British Medical Bulletin 58:3-5 (2001)
© 2001 The British Council
Introduction
Executive Director, UNAIDS, Geneva, Switzerland
In June 2001, the world not only marked the twentieth anniversary of the first report of AIDS, but also held its highest level meeting ever on the subject: a special session of the United Nations General Assembly.
Twenty years of the epidemic have taught us that HIV is a formidable enemy both biologically and socio-politically. HIV is perhaps the most complex problem facing humanity today – without doubt it is the most devastating disease humankind has ever faced. A cumulative total of 60 million people have been infected, 22 million of whom have died.
Recent months have seen a new level of energy from scientific and policy communities in insisting that the world is ready to vastly increase the scale of the AIDS response as well as deal with its complexity.
The General Assembly Special Session on HIV/AIDS set new ground-rules for national accountability. Every member state of the United Nations signed on to a Declaration that commits them to a comprehensive AIDS response. The agreed Declaration of Commitment endorsed specific targets against which progress in responding to the epidemic can be measured – for example in relation to young people, where the goal is a 25% reduction in prevalence in the most affected countries by 2005 and 25% globally by 2010.
But even the full and immediate implementation of these commitments will not see the end of the epidemic. At best it will represent ‘the end of the beginning’.
In order to make significant progress in meeting any of the targets set by the General Assembly, there needs to be an order-of-magnitude boost in spending on the AIDS response in non-industrialised countries. The General Assembly joined other bodies such as the Organisation of African Unity and the G8 in declaring support for a new Global AIDS and Health Fund. By July, $1.4 billion had already been pledged to the Fund, which was called for by United Nations' Secretary General Kofi Annan only in April 2001.
The fund will be an important new source of resources, but it cannot be the only one. Continued intergovernmental assistance through bilateral channels, national budget allocations, funds liberated through further debt relief or cancellation, social insurance, and private sector efforts will all be needed.
The detailed calculations by UNAIDS and its collaborators on the resource needs of low-and middle-income countries show that by 2005, $9.2 billion ought to be spent on AIDS annually: $4.8 billion on prevention and $4.4 billion on care1.
This level of spending would provide 6 billion condoms, treatment for 22 million sexually transmitted infections, and voluntary counselling and testing for 9 million people. An additional 35 million women would receive testing at prenatal clinics and 900,000 would receive antiretrovirals to prevent mother-to-child transmission. Special prevention programs would reach almost 6 million sex workers, 28 million men who have sex with men and 3 million injecting drug users.
The past year has seen a convergence of science, economics and policy on the question of resources. Demanding billions for the response to AIDS in the non-industrialised world has moved from being a naïve plea to a political imperative.
At the same time, access to a wider range of HIV care has moved from the realm of the impossible to the possible. For many years, the price of drugs seemed to be an impassable barrier. But today, preferential prices for non-industrialised countries for AIDS drugs have been widely accepted within both the pharmaceutical industry and by policy makers, with benchmark prices for non-industrialised countries falling to 5% or less of those paid in wealthy countries.
A radically new context is emerging in which the prospects for major global advances in both HIV care and prevention have markedly improved. Progress depends on linking prevention and care, as both work best when they work together. Successful prevention and care build a common constituency for action.
In the North, where most people with HIV have been able to access the new combinations of HIV antiretrovirals, mortality dropped sharply in 1996 and 1997 and has since plateaued. Attention has been focused on the complex medical problem of adjusting drug combinations to stay one step ahead of a mutating drug-resistant virus, but meanwhile, progress on prevention fell behind.
In nearly every high-income country, the past few years have seen the epidemic move into poorer and more marginalised parts of the community. Indigenous, migrant and heterosexual populations are comprising a growing proportion of a more complex epidemic. Among gay men, once the champions of behaviour change, unsafe sex is on the rise – from London to San Francisco, Sydney to Vancouver – and rising HIV infections are the result.
Meanwhile, in the South, the slogan ‘prevention is the only cure’ began to sound morally bankrupt in the face of growing numbers of infections and the limited level of national and global resources available to address the epidemic. For as long as the South is denied access to the treatments that have transformed AIDS in wealthy countries, it is denied not only hope, but also any incentive for people to go for HIV testing.
Antiretrovirals are no magic bullet, and unless extending access is managed carefully their benefits in lives prolonged will last for only a few years. But there is a key opportunity for the South to gain the benefits of sustainably enhanced care while avoiding the divorce between prevention and care that threatens to undermine the response in the North.
AIDS is a large-scale humanitarian emergency, but it is a long-term emergency. We are only just beginning to realise that, globally, the epidemic is still in its early stages. The natural dynamic of AIDS is to show up first among the most exposed populations, but only after decades will the final shape of the epidemic become evident.
The thought that the AIDS epidemic is only beginning is a daunting one – but it ought also be a hopeful one. The fact is that the future course of the epidemic can be changed. Investment now will prevent tens of millions of new infections as well as extend the lives of millions already living with HIV. It also justifies according special priority to young people – changing behaviours and expectations early will result in a life-time of benefit both in HIV prevention and in helping to overcome HIV-related stigma.
For the first time in the history of this epidemic we have the opportunity to turn the tide on a truly large scale – the scale that matches the extent of the epidemic. We know what we need to do to slow new infections, and provide care for those who are ill. The only question, 20 years after that first report of the disease called AIDS, is whether we have the will to do it. History will be our judge.
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Footnotes |
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Correspondence to: Dr Peter Piot, Executive Director, UNAIDS, 20 avenue Appia, 1211 Geneva 27, Switzerland
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References |
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 Top References |
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- Schwartländer B, Stover J, Walker N et al. Resource needs for HIV/AIDS. Science 2001; 292: 2434–6
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