Global AIDS into the 1990s / Jonathan Mann

Global .AIDS into the 1990s A s of 1 October 1989, a cumulative total of 182,463 people with acquired immuno-deficiency syndrome (AIDS) were reported officially to WHO from 152 countries throughout the world. However, under-recognition and under-reporting mean that the actual cumulative number of people with AIDS is much higher than this. WHO estimates that the actual cumulative total of people with AIDS is over one-half million, that is, more than three times the number reported. Moreover, we estimate that at least five million people worldwide are infected with human immunodeficiency virus (HN), the virus which causes AIDS. Of these, about 2.5 million are in Africa, 2 million in the Americas, 500,000 in Europe and about 100,000 in Asia and Oceania. Projecting into the 1990s To predict trends of HN infection and AIDS in the 1990s, the WHO Global Programme on AIDS (GPA) recently completed a Delphi study - a method to develop expert judgments on relatively uncertain issues - and used this method to collect and synthesise expert opinion. The projections are based on the assumptions that five million adults had already been infected with HN, and that during the next decade no effective vaccine or treatment would be available. The Delphi estimates were then fitted into a model to project AIDS cases to the year 2000. The Delphi study predicted that during the 1990s about three times more HN infections would occur than had occurred during the 1980s. But over one-third of these new infections were considered preventable by a globally coordinated AIDS pro- gramme, in concert with national pro- grammes. Further, about nine times more adults were predicted to develop AIDS during the 1990s compared with the 1980s; roughly half of these people who develop AIDS during the 1990s were already infected with HN during the 1980s. Over one-third of the AIDS cases resulting from new 6 by Dr Jonathan Mann Director, WHO Global Programme on AIDS ' - Bringing about positive behaviour change calls for relev?!._nt and targeted informa- tion and education. Street children in Mexico City are advised by a prostitute - who has herself tested sero-positive. infections in the 1990s were con- sidered preventable through global and national efforts. Whether considering the cumulative number of adult AIDS cases worldwide, or comparing the annual number of new AIDS cases in 1990, 1995 and the year 2000, the HN I AIDS situation in the decade of the 1990s will be much more serious than WHO/J . Hemimdez-Ciaire what we have experienced during the 1980s. In particular, the number of people with AIDS will increase greatly. In view of these predictions, it is vital that health and social services are planned and developed as far as possible to meet the forecasted needs of the 1990s and beyond. Action for the 1990s The HN I AIDS epidemic is much more than statistics and figures. An overview of the individual and col- lective response to the epidemic shows that, in many countries, there is already a strong and growing capacity to prevent infection and to care for those Reported and Estimated AIDS Cases (1 October 1989) Area Africa Americas Asia Europe Oceania TOTAL Number of Countries reporting Reported cases Estimated cases cases 48 43 25 29 7 152 31,512 123,343 435 25,589 1,584 182,463 280,000 200,000 1,000 33,000 2,000 516,000 W ORLD HEALTH. October 1989 who are ill; there is a steadily expanding body of scientific know- ledge; and there is learning based on years of hard work. In many countries, the work of international, national and community- based organizations is showing results in behavioural changes which will help to prevent the spread of HIV. Experi- ence and analysis of work carried out so far shows that three elements have been present wherever positive beha- viour change has occurred. First, locally relevant and targeted informa- tion and education have been pro- vided by credible sources. Second, the information and education have been linked with those health and social services needed to support and strengthen behaviour change. Finally, the programme has been introduced and implemented in conjunction with a strong social commitment to support; a supportive environment for AIDS prevention and control program- mes is a requirement, not a luxury. These are the principles of successful prevention programmes, which can be adapted to any culture or society. Yet it is vital also to recognise the limits of current national and interna- tional progress, and to look to the future, with confidence in the work already accomplished and understand- ing of the challenge that remains. Looking to this future, national AIDS programmes must accomplish three tasks. First, existing programmes must be consolidated. To ensure sustained capability in the coming decade, stronger linkages must be forged with other health and social programmes; more attention must be paid to pro- gramme staff and staff development; and the capability for management, planning and evaluation must be improved. focused renewed attention, is an important contribution that the efforts against AIDS can make towards the improvement of public health in gen- eral. Finally, AIDS programmes must continue to innovate, since some of the challenges which AIDS presents to individuals and societies will require new approaches - for prevention, for care, and for ensuring equity in the provision of health and social services, including therapeutic agents and, eventually, a vaccine. AIDS program- mes must not stop challenging the status quo when the status quo is simply not good enough. Only a worldwide effort These measures will help to convert the initial efforts of the 1980s into strong and resourceful programmes to deal with HN infection and AIDS during the 1990s. Yet the epidemics of HN and AIDS are only two of the three epidemics we face. The third epidemic - that of social, cultural and political reaction and response to HN / AIDS - may be as important to our future as the virus itself. This third epidemic can threaten to overshadow and overwhelm the epi- demics of HN and AIDS. Myths about Young people such as this group in Switzerland are on the front line; their response to information and education may determine our future. Second, programmes need to identify specific areas which merit focus and strengthening. In every com- munity and country, AIDS has inevita- bly highlighted certain pre-existing and complex health and social problems. Worldwide, the broad issues are simi- lar, yet the specific circumstances and emphases are quite varied. To take some examples, in India AIDS has focused attention on to the quality of blood products; in Italy to drug injec- tors; in Pakistan, on to the blood transfusion services; in the United Kingdom, to health education, particu- larly of youth; in the Soviet Union to the quality of health services; and in Sri Lanka to control of sexually trans- i mitted diseases. Each AIDS pro- o gramme must select its own priority 0:. areas for particular emphasis. Commit- .::?. ment to these deep and longstanding ~ problems, upon which AIDS has ~ WORLD HEALTH. October 1989 HN and AIDS persist, generally involv- ing unfounded fears about casual contact. Similarly, assaults on the rights and dignity of HN-infected people continue to arise. To meet the challenge of this third epidemic will require solidarity. In the Photos in this issue not marked WHO or © for copyright are entries in WHO's 40th anniversary International Photo Competition 1980s we have learned and we have taught that discrimination and stigrnati- sation of HN-infected people must be prevented - for the sake of us all. More recently, we have discovered that beyond the concept of anti- discrimination there is a more positive and active quality - a respect for human rights and dignity: a spirit of active tolerance. Yet beyond even anti-discrimination and active tolerance there is a still higher call - a call for solidarity. As we turn towards the decade of the 1990s, we are confronted by a great challenge to develop our response to the three epidemics locally, nationally and internationally. In facing this challenge, the dynamism of modern science inspires us, the · deep internationalism of the global fight against AIDS strengthens us, and the remarkable history of our personal and collective efforts in the 1980s - all these give us courage and confidence to face the challenge of the 1990s. • 7