Expanding the global response to HIV/AIDS

World Health • 5 l st Year, No. 6, November-December 1998 5 Expanding the global response to HIV/AIDS Peter Piot A social worker in Brazil counsels a mother and her child, who are both suffering from AIDS. During 1998, almost 6 million people worldwide became infected with HIV, including half a million children. Photo Panos Pictures/5. Sprague © The most effective HIV prevention programmes benefit from high-level political commitment and promote safe behaviour while providing care for those affected by HIV. They can succeed in slowing down - and eventually reversing - the epidemic. The consequences of failure are unthinkable. During 1998, almost six million people became infected with HIV, including over half a million children. And HIV again claimed as many lives as malaria. By the year 2000, nearly 40 million people worldwide are likely to be infected. Unless an inexpensive cure or treatment becomes available in the near future, most of those people- many of them parents and breadwin- ners- will die over the next decade. Very few of the children will live to see their fifth birthday. Although HIV prevention pro- grammes in some countries - Senegal, Switzerland, Thailand, Uganda and the United Republic of Tanzania for example- have been successful in reducing unsafe behav- iour and lowering the rate of infec- tion, the number of new infections worldwide continues to rise inex- orably. Over the next 24 hours alone from the time of your reading this, another 16 000 people will become infected. Why is the epidemic con- tinuing to spiral out of control? The problem is that in many countries, existing HIV prevention programmes are either weak or limited in scope. Many are under- resourced and operate in a piecemeal, uncoordinated way. And most have focused exclusively on the need to change individual risk-taking behav- iour, thus turning a blind eye to the underlying social, cultural and eco- nomic forces which encourage un- safe behaviour in the first place and make it extremely difficult to change. To make matters worse, confidential counselling and HIV testing services, as well as care and support for people living with AIDS, are inadequate in most countries, offering little opportunity or motiva- tion for people to be tested. As a result, HIV remains invisible and continues to spread. Today, 90% of those with HIV- over 33 million people - do not even know they are infected. The role of poverty It is no coincidence that AIDS has disproportionately affected the poor and disadvantaged in developing countries, together with marginal- ized groups in the industrialized countries. Around 95% of people with HIV live in sub-Saharan Africa and the developing countries of Asia and Latin America. Poverty, dis- crimination, sexual inequality, the inadequacy of health or social ser- vices, rapid urbanization, a migrant labour force and inappropriate development projects are among the key factors that can increase vulner- ability to HIV. Poverty is the reason why young girls are sold into prostitution and why they may have little control over the use of condoms. Economic dependence and the desire to have children are among the reasons why many women continue to have unprotected sex with a husband or partner they know has other part- ners. If we are to contain this epidemic and cushion its impact we need to expand the response considerably- not by doing more of the same but by expanding the best, so as to ensure that HIV is not just on the health agenda but is firmly placed on the development agenda as well. 6 World Health • 51st Year, No. 6, November-December 1998 A shanty town in the Philippines . Poverty and inequality increase vulnerability to HIV /AIDS Photo Format Photographers Ltd © Distribution of condoms in Ghana . The most effective HIV programmes ore those that benefit from high-level political commitment. Photo Still Pictures/M. Edwords © The expanded response involves a two-pronged approach: reducing individual risk and lowering vulner- ability to HIV. First, there is a need to improve the quality, scope and coverage of existing efforts to prevent HIV and provide care and support for those infected. To achieve this, planners and health workers need to draw on the experience of those countries or communities which have succeeded in stabilizing or lowering infection rates, thus proving beyond doubt that prevention does work. Up till now, there has been little effort to share this expertise and adapt suc- cessful programmes ("best prac- tices") for use elsewhere. The most effective HIV preven- tion programmes have key features in common. They benefit from high-level political commitment and work on many levels at the same time, promoting safe behaviour and providing care and support for people affected by HIV. They offer a broad range of prevention mea- sures, including access to cheap and good quality condoms, confidential counselling and testing, prevention of mother-to-child transmission, and early treatment for other sexually transmitted diseases, which multiply the risk of infection with HIV. Other critical elements are long-term education and mass media cam- paigns to ensure broad public aware- ness about HIV- especially among young people in whom over half of all infections now occur. Finally, the communities affected and people living with HIV are actively in- volved in the planning and execution of AIDS programmes. Secondly, action must be taken to reduce people's vulnerability to HIV, through measures to bring about social, cultural and economic change. The aim is to create a more favourable environment in which people are able to take advantage of risk-reduction strategies. This will require coordinated action within every sector of government (not just the ministry of health) and within a broad range of other sectors as well - business, tourism, the armed forces, education, religious organi- zations, labour organizations, devel- opment agencies and the mass media. There is no "quick fix" for devel- opment issues that require social and economic reform. However, govern- ments can set shorter-term goals, for instance, providing incentives to enable girls to complete secondary school education. Or they can take steps to change laws and policies that criminalize or discriminate against specific populations such as sex workers and injecting drug users. In Thailand, for example, where prostitution remains illegal, the governrrlent's pragmatic approach to slowing down the epidemic has been exemplary. In response to a 1989 study showing that 44% of the sex workers in Chiang Mai were HIV- positive, the government launched an impressive multisectoral inter- vention. This involved working with brothel owners to urge 100% condom use in brothels, the launch of mass media campaigns to encour- age respect for women and discour- age men from visiting sex workers, and improved access to care for people living with AIDS. As a result, HIV prevalence has declined significantly- especially among young people. In Senegal, a rapid, broad-based response to the epidemic, supported by both Islamic and Christian lead- ers, has kept the rate of HIV infec- tion below 2%. Recent behavioural surveys indicate that over 60% of men and 40% of women aged 15-24 are now using condoms with casual partners. If governments can be helped to build on the success of countries like these, they will succeed in slowing down -and eventually reversing- the course of the epi- demic. The consequences of failure are unthinkable. • Or Peter Pial is Executive Director of the joint United Notions Programme on HIV /AIDS (UNA/OS}, 12 I I Geneva 27 Switzerland