Chapter 4
A Global Epidemic

Though HAART has been successful in treating HIV infection, in reality, this therapy is available mainly to people in wealthier nations such as the United States and those in western Europe. In other places, such as Africa and Asia, where the epidemic is growing at an alarming rate, people simply cannot afford expensive HAART drugs, even at the reduced prices now being offered. Education and prevention efforts, which have slowed the spread of HIV in some parts of the world, have also been a challenge to implement in the developing world where cultural barriers, paired with the lack of access to educational materials, often thwart prevention efforts.

Bleak Prospects

According to a 2003 Joint United Nations Program on HIV/AIDS (UNAIDS) estimate, there are over 40 million people worldwide living with HIV or AIDS. Over 28 million of these cases are found in sub-Saharan Africa alone. In fact, all the HIV and AIDS cases in North America, Europe, and Central Asia combined account for fewer than 10 percent of the global total.

In places such as the United States and the nations of western Europe, the spread of HIV has often been reduced through public safety efforts and public education campaigns. For example, the blood supply in the United States is screened for HIV. This has reduced the rate of HIV transmission from blood transfusions to almost zero. Similarly, other preventive measures have curbed infection rates. As Americans were informed that the use of condoms during sexual activity reduced the risk of HIV transmission, a great majority of the population took the advice seriously. Likewise, public policy initiatives such as needle exchange programs helped reduce the spread of HIV among intravenous drug users.

The problem, however, is that all too often in the developing world, similar measures are not used. Sex education in any form is rare in many parts of the developing world. Consequently, a great number of people there lack even a basic understanding of how HIV is spread. Misconceptions arise and proliferate, often with devastating results. For example, when some prostitutes in Kenya learned that, in Africa, HIV was transmitted mainly through heterosexual contact, they began to offer their clients unprotected anal intercourse, since they considered this to be homosexual contact and thus safe. In reality, anal sex is even more likely to result in HIV transmission, so the virus spread even more easily. Other unsafe practices, including needle sharing, are similarly unrecognized and therefore uncurbed in much of the developing world. As a result, HIV infection due to intravenous drug use is increasing in many parts of the world.

The African Epidemic

Among the regions hardest hit by AIDS is Africa. Seven African countries now report that 20 percent or more of their citizens are infected with HIV. In South Africa, experts estimate one in five adults is infected, while in Botswana and Zimbabwe the estimates are one in three and one in four, respectively. One of the reasons that sub-Saharan Africa is so devastated by HIV is that the public health systems in these countries are ill-equipped to treat any kind of epidemic, least of all one that produces so many victims requiring expensive and complicated long-term care. As a consequence, average annual health care spending per person in Africa is estimated by the World Bank to be thirty-four dollars, as compared to the twenty-five-hundred-dollar average spent in developed countries such as the United States. Given the lack of funds, it is highly unlikely that African countries can buy and distribute the HAART drugs necessary to prolong the lives of their HIV-infected population, even at the reduced prices that many pharmaceutical companies have promised.

Contributing to the AIDS crisis in Africa is a tendency among many African leaders to ignore the epidemic. Not a single African head of state or government attended the 11th International Conference on AIDS in Zambia in 1999. Even the president of Zambia, Frederick Chiluba, who officially hosted the event, failed to show up. This inattention came in spite of the fact that the same year, 1999, marked the first time that President Daniel Arap Moi of Kenya and President Robert Mugabe of Zimbabwe used the word disaster to describe the AIDS epidemic.

An initial failure to grasp some basic facts about AIDS exacerbated the problems in Africa. For example, South African president Thabo Mbeki for many years publicly questioned the link between HIV and AIDS and opposed efforts to develop a national plan to provide antiretroviral drugs to South Africans. It was not until 2003 that former American president Bill Clinton and others convinced Mbeki to change his position and support anti-HIV drug programs.

Partly as a consequence of their leaders being misinformed or in denial, the average person in Africa, especially in rural areas, does not know basic facts about HIV and AIDS; even many of those dying of AIDS do not understand what is killing them. The tragedy goes beyond the individuals struck down by AIDS: Because the epidemic has become so widespread, over 10 million African children have been orphaned by AIDS. Experts estimate this number could reach 30 million by 2010. Many of these orphans are themselves infected with HIV, and, left to fend for themselves, many face a bleak future.

HIV in Asia

As compared to Africa, statistics seem to suggest that Asia has yet to feel the full effects of the AIDS epidemic. After all, only Cambodia, Thailand, and Myanmar have infection rates above 1 percent, and India boasts an infection rate of 0.7 percent. These statistics, however, are only part of the story. Given the large populations in Asian countries, even the low percentages translate into huge numbers of HIV-infected individuals. There are now an estimated 7 million people in Asia living with HIV.

