A global strategy ... for a global challenge / by Jonathan M. Mann

••• tor a global challenge by Dr Jonathan M. Mann Director of the WHO's Global Programme on AIDS (GPA) T he AIDS virus swept across the world, silently, before we even knew it existed. The worldwide epidemic was well under way by 1981, when AIDS was first recognised and was given a name. Since then, seven years have passed and it has taken these seven years of discovery and struggle to learn enough to rise above the flood of ignorance and fear, and to view clearly the dimensions of this new threat to global health. However, if AIDS was destined to occur, we were at least fortunate that the epidemic came in the late 1970s and 1980s, rather than fifty years ago. At that time , lacking modern scientific knowledge and technical expertise , we would liter- ally not have understood what was happening to us. Yet today , re- markably , only ·seven years after the disease was first recognized , we do know enough to seize the initia- tive to stop AIDS. For analytic purposes, it is useful to consider AIDS as three distinct yet inter-twined global epidemics. The first is the epidemic of AIDS virus infection itself. The second epidemic, inexorably following the first , but with a delay of several years , is the epidemic of the disease AIDS . For unlike most infectious diseases , such as measles or yellow fever, in which the disease develops days or weeks after infection, AIDS may not occur until years or possibly even decades after the initial virus infection. Finally , the third epidemic-of social , cultural , economic and political reaction to AIDS-is also worldwide and is as central to the global AIDS chal- lenge as the disease itself. Because initial infection with the AIDS virus , now officially called the Human Immunodeficiency Virus (HIV), is silent , without signs or symptoms, the virus was able to spread widely , unnoticed and undetected , starting in the mid- to late-1970s. 4 We do not know the geographi- cal origin of this virus. We consider speculation about the virus's ori- gins, based on the limited informa- tion now available-to be just that: speculation. However we are be- ginning to receive considerable in- formation on the current extent of AIDS virus infection. Based on this information , we estimate that be- tween five and ten million people worldwide may now be infected, and that the virus appears to be present, at least to some extent , in virtually every country. AIDS virus infected persons should, and must, remain in society, for at least two reasons. The first is that. except for unprotected sex, blood transfusions and needle-shar- ing-all of which can be prevented, AIDS virus infected persons are sim- ply not dangerous to others. The second reason is that threatening infected persons with exclusion- or worse-will drive the problem "underground," wreaking havoc with educational efforts and testing strategies. Therefore, how societies treat such persons will not only reflect fundamenta l values, but will probably make the difference be- tween success and failure of AIDS control strategies at the national level. To the extent that we exclude infected persons from society, we endanger society; while to the ex- tent that we maintain infected per- sons within society, we protect soci- ety. This is the message of realism and of tolerance . In addition , global epidemiologi- cal studies have clarified how the virus spreads from person to per- son; this knowledge is most pre- cious, for it tells us how to prevent the spread of AIDS. Fortunately , the virus is quite limited in its routes of spread-limited to sexual contact, blood, and spread from in- fected mother to child. Sexual transmission accounts for the majority of AIDS virus infec- tions in the world. Spread of the virus can occur from any infected person to his or her sexual partner- from infected men to women , from infected women to men , and from infected men to men. The risk from each unprotected sexual contact with an infected person appears small, yet infection can occur from a single sexual contact. Spread of the virus through blood occurs through specific , iden- tifiable practices and in specific, identifiable situations. These in- clude blood transfusion , sharing of blood contaminated needles and sy- ringes by intravenous drug abusers, or the re-use of any needle, syringe or other skin-piercing instrument without proper cleaning and sterilisation. Spread of the virus from infected mother to child can occur before , during or shortly after birth. Re- cent studies have suggested that ap- proximately half of the babies born to infected mothers will be infected with the virus. AIDS in children is mainly due to the virus infection in the mother. AIDS spreads through sex and through blood-through specific , identifiable