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The Changing Face of the AIDS Epidemic

By Alan Whiteside

More than thirty years ago the first cases of AIDS were appearing in hospitals across United States, Europe and in Central Africa.  The first published reports of this unusual disease appeared in 1981.  It took a further two years before the cause, a retrovirus named the Human Immunodeficiency Virus, was identified.

The initial media responses to this sexually transmitted disease were hysterical with reports of police demanding protective clothing, funeral directors unwilling to bury the dead, and fears that AIDS would spread rapidly through entire populations laying waste to humankind.

It soon became apparent that HIV was difficult to transmit requiring direct contact with blood or body fluids. By 2000 the shape of the epidemic was clear.  In most of the wealthy world it is primarily a disease of marginalized populations with specific patterns of behaviour that put them at risk. These include injecting drugs users and men who have sex with men without using protection.  Across much of Latin America and Asia it is a limited disease affecting largely specific groups.

But there are areas where AIDS is a serious and growing problem.  In Russia, Ukraine and some of the other former Soviet countries HIV transmission through injecting drug users is affecting significant proportions of young men and is spreading quickly.  They in turn pass the disease on to their partners, who may then transmit it to their children.  While the absolute numbers are not high, the proportionate impact will be significant.

In Africa AIDS is again different.  There are some African countries, mainly in the west and north, with few infections. In other areas, HIV prevalence is in the order five to eight percent of adults and has consistently remained at this level.  The real problem lies in the hyper-endemic countries of Southern Africa.  Here prevalence levels among adults are above 15%. In Swaziland about 40% of ante-natal clinic attenders are infected and HIV prevalence among women aged between 25 and 29 has reached the astounding figure of 49 percent.

There are three major challenges.  The first challenge is to prevent HIV from being transmitted; if we succeed in this then the second two challenges become largely irrelevant.  Where we fail in prevention we have the challenge of treating people who have the misfortune to be infected and who fall ill.  Antiretroviral therapy is available, can buy years of life, but it is not a cure and it is expensive. There are issues of sustainability and affordability in provision of drugs which need to be addressed. The third challenge is dealing with the consequences of the disease especially among orphaned children.

The key stakeholders in the AIDS community, from civil society through to researchers and governing bodies, continue to work to address these challenges. HIV/AIDS has become a highly politicized epidemic. Responses are constrained by the political agenda of the day, and we are seeing both fatigue and changing global priorities.

This epidemic was described in my Very Short Introduction to HIV/AIDS, published by Oxford University Press in 2008.  In the conclusion I discussed the imperatives for prevention. At the time I thought we needed new ideas. I am now convinced of it. Medical male circumcision is being carried out and provides protection – but only for men. In the last few months there has been good news on microbicides – a gel that a woman can insert into the vagina prior to sexual intercourse. A trial has found one that is safe and that will reduce the chances of infection, but there are many more steps before it will be made available to the general female population.

Recently, with Justin Parkhurst from the London School of Hygiene and Tropical Medicine we developed and published just such a new idea.  A month of “safe sex/no sex”.  We postulated that such a programme, if carried out on a population basis, would have the effect of halting the epidemic in its tracks.  The reasoning is based on our understandings of infectiousness and viral load. People living with HIV are most infectious—that is, they have the highest viral load—within the first few weeks of infection.  A holiday from transmission would have the effect of reducing their viral load and potentially having a dramatic effect on incidence of new infections. This idea caused hot debate and was readily picked up by the media.  It was hardly surprising that the caption was “scientists call for no sex month”, as this was the sensationalist headline-grabbing message that would sell papers. We accepted this sensationalized spin as sometimes necessary for opening spaces for dialogue and debate about innovate ways of addressing HIV/AIDS.

What is clear is we have to find innovative ways of addressing the epidemic now. Science will take time to deliver and structural responses are complicated and long term.  We simply cannot continue with the appalling incidence rates we are seeing across Southern Africa.  We need innovation.  We need new ideas.  This is one such idea.  Would it work?  I don’t know but I do know that it is worth modeling at the very least. As we watch the epidemic spread in my region we are willing to try almost anything.

Alan Whiteside is the Founder and Executive Director of HEARD and the author of HIV/AIDS: A Very Short Introduction. He started and edited the newsletter AIDS Analysis Africa, was appointed by Secretary General Kofi Annan as one of the Commissioners on the Commission for HIV/AIDS and Governance in Africa, and is an elected Member of the Governing Council of the International AIDS Society. He lives in South Africa.

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