HIV/AIDS

World AIDS Day

William D Bowtell

HIV will only be defeated when behavioural means of prevention become the basis of the global response

or nearly three decades, the quickly became virtually universal. world has struggled to man- From the late 1990s, deaths from F age the vast human, social, AIDS declined and HIV became a economic and political impact of more manageable chronic condi- the emergence of HIV/AIDS. tion. This in turn led to an abatement of The history of the global HIV/AIDS pandemic the worst excesses of fear-mongering and a is broadlyThe Medicaldivisible Journal into two phases — before perceptible decline in HIV-related stigma and and afterof Australia the introduction, ISSN: in 1996, of effec- discrimination. tive antiretroviral0025-729X therapy 6/20 (ART). The international response to HIV/AIDS TheDecember first phase 2010 of the193 pandemic — from was galvanised by two highly significant the earliest11/12 653-654 reported cases of HIV/AIDS in developments. New York©The inMedical October Journal 1982 until treatments Firstly, in 1996, the United Nations (UN) becameof availableAustralia in 2010 1996 — constituted established UNAIDS, a specialised UN agency nothingwww.mja.com.au less than a public-health catastrophe. set up to provide strategic direction and to In manyHIV/Aids countries, notably the United States develop and oversee a coordinated international and South Africa, political leaders responded to response to HIV/AIDS. the appearance of HIV/AIDS with a toxic combination Secondly, in 2002, the G8 countries (United King- of ignorance, prejudice and political cynicism dom, US, France, Germany, Italy, Japan, Canada and directed at those in whom the disease had first Russia) established the Global Fund to Fight AIDS, appeared in industrialised countries — gay men, and Malaria. The Global Fund was sex workers and injecting drug users. charged with funding and supporting the large-scale Only a few countries, including Australia, moved distribution of ART in developing countries, espe- decisively during the 1980s to control HIV/AIDS cially African countries, which have been most griev- and to prevent its spread into the general commu- ously affected by the uncontrolled spread of HIV/AIDS. nity. These pragmatic prevention strategies were based These two institutions — one handling on rapidly accumulating evidence that strategy and politics and the other raising simple changes in sexual and needle- and disbursing money — have brought sharing behaviour among young about tremendous improvement in the people, complemented by access to international management of HIV/ and clean needles, dramati- AIDS. cally reduced HIV transmission rates. Since 2002, the Global Fund has By the mid to late 1990s, there was clear evidence from sourced nearly US$20 billion from public and private donors,5 of published studies that such strategies were effective in containing which about US$10 billion has been applied to the subsidised new HIV infection rates,1,2 and their success in Australia and a distribution of HIV/AIDS treatment, care and prevention services small number of other countries was undeniable. in some 140 poor and developing countries. The Global Fund is Yet almost none of these strategies were implemented on a now the major international financer of programs to eradicate sufficiently large scale or in time to reduce the impact of HIV/ mother-to-child transmission of HIV and to support harm reduc- AIDS in regions and countries then largely unaffected by the tion among injecting drug users. At the end of December 2009, problem. To put it mildly, an epic failure of leadership and programs financed directly by the Global Fund were providing political will to accept and act on scientific evidence turned a ART to 2.5 million people.6 potentially containable problem into a pandemic that, by the late Together with ART distribution financed by the US under the 1990s, was beyond control. President’s Emergency Plan for AIDS Relief, more than four million Nature created HIV, but anti-prevention politicians and their people in low- and middle-income countries now have access to associates created the HIV pandemic.3 ART, representing about 40% of those in urgent need. The human consequences of the HIV pandemic, and the failure Sensible HIV strategies backed with large funding have begun to to contain the problem in the mid 1980s, are shocking. Since stabilise the spread of HIV/AIDS in most high-burden African 1982, HIV has infected 60 million people, and there have been countries. In Ethiopia’s capital, Addis Ababa, for example, the 25 million deaths from AIDS caused by HIV infection.4 rollout of ART has led to a decline of about 50% in adult AIDS The second, and much more encouraging and enlightened, deaths over a period of 5 years.6 phase of the HIV pandemic dates from 1996, with the develop- As the number of global deaths from AIDS has fallen, the ment and introduction of highly effective ART. In almost all number of those living with HIV has increased. There are now industrialised countries, access to this lifesaving treatment some 33.4 million people living with HIV infection.4 But, despite