human actions , all sub- ject to human influence and con- trol. So it is controllable and pre- ventable. Sexual behaviour can be modified, blood for transfusion can be screened, and needles and sy- ringes can be sterilised. It is most important to emphasise that the AIDS virus is not transmitted through food or water; it does not spread through insects or toilet seats , swimming pools or tele- phones , shaking hands , hugging , coughing or sneezing. Most impor- tantly , there is no evidence , any- where in the world , for casual transmiSSion or for person to person spread in schools or in the work place. AIDS virus infec- tion is spread by, and control- able through , conscious human behaviour. W ORLD HEALTH , March 1988 The second epidemic, of the dis- ease AIDS , follows the epidemic of infection , but with a delay of sever- al years. The epidemic spread of the AIDS virus in the mid- to late- 1970s was followed by the global appearance of AIDS cases in the early and mid-1980s. Thus, in 1981, when the disease was first described in the United States, AIDS cases were already occurring in several areas of the world. As of 31 January 1988, a total of 77 ,266 AIDS cases were officially reported to WHO from 132 coun- tries; 35 countries have each re- ported 100 or more cases, including 11 from the Americas, 11 from Europe, 12 from Africa and 1 from Oceania. Reported cases are only a fraction of all cases; in some coun- tries , the disease may not yet be re- cognised or reported to national health authorities , and some coun- tries remain reluctant to speak openly or fully about it. We esti- mate that the actual numbers of AIDS cases worldwide have been between 100,000 and 150,000. Since the disease AIDS occurs years after the AIDS virus infec- tion , the number of cases occurring today does not tell us about the present level of infection in the population. We estimate that for each actual case , there are likely to be an additional 50 to 100 virus in- fected people. Thus, AIDS cases are only the most visible part of a much larger AIDS virus infected population. Infection with the virus is prob- ably life long. The virus inserts its genetic material into the genetic material of some of the infected person's cells. Then , the virus can remain in the body, dormant and hidden , for years or perhaps de- cades . Most infected people are un- aware of their infection. Once the dormant AIDS virus is activated, it destroys a critical piece of the im- mune system and leaves the person vulnerable and defenceless against infectious diseases and some can- cers. Some infected people suffer a less profound weakening of the im- mune system and develop other, usually less severe diseases, called "AIDS-related conditions." And , for reasons not yet understood , in some infected people the virus has remained dormant and thus they have remained healthy. At present , we do not know what W oRLD HEALTH , March 1988 Like a floating sea-mine, the knobbly spheres of the human immuno- deficiency virus threaten to "sink " our defence system against disease. Photo C. Dauguet/lnstitut Pasteur © Above: Comfort and cheer from his parents for an AIDS patient in a United States hospital. The visitors know that they need not wear gloves or masks. Below: By contrast, police arresting a demonstrator during a "gay rights " march unnecessarily clutched their batons in gloved hands. Photos Contact Press/A. Reininger © (winn ing entries in WHO's Photo Competition) 5 ... for a global challenge proportion of infected people will ultimately develop the disease. However, in the first five years after infection, 10 to 30 per cent of infected people will develop AIDS and perhaps 20 to 50 per cent more will develop AIDS-related condi- tions. If 10 to 30 per cent of the five to ten million AIDS virus infected people in the world develop AIDS during the next five years , this would mean 500,000 to three mil- lion new cases or a greater than ten-fold increase in those five years , compared to the total num- ber of cases thus far. Unless a treat- ment is found to protect healthy AIDS virus infected persons from developing AIDS, we will be help- less to avert this large wave of new AIDS cases. What about a vaccine to prevent infection and treatment for those already infected? A human vaccine has never before been made against a retrovirus , such as the AIDS virus. So vaccine researchers have been confronting the mysteries of the virus itself, at the frontiers of The symbol for AIDS chosen by WHO shows two hearts blending into a central fright-mask. virology and immunology. The dis- covery in 1986 of a second AIDS- causing virus , now called Human Immunodeficiency Virus Type 11 , (HIV-11) has further complicated the problem. Nevertheless, with unprecedente1jd speed, the first can- didate AIDS vaccines have been