Spotlight
A World Transformed: Lessons from HIV/AIDS
June 08, 2011
This week marks the 30th year of living in a world transformed by awareness of AIDS - and of understanding that the devastating pandemic actually began decades earlier.
This 30-year marker recognizes that on 5 June 1981, CDC published a report describing puzzling pneumonias in five previously healthy young homosexual men in Los Angeles. By July 1982, the disease that left individuals defenseless against opportunistic infections had gained a name - acquired immune deficiency syndrome, or AIDS - and doctors had diagnosed more than 400 cases in the US.
In those early days, diagnosis evoked a near-certain death sentence compounded by stigma and discrimination. Most of the US cases occurred among specific high-risk groups: men who have sex with men, commercial sex workers, injecting drug users, recipients of blood products. In the next decade, these risk factors would also drive epidemics in parts of Asia and the Caribbean.
The tragedy of HIV/AIDS in sub-Saharan Africa began long before AIDS had a name. Evidence suggests that HIV crossed from chimpanzees into humans in west-central Africa around 1930 or even earlier, coinciding with a period of forced labor mobility in the interior rainforest. Scientists speculate that humans contracted the virus during the slaughter of chimps for "bush meat." HIV could go undetected for so long because years often intervene between transmission and debilitating symptoms, and because the disease was spreading among impoverished people with exposures to many other infectious diseases and uneven access to essential health services. Infection rates most likely surged when highly mobile workers forged sexual networks that linked affected groups to dynamic urban communities.
In the 1970s, doctors in Zaire, Uganda, Tanzania, Rwanda, and Zambia independently noted increases in AIDS-related illnesses. No one compared those notes until the 1980s, when the AIDS crisis escalated in the "First World."
By the mid-1980s, generalized epidemics had exploded in East and Southern Africa, as HIV spread through heterosexual transmission. Adult prevalence rates in the most heavily affected countries climbed as high as 25 percent. The toll on working-age adults ravaged households and institutions in nations already facing steep climbs toward economic and political stability.
In a world sensitized by 30 years of living with awareness of HIV/AIDS, what lessons have been learned to bring the pandemic to a close, and to prevent the next HIV?
Gains and gaps. In the win column, researchers learned more about HIV, more quickly, than any other virus in history - once it was detected. Anti-retroviral therapies now make HIV manageable for years and slash the risk of transmitting the virus to a sexual partner or during pregnancy and childbirth. More people worldwide gained access to these drugs in 2010 than ever before, and the rate of new infections has declined steadily since 2001.
An unprecedented commitment of public and private sector resources made this possible. UNAIDS estimated that donor governments, multilateral organizations, the private sector, and domestic sources made $15.9 billion available to address HIV/AIDS in low-and middle-income countries in 2009, a 10-fold increase over 2001 levels.
Despite these remarkable gains, 9 million people who met treatment criteria lacked access to antiretroviral therapies at the end of 2010, and 7,000 new infections still occur every day. In many cases, socio-cultural biases stand in the way of implementing cost-effective interventions - or even sharing accurate information about the risks of sexual transmission and drug use. The worldwide economic recession is cutting into the resources that nations and donors can bring to health initiatives. Despite a well-earned sense of optimism, it's too early to break out the champagne.
Could it happen again? The conditions that gave rise to HIV in the first place -catapulting global health issues to the top of development and security agendas - remain unchanged. Researchers described an average of one emerging or re-emerging infection of public health significance each year between 1973 and 2003, primarily of animal or zoonotic origin.
This is because changing land use and new behaviors disrupt ecosystems, leading to new interactions among people, domesticated animals, wildlife, and insects. Human populations can be exposed to new health threats directly or when a domestic animal or disease vector acts as a bridge between species. As HIV/AIDS and other diseases have taught us, once a disease has crossed into humans, urbanization and population mobility act as "disease multipliers."
The HIV/AIDS catastrophe and the SARS crisis almost 20 years later, although very different in scope, helped jointly set new expectations for global health actions. As the HIV/AIDS epidemic gave rise to a new health assistance paradigm, the 2003 SARS crisis created the political momentum for an entirely new approach to international cooperation on disease detection and response. The revised International Health Regulations (IHR) adopted by the World Health Assembly in 2005 require all 194 state parties to develop core capacities to detect, report, and respond promptly to public health emergencies of international concern by 2012. If successful, these investments and agreements promise to strengthen the weakest links in global public health surveillance and response.
Most of the countries that carry the heaviest burden of AIDS are also least equipped to detect the next emerging infection. Finding the resources to change this dynamic will not be easy. About half of development assistance for health currently targets the "big three" diseases: HIV, malaria and tuberculosis. Only a fraction is specifically allocated for building basic health infrastructure, education and training, and other essential elements of strong and adaptable health systems. The US and other major donors have committed to more integrated approaches to global health, strategies that would make sure that HIV/AIDS funds strengthen health systems sustainably rather than reinforcing operational silos, but advocates and political leaders do not automatically rally around the cry "capacity building now!" Gaps in disease detection and response capabilities, like the ones that existed in sub-Saharan Africa when HIV first jumped into humans, will not close anytime soon.
This year does not mark the 30th anniversary of AIDS, but the 30th year of acknowledging that we missed this disease for at least half a century. An earlier response might have spared millions of lives, billions of dollars, and a security and development crisis that continues to engulf Southern Africa. On this grim anniversary, it would be wise for us to focus our resources on strengthening the systems that will equip us better next time - because chances are, there will be a next time.
Photo Credit: Cynthia Goldsmith, Centers for Disease Control and Prevention (PHIL ID # 10000)