MJA • Volume 193 Number 11/12 • 6/20 December 2010 653 HIV/AIDS these advances, each year about 2.7 million people acquire HIV ment assistance budgets, not to mention expenditure on arma- and about two million people die from AIDS, mostly within the ments and weapons, while the benefits are abundantly obvious. developing world.4 The third phase of the global response to HIV/AIDS must be Other regions have not responded as well as Africa. dominated by a renewed commitment to behavioural prevention In Eastern Europe and Central Asia,* many national govern- as the surest and most sustainable way to contain the pandemic. ments reject the lessons of how the spread of HIV can be contained We can contain HIV by improving access to treatments and through education and behavioural change. They oppose the providing care to people with the disease. But HIV will only be widespread availability of condoms and the introduction of needle defeated and eradicated when the lessons of behavioural preven- and syringe programs for those at highest risk of HIV infection. tion that we developed and applied in Australia two decades ago Consequently, rates of HIV infection in these countries are increas- become the basis of the global response. ing at an alarming rate. In Eastern Europe and Central Asia, an estimated 110000 people were newly infected with HIV in 2008, * Eastern Europe and Central Asia is one of the 10 regions defined and used bringing the number of people living with HIV in the region to 1.5 by UNAIDS. The region includes Armenia, Azerbaijan, Belarus, Bosnia and Herzegovina, Bulgaria, Croatia, Estonia, Georgia, Kazakhstan, Kyrgyzstan, million, compared with 900 000 in 2001 — a 67% increase over Latvia, Lithuania, the Republic of Moldova, Romania, the Russian Federation, 7 this period. Ukraine and the Russian Federation are experiencing Tajikistan, Turkmenistan, Ukraine and Uzbekistan. especially severe and growing national epidemics. With an HIV prevalence of over 1.6% in adults, Ukraine has the highest infection level reported in all of Europe.4 Author details So, as we mark the recent occasion of World AIDS Day 2010, the William D Bowtell, BA(Hons), Director HIV/AIDS Project best that can be said about the state of the global fight against HIV/ Lowy Institute for International Policy, Sydney, NSW. AIDS is that our successes have been relative. Correspondence: [email protected] The world supported care and treatment for people with HIV/ AIDS when effective therapies became available. During the boom References conditions of the 1990s, it was relatively easy for the largest donors to put real financial resources behind the distribution of ART that 1 Lurie P, Reingold AL, Bowser B, et al. The impact of needle exchange programs in the United States and abroad. San Francisco: saved millions of lives in the poorest countries. University of California, 1993. But economic times have changed. In October 2010, the Global 2 Van Ameijden EJ, Watters JK, van den Hoek JA, Coutinho RA. Interven- Fund went to donors seeking some US$20 billion for the period tions among injecting drug users: do they work? AIDS 1995; 9 Suppl A: 2011–13 so that the most urgent unmet need for ART in the S75-S84. developing world could be met.8 But, instead of US$20 billion, 3 Shilts R. And the band played on: politics, people, and the AIDS donors provided only US$11.7 billion. (Australia was one of the epidemic. New York: St Martin’s Press, 1988. 4 UNAIDS Joint United Nations Programme on HIV/AIDS. Annual report few countries that increased its support for the Global Fund.) 2009: uniting the world against AIDS. Geneva: UNAIDS, 2010. http:// In summary, the first phase of the HIV/AIDS pandemic was data.unaids.org/pub/Report/2010/2009_annual_report_en.pdf (accessed chaotic and lamentable. The second phase was encouraging and Nov 2010). hopeful. 5 The Global Fund 2010: innovation and impact. Geneva: The Global Fund, We are now entering the third phase of the response. At a critical 2010. http://www.theglobalfund.org/documents/replenishment/2010/ moment, transient economic difficulties in the donor countries Global_Fund_2010_Innovation_and_Impact_en.pdf (accessed Nov 2010). threaten to jeopardise the great progress that has been made since 6 The Global Fund. By 2015 we can. Geneva: The Global Fund, 2010. http:// the late 1990s. It would be appallingly callous and retrograde to www.theglobalfund.org/documents/replenishment/2010/Global_Fund_ take HIV treatments away from those whose lives have been saved Achieving_by_2015_en.pdf (accessed Nov 2010). thanks to the efforts of donors working through the Global Fund. 7 UNAIDS/World Health Organization. 2009 AIDS epidemic update. We must not falter in our determination to provide universal Geneva: UNAIDS/WHO, 2009: 48-52. http://data.unaids.org/pub/ Report/2009/JC1700_Epi_Update_2009_en.pdf (accessed Nov 2010). access to care and treatment to all who still require it. 8 The Global Fund. Donors commit US$11.7 billion to The Global Fund for The costs of ensuring universal access to ART by 2015 are, in the next three years [press release]. 5 Oct 2010. http://www.theglobal- scheme of things, trivial compared with overall global develop- fund.org/en/pressreleases/?pr=pr_101005c (accessed Nov 2010). ❏

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