prepared; initial human studies are already under way. However, these first trials are only the beginning. The final tes~s- to determine if a candidate va9cine actually protects against the virus-must be complet- ed before w~ can truly claim to have a vaccine. Under the best of circumstances and with luck, a safe and effective vaccine could become available for use in large popula- tions in about five years. But many experts believe we will not have such a vaccine until at least the mid-1990s. Remarkable progress has been made towards treatment of AIDS virus infection. A single drug, zido- vudine, also called AZT, has been shown to be effective in treating some categories of the disease; al- though AZT has important side- effects and is quite expensive, it does prolong the life of persons with AIDS. Newer drugs, using AIDS A worldwide effort will stop it. 6 similar principles of action, and taking full advantage of what has been learnt about the AIDS virus, are under development: it is just too early to tell if they will be effec- tive and safe. Recently , important trials were started to see if AZT, or other drugs, can block the pro- gression to AIDS in healthy AIDS virus-infected people. The personal and public health benefits of such protection would be enormous. The third epidemic relentlessly follows the first two epidemics. This is the epidemic of economic, social, political and cultural reac- tion and response to AIDS virus in- fection and to AIDS. This world- wide epidemic has only started, yet it is an integral part of the global problem. As public awareness about the disease grows , as the vi- rus spreads and as the number of cases rises steeply during the next five years, this third pandemic can also be expected to intensify . The impact goes far beyond the health statistics. A world- wide AIDS epidemic is a major economic challenge. In industrial- ised countries , medical care costs for each AIDS patient range from approximately US $20,000 to over US $100,000, while indirect costs dwarf the medical costs because it is the young and middle-aged who most often die of the disease. In developing countries, the medical costs have yet to be measured. Cer- tainly , the added cost of AIDS for already over-burdened medical care systems must be considerable. The impact of AIDS on social and economic development may be critical, since it robs societies of people who are in their most pro- ductive years. In areas where ten per cent or more of pregnant wom- en are infected with the AIDS vi- rus , infant mortality from this cause alone may exceed the infant mor- tality rate from all causes in indus- trialised countries. As a result, in those areas the projected gains in infant and child health anticipated through child survival initiatives may be cancelled tragically by AIDS. Fear and ignorance about AIDS has unveiled thinly disguised preju- dices about race , religion , social class, sex and nationality. So AIDS now threatens free travel between countries and open international communication and exchange. W ORLD HEALTH , March 1988 Testing donated blood for possible AIDS contamination at Moscow's Haematology and Blood Transfusion Research Institute. Photo L. Sirman © These three epidemics-of the AIDS virus, of AIDS itself, and of the social reaction and response- together constitute what the World Health Assembly last year called a " worldwide emergency." In re- sponse , WHO's Global Programme on AIDS (GPA) has designed the Global AIDS Plan, has received funding from 14 countries to get the Plan going, and has received unani- mous support from the United Nations General Assembly , the World Health Assembly and the Economic and Social Council of the United Nations (ECOSOC). The global plan is based on the following concepts : - We know enough now about AIDS to stop its spread, even though a vaccine is not yet available . - Education remains the key to AIDS prevention and control. - AIDS control will require a sustained long-term commitment. W ORLD HEALTH , March 1988 AIDS came upon us rapidly, but it will not rapidly recede. - AIDS prevention and control must be integrated into national health systems and strengthen them. - AIDS prevention and control will require both national AIDS programmes and strong interna- tional leadership, coordination and cooperation. The plan has three objectives: - to prevent AIDS virus trans- mission; - to take care of AIDS virus in- fected persons ; - to unify national and interna- tional efforts against AIDS. The disease affects both the de- veloping and industrialised world, so every country will need a Na- tional AIDS Programme. This is vi- tal not only for national interests but also because ultimately the in- fection cannot be stopped in any one country unless it is stopped in all countries. Once there is the po- litical