Experts find the trend in HIV incidence in Asia at least as troubling as the actual numbers. As Dr. Peter Piot, executive director of UNAIDS, warned, "The epidemic in Asia threatens to become the largest in the world.… With more than half the world's population, the region must treat AIDS as an issue of regional urgency. The question is no longer whether Asia will have a major epidemic, but rather how massive it will be."³³ Though the Asian population at large remains relatively free of HIV, a large percentage of intravenous drug users and sex workers are now infected with the virus. In some areas, the HIV incidence in these groups is at least 20 percent and can be as high as a staggering 80 percent. Such high rates of infection mean that serious HIV outbreaks could happen at any time. According to UNAIDS, "Injecting drug use and sex work are so pervasive in some areas that even countries with currently low infection levels could see epidemics surge suddenly."³⁴

As in Africa, most Asian countries have not adequately educated their citizens about HIV and AIDS. Although sexual intercourse is the major means of HIV transmission in Asia, many people do not know to take basic precautions such as using condoms during intercourse to prevent the spread of HIV. However, in the countries that have taken measures to educate the public, there has been notable success. In Thailand and Cambodia, where large government-sponsored programs to promote the use of condoms are in effect, HIV incidence is actually on the decline.

Potential Problem Areas

Though Africa is by far the region hardest hit by HIV, and Asia is considered by experts to be where the next massive AIDS outbreak will strike, there are many other regions of the world at risk from HIV. As is the case with Asia, there is an overall low rate of HIV infection in Latin America, but experts feel that an epidemic may explode at any time. A 2003 study reported that though HIV is still concentrated in high-risk populations, such as prisoners, intravenous drug users, commercial sex workers, and homosexual men, the virus is slowly spreading to the general population. In some places such as Honduras and southeastern Brazil, HIV is already present in the population at large.

The countries of the Caribbean do not account for a large number of worldwide HIV infections, but as a percentage of the population, HIV now infects over 2 percent of the adults in the region. Certain countries are far more beleaguered by the disease; Haiti, for example, reports HIV incidence levels of 5 percent to 6 percent. In general, the virus is poised to spread to the larger Caribbean population if effective prevention programs are not put into place.

In many of these areas where HIV is becoming increasingly problematic, social isolation and discrimination prevent adequate treatment or education. Homosexual men and commercial sex workers, for example, often are stigmatized and as a result tend to be overlooked by those offering HIV care or counseling. Developing nations face the dual challenge of overcoming social stigmas accompanying high-risk lifestyles as well as misconceptions surrounding HIV in order to keep the spread of the virus in check.

Women at Risk

Throughout the developing world, women are at the highest risk of contracting HIV. In part, this is due to social custom. Heterosexual contact is the primary mode of HIV transmission in these areas, and in what are often male-dominated cultures, women are often ignored if they demand that their partners use condoms during intercourse. In addition, some of the most reliable preventive measures can stigmatize those who use them. According to Karungari Kiragu of Johns Hopkins University, "If women demand condoms to be used, [it] means they must have been running around."³⁵

The higher risk for women is especially pronounced in Africa. According to UNAIDS, African women are 1.2 times more likely to be infected with HIV than men; among women age fifteen to twenty-four, the ratio increases to 2.5 times more likely to be infected with HIV. Cultural traditions such as wife inheritance, whereby a brother-in-law marries his brother's widow, also place women at greater risk. Said Kiragu, "The problem is, if the new husband has HIV, the woman may not know and may not have a choice [to refrain from sexual activity] anyway."³⁶

Another reason that women are particularly at risk is that it is much easier to transmit the virus from a man to a woman than the other way around. The sensitive tissues of the vagina and cervix can easily be bruised and torn during intercourse; these small cuts and abrasions make it easier for HIV to enter the body. On the other hand, penile tissue does not sustain the same amount of damage and therefore does not as often present open cuts through which the virus can enter.

Even in areas where some types of HIV transmission have been stemmed, women remain at risk. For example, through well-funded and politically supported prevention programs, Thailand reduced the number of new HIV infections from 143,000 in 1991 to 29,000 in 2001. Women, however, are still disproportionately infected during heterosexual contact with their husbands, boyfriends, and, in the case of sex workers, clients. Many of these women are the partners of intravenous drug users who have contracted HIV through infected needles. Though this is a large problem, the Thai government has yet to prioritize prevention programs for drug users, and HIV continues to spread in the population of drug users and their sexual partners.

From Mother to Child

With the numbers of HIV-infected women on the rise, the problem of mother-to-child transmission (MTCT) of HIV is becoming more serious as well. In fact, MTCT is responsible for over 90 percent of the HIV infections in children under age fifteen.

HIV can be transmitted from an infected mother during pregnancy, during childbirth, or after birth through contaminated breast milk. The risk of transmission is approximately 15 percent to 30 percent, even if a mother does not breast-feed her infant. When infected mothers breast-feed, however, the risk of HIV transmission to their babies rises to 25 percent to 50 percent. Approximately six hundred thousand HIV-infected infants are born each year around the world, with over 90 percent of these infections taking place in sub-Saharan Africa.

