By Alan Whiteside
The biennial International AIDS Conference was held in Washington D.C. in July of 2012. This was the first time that the conference had been on US soil for 20 years. The International AIDS Society had previously decided that while legislation prevented HIV positive people from travelling to the States, the conference would not be held there. However, these laws were repealed by the Obama administration in 2010. The meeting was huge: 25000 people. Speaking at the conference, I identified three key issues: the location of the epidemic; the changing response; and availability of resources, including financial support.
The location of the epidemic
The highest HIV prevalence levels are in eastern and Southern Africa. For example, in South Africa an estimated 5.6 million people are infected, and in Swaziland 54% of women in the 35- 39 age cohort are living with HIV. In the rest of the world, and especially in Arabic speaking countries, the disease is primarily located in the ‘most at risk populations’ which includes groups such as drug users, men who have sex with men, and commercial sex workers.
Over recent years it has become abundantly clear that HIV is unlikely to spread in general populations. This creates particular challenges for the response in Arabic speaking countries (and in parts of Eastern Europe). All major Islamic sects prohibit homosexuality; it is a crime under Sharia law. Drug use is illegal and the penalties are usually draconian. Commercial sex is frowned upon – although Senegal’s pragmatic approach in the 1980s and 1990s contributed to stopping HIV spread there. Adultery (by definition, sex outside marriage) and premarital sex are forbidden and subject to punishment although we note it is almost always the women who are punished. This combination of circumstances makes responding to HIV difficult for UNAIDS, other international agencies, Ministries of Health, and NGOs. It is fortunate that the epidemics are small.
A changing response
In Washington this summer, it was apparent that response has been medicalised. Biomedical science ruled and there was little discussion of behaviour change. The mantra was: if everyone who is infected is put on treatment this will greatly reduce transmission sufficiently to halt the epidemic. While the science is clear — there is a 96% reduction in HIV acquisition from people on treatment to their partners — the black box is getting enough people on the drugs to alter the course of the epidemic. When the target population is marginalized or engaged in illegal activities this becomes even more problematic.
The availability of resources
Funding was and will remain a hot topic. Between 2008 and 2011 resources for HIV and AIDS plateaued. In Washington we learnt global spending in 2011 was US$16.8 billion, an 11% increase over 2010. International spending has flat lined. The main source of additional funding is domestic: national governments responding to needs in their countries. However there is a large funding gap especially in the poorer African countries. UNAIDS estimates in 2015 the requirement for a comprehensive response will be $24 billion of which, on current projections, only $17 billion will be available. At the meeting Bernhard Schwartlander of UNAIDS noted: “The lives of more than 80% of the people, who receive AIDS treatment in Africa, depend every morning on whether or not a donor writes another check.”
The central theme of the conference was moving to ‘an AIDS free generation’. This means everyone who needs it is on treatment (thus people living with AIDS but not dying from the disease) and there are zero new infections. Small epidemics and reasonable wealth means most Arabic speaking countries have the capacity to put people on treatment. However as Mead Over of the Centre for Global Development has consistently pointed out there has to be an AIDS transition where the number of new infections falls below the number of AIDS deaths. Until this happens the number of people living with HIV and AIDS will increase. Globally we are not at this tipping point yet. The key challenge for Arabic speaking countries is to care for infected people; ensure the right sorts of prevention, targeted at the right people are put in place; and perhaps to understand their role in the global community, in some case this may be in providing development assistance.
Alan Whiteside is Director and Professor of Health Economics and HIV/AIDS Research Division (HEARD) which he established in 1998, at the University of KwaZulu-Natal, Durban, South Africa. He has been researching HIV/AIDS since 1987. He is the author of HIV/AIDS: A Very Short Introduction.
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Image credit: Globe with World AIDS Day red ribbon. Illustration by JuSun, iStockphoto.