will to recognise the problem, the first step is to establish a broad- ly representative national AIDS committee with responsibility for drawing up a national plan. An ini- tial assessment of the extent of ... for a global challenge infection in the country is essential. Then, epidemiological surveillance must be established, along with lab- oratory support for diagnosis and testing. Health workers at all levels must be educated, for not only are they responsible for the care of people with AIDS, but they are vi- tal sources of accurate information to the public. Specific prevention programmes must be started : - to prevent sexual transmission of the disease through information and education ; - to prevent blood transmission by making blood and blood prod- ucts safe, curbing intravenous drug abuse and educating and treating those who practise it , and ensuring that injection equipment and other skin-pierc- ing instruments are always sterile; - to prevent mother-to-child spread. Finally, a comprehensive nation- al AIDS programme must help people already infected with the AIDS virus , including persons with AIDS , and also help them in their responsibility to protect others . 7 ... for a global challenge A fragile world teeters on the brink of "a great fall. " Only a worldwide effort will stop it. Original design by Peter Davies . National AIDS programmes are being rapidly established through- out the world with the technical and :5.Pancial support of WHO's Global Programme on AIDS. GPA already collaborates with over 100 coun- tries; by the end of this year, it will support every country which re- quests this collaboration, and will be closely involved in monitoring and evaluating national pro- grammes. Just as smallpox eradi- cation became possible when an effective , epidemiologically-based strategy was developed , so strategy development is crucial to global AIDS control. Together, we must 8 learn by doing and by rigorously and dispassionately evaluating what is accomplished. At the global level , GPA is re- sponsible for strategic leadership , developing consensus , coordinating scientific research (biomedical , social, behavioural and epidemio- logical), exchanging information, assuring technical cooperation and mobilising and coordinating re- sources. WHO alerted the interna- tional community to the global scope of AIDS and continues to provide vital exchanges of technical and policy information. Contribut- ing their energies to the global AIDS plan are many important organizations , bilateral and multi- lateral aid agencies , U N agencies including U NDP , U NESCO, UNICEF, UNFPA and the World Bank, non- governmental organizations such as the League of Red Cross and Red Crescent Societies , and private vol- untary organizations. If AIDS had appeared 50 years ago , we would have been nearly de- fenceless against it; science would not yet have been able to define the cause , develop diagnostic and screening methods , and progress so rapidly toward treatment and pre- vention through vaccine. Yet in at least three other ways today's world is well armed and equipped to com- bat AIDS. First , the concept and infrastruc- ture of primary health care is now well established throughout the world. Primary health care delivers basic and fundamental health ser- vices to people where they live ; and it stresses the capacity and re- sponsibility of individuals and com- munities to prevent disease through information and education leading to changes in individual and collec- tive behaviour. Primary health care is therefore vital to ensure active community involvement and to guarantee delivery to the people of AIDS prevention services and programmes. The second major factor is the development of modern social and behavioural science , which we are now applying to design efficient and socially acceptable public health information and education strategies. The third factor is the emergence of a global capacity for action and a global conscience, expressed con- cretely in the bilateral and multilat- eral aid programmes of the world and through the deliberations of the UN system. We recognise that the AIDS situ- ation is likely to become even more serious during the next few years. In the face of this global emer- gency , we cannot give AIDS a " grace period," and the opportuni- ty for prevention must not be lost. We have a collective and historical responsibility to take action now against a worldwide epidemic whose ultimate scope and dimen- sions we cannot yet predict. The awareness of our collective strength heightens our sense of responsi- bility. What has so far, amazingly , been accomplished during the past seven years is a credit to many throughout the world. The global challenge which lies ahead will truly demand the best of us all. • W ORLD HEALTH , March 1988