There is hope, however, for curbing MTCT. In fact, through education, counseling, access to antiretroviral drugs, safe delivery practices, and the availability of breast-milk substitutes, MTCT has been virtually eliminated in the developed world. Taking antiretroviral drugs, including nevirapine and AZT, can reduce the risk for MTCT dramatically when administered during pregnancy, during labor, and soon after birth. In addition, the use of breast-milk substitutes eliminates the risk of MTCT through breast milk. Unfortunately for the women at greatest risk, that is, women in the developing world, drugs are not always available, and often the women do not even know to seek treatment. In addition, many of them do not have access to clean water for mixing infants' formula, thus limiting their ability to avoid breast-feeding.

A number of groups, including the United Nations Inter-Agency Task Team on MTCT and several private foundations, have put programs into place to reduce MTCT. These programs currently include pilot projects in Botswana, Brazil, Burundi, Cambodia, Côte d'Ivoire, Honduras, Kenya, Rwanda, Thailand, Uganda, the United Republic of Tanzania, Zambia, and Zimbabwe. Along with counseling and education, drugs such as nevirapine are now being offered free of charge to developing countries. This is vital to the effort to stop the spread of HIV and could potentially save the lives of three hundred thousand children each year. Still, the most effective way to prevent MTCT remains to protect women from HIV infection in the first place.

Headway

In light of the wealth of new information about HIV's incidence and treatment, many developing countries have stepped up their efforts to address the AIDS crisis. India, for example, with at least 4 million reported cases of HIV infection, has instituted a number of national programs to stanch the spread of the disease. The National AIDS Control Organization (NACO) is actively upgrading the Indian blood-banking industry to prevent the spread of HIV through infected blood, as well as establishing countrywide HIV testing centers to give people an opportunity to learn their HIV status. NACO's goals also include the institution of public education programs about HIV and AIDS, aimed especially at young people and commercial sex workers, as well as financial assistance for HIV research within India.

The governments of South Africa and China, both of which spent years downplaying the risks of AIDS to their citizens, announced in 2003 that their governments would provide antiretroviral drugs to anyone who needed them. This represents a $680-million-a-year commitment by these countries to buy HIV drugs and to set up the health care infrastructure to administer them properly.

Help from Abroad

For the most part, however, since the countries that are most devastated by HIV are often also the poorest ones, government-funded national programs to combat HIV and AIDS can only go so far in dealing with the problem. Experts feel strongly that it will take a global approach with humanitarian efforts by wealthier nations and organizations to get a handle on the AIDS crisis.

To that end, a number of groups have endeavored to battle AIDS around the world. UNAIDS was founded in 1996 to pool resources from several agencies including the World Health Organization; the UN Children's Fund; the UN Development Program; the UN Educational, Scientific, and Cultural Organization; the UN Fund for Population; and the World Bank. The projected overall UNAIDS 2004–2005 budget exceeds $522 million, with more than $200 million pledged by the United States. Said Piot, "I feel strongly that this year, we really are entering a new phase of the global response.… There is a growing political momentum never seen for any public health problem, and indeed rarely for any international issue."³⁷ Even with this increased global response, unfortunately for the victims of HIV and AIDS, UNAIDS projects that it will need at least $10 billion annually to fight AIDS in the developing world.

Private foundations have joined in the battle against AIDS in an effort to reduce that gap between the money pledged by various nations and the money that is actually needed. The Bill and Melinda Gates Foundation, for example, has committed over $500 million to curtail the spread of HIV and to treat HIV-positive individuals around the world, including a 2003 pledge of $200 million over five years to India. The Clinton Foundation, established by former American president Bill Clinton, has arranged for antiretroviral drugs to be made available at low cost or no cost in developing countries. For example, thanks to the Clinton Foundation's intervention, four Indian drugmakers will begin producing these drugs for only $140 per patient annually. A similar plan has been put into place in Africa and in the Caribbean through the efforts of the Clinton Foundation.

The Cost of Health

With all antiretroviral drugs or other HIV treatments, cost is always a concern. At the current spending rates, billions of dollars annually will be necessary to treat the global AIDS crisis. In 2003 alone, an estimated $4.7 billion was spent by governments, global organizations, private foundations, and individuals on AIDS treatment and prevention. There is, however, no end in sight. Unless prevention and education programs soon become much more successful, the total cost of the AIDS crisis has the potential to become destructive to the economies of the nations hardest hit. Said Jose M. Gatell, cochair of the 14th International AIDS Conference, "Access to life-saving medicines is not a gift or a commodity but a basic human right, in fact one of the most basic human rights."³⁸ In light of this, scientists have realized that an HIV vaccine is essential to ensure that AIDS will no longer be a threat.