS damage to economies, to education, and to social services are almost too great to imagine.
While the world may be at long last beginning to organize an adequate medical response to AIDS, we have not even begun to identify the vast socio-economic implications of this global plague let alone the kinds of programs and funding needed to deal with the wreckage left in it's wake.
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