Facing the reality of AIDS--a 15-year process?

Girls and boys who celebrate their 15th birthday this year have never known a world without AIDS. In 1986 WHO began work on a global strategy for dealing with the new pandemic, but this was not universally perceived as a sound public health policy commitment. Many saw it as a diversion of health resources from more urgent problems, such as high childhood mortality rates caused by preventable infections and malnutrition, unsafe water and sanitation, the need for new tools to combat tropical diseases, and ever-rising birth rates. These problems were high on the health agenda of developing countries, though unevenly acted on and often severely underfunded. The new era had begun almost invisibly, reflected in rising rates of HIV infection in young men and women and the steady increase of dying AIDS patients in crowded hospital wards. The emergence of HIV and AIDS was accompanied by extreme social stigma, fear, and a sense of powerlessness among care providers. The days in which public health seemed capable of solving all problems were coming to an end. There was no magic bullet, no treatment, and apparently no way to stop the spread of the new virus except by engaging in dubious efforts to change people’s behaviour. That meant talking about sexually transmitted infections, condoms and injecting drug use. It meant acknowledging the existence in all societies of practices and behaviours that were condemned by public opinion and often by the law as well. Slow progress was being made in promoting primary health care approaches, and structural adjustment in developing economies had shrunk health budgets, facilities and staff. Now the rise of HIV/AIDS required radical change in the public health agenda, a new and major long-term prevention and control effort, and resources that were simply not available. The global programme on AIDS was in operation by the beginning of 1987. Its aims were to reduce the spread of HIV, reduce the impact ofHIV/AIDS on societies and individuals, and exchange information on the pandemic and the fight against it. By 1990, most countries around the world had a national AIDS programme in place. These programmes were praised by some for their capacity to stimulate a national response and transfer funds to where they were most needed, and criticized by others for their insensitivity to local realities. They were aimed mostly at preventing HIV transmission, since what treatments there were for AIDS were found to be neither effective nor affordable. Thus, in developing countries, insufficient attention was given to equipping health systems to deliver even simple care. A burgeoning movement of nongovernmental organizations, with varying national and international support, shouldered a large part of this burden. The epidemic spread more quickly than the programmes designed to prevent it. By 1996, many projects had been successful on a small scale but had not been sufficiently amplified or replicated. A joint cosponsored United Nations programme on HIV/AIDS (UNAIDS) was started, to broaden the range of responses to the pandemic. Though AIDS was plainly a health problem of the first magnitude, it was also increasingly recognized as one that had its roots in social and economic injustice, discrimination and marginalization. Socioeconomic factors not only fostered the spread of infection but added to the severity of its impact on individuals, communities and nations. UNAIDS evolved the concept of an expanded response to HIV and AIDS, though still with amajor focus on prevention. In the year that this new programme started, the efficacy of a new cocktail of drugs was demonstrated. This presented a compelling opportunity to recast the perception of AIDS. It could now be seen as a treatable — though not curable — disease. An expanded response could include enhancing prevention with care, support and impact mitigation. A deep gap had been growing for several years between those committed to broadening the public health response to the epidemic through preventive measures, and those in the research community who were committed to finding new biomedical tools based on increasingly complex technologies. When treatment became a valid option, at least for those who could afford it, these two worlds began to reunite. Calls for more attention and resources for AIDS turned into an uproar. Protests targeted those thought to hold the keys to the drug chests. New advocates came forward and began to speak out loudly through manifestos and newspaper articles. Projected costs for a meaningful response to the pandemic rose swiftly from millions of dollars to billions. The year 2001 witnessed an unprecedented mobilization of minds culminating in political recognition of the magnitude of the effort needed to halt an epidemic that had been spinning out of control for many years. A Special Session of the UN General Assembly (UNGASS), in June 2001, drew worldwide attention to the need and how to meet it. First and foremost, prevention efforts had been shown to work, particularly when affected communities were actively involved in the design and implementation of programmes intended for them. Second, prevention and care were interdependent and mutually reinforcing. Third, exclusion, discrimination and other forms of infringement of human rights were obstacles to effective prevention and care. And fourth, it was time for an unprecedented global effort to scale up the resources for AIDS control and accelerate research on simpler, less costly treatment regimens and vaccines. This issue of the Bulletin brings together evidence that can inform the renewal of the world’s response to AIDS. It maps out interventions that have been effectively applied to prevention, care and treatment and that now need to be considerably expanded. The UNGASS resolution was a call to arms. Here are some of the arms. They are not magic, or immediately universally affordable and accessible, but they are well tested through solid public health work inspired by individuals who deeply care about HIV/AIDS. Investing in them will have incommensurable long-term benefits. 2001 will be remembered not only as a year of global crisis but as the time when the stage was set for translating political commitment to HIV and AIDS control into determined action. n 1 Senior Policy Adviser to the Director-General and Director, Vaccines and Biologicals, World Health Organization, 1211 Geneva 27, Switzerland (email: [email protected]).