What they say about HIV/Aids, 25 years on

June 1, 2006

" 2005 was the least bad year in the history of the Aids epidemic "

Piot, Unaids

Report Shows AIDS Epidemic Slowdown in 2005

By LAWRENCE K. ALTMAN

Published: May 31, 2006

UNITED NATIONS, May 30 — New surveys suggest that the global AIDS

epidemic has begun to slow, with a decline in new H.I.V. infections in

about 10 countries, the leader of the United Nations AIDS program said

Tuesday.

Outside of those countries — which include Haiti, Cambodia, Kenya and

Zimbabwe — the number of new AIDS infections continues to rise or

hover at its current pace. Meanwhile, public health efforts are

reaching only a small proportion of people at risk, Dr. Piot,

the executive director of Unaids, said at a news conference here on

Tuesday.

" It's a very complex epidemic, " he said. " We can no longer talk about

AIDS " as a single epidemic, but as many diverse ones.

India, for example, is at about the same level as South Africa as the

country with the largest number of H.I.V. infections. India has 5.7

million infected people and South Africa 5.5 million, but India's

population is far greater. Showing no sign of decline, South Africa

has a prevalence rate of about 19 percent of 47 million people. In

India, the rate is less than 1 percent of its population of 1.1 billion.

The progress against AIDS in some regions represents dividends from a

surge in financing since 2001, when the United Nations pledged its

commitment to stem the epidemic by 2010. That declaration called for

countries to report regularly on their responses to AIDS. This week,

the General Assembly will review the progress that 126 countries have

said they have made.

The report, the most comprehensive survey ever compiled from country

data, pointed to the 2001 United Nations meeting as a turning point

for AIDS financing. In 2005, the United States and the rest of the

world spent $8.3 billion on AIDS, compared with $1.6 billion in 2001.

" We are seeing the impact, " Dr. Piot said. " It's about time. " He cited

increased condom use, a rise in the postponement of sexual intercourse

and a decrease in the number of sex partners as factors in the slowing

of the epidemic.

Summarizing the report's findings, Dr. Piot said that " 2005 was the

least bad year in the history of the AIDS epidemic, " first detected 25

years ago.

The most promising news, Dr. Piot said, is that the number of new

H.I.V. infections has dropped in three African countries — Kenya,

Zimbabwe and urban areas of Burkina Faso. Earlier, Uganda reported

decreases.

Dr. Piot said Cambodia and four states in India (Andhra Pradesh,

Karnataka, Maharashtra and Tamil Nadu) showed a drop in new

infections, joining Thailand's earlier success.

In the Caribbean, the world's second-most-affected region behind

Africa, new infections have declined in urban areas of Haiti and in

the Bahamas. AIDS is the region's leading cause of death in people

aged 15 to 44.

In Haiti, the percentage of pregnant women infected with H.I.V.

declined to 3.7 percent in 2003-2004 from 9.4 percent in 1993, Dr.

Piot said.

Despite the positive trends, Dr. Piot reported grim findings from

China, Indonesia, Papua New Guinea, Russia and Vietnam, with signs of

outbreaks in Bangladesh and Pakistan.

Ending the pandemic will depend largely on changing social norms like

empowering women, reducing the stigma of the disease and encouraging a

greater reduction in the number of sex partners, the report said. Most

countries have strong foundations for building an effective response

against AIDS, the report said, but systems to carry out the plans

remain inconsistent.

The thoroughness of the individual national reports varied, and many

countries did not provide data for all categories, so summarizing them

was difficult, Dr. Piot said in an interview. Still, the replies

identified significant weaknesses, he said:

¶Fewer than 50 percent of young people achieved comprehensive

knowledge levels about H.I.V., far fewer than the 90 percent goal.

¶Only 9 percent of gay men and fewer than 20 percent of intravenous

drug users received any kind of H.I.V. prevention help in 2005.

¶Services to prevent H.I.V. infections in infants have not scaled up

as rapidly as programs to provide antiretroviral therapy. Just 9

percent of pregnant women were covered.

The United States, Britain, Canada, France and Germany gave no

statistics on surveys about the percentage of young people who

correctly identify ways to prevent H.I.V.; who had sex with casual

partners in the last year; who had sex before 15; or who used condoms

during the most recent sexual intercourse with casual partners.

Thoraya Ahmed Obaid, the United Nations Population Fund executive

director, said the world needed to increase its prevention efforts.

The report shows that the epicenter of the epidemic remains in

sub-Saharan Africa. There the epidemic has reached a peak, but

incidence remains unacceptably high, Dr. Piot said. Across most of

Africa, H.I.V. prevalence among pregnant women attending clinics has

remained roughly level for several years.

The United Nations disputed contentions by some observers that the

leveling off showed a turning point in the AIDS epidemic in Africa.

" Available evidence does not offer grounds for such conclusions, " Dr.

Piot said, in part because " the actual number of people infected

continues to rise because of population growth. "

" (India) will need to improve its prevention efforts if it is to avoid

serious HIV outbreaks "

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" We are at a real turning point in the balance between optimism and

despair "

Feachem, Global Fund

Between hope and despair: why the fight against Aids is at a turning point

By Jack

Published: May 31 2006 03:00 | Last updated: May 31 2006 03:00

As leaders of nations corroded by Aids gather at the United Nations in

New York today to discuss the disease, another group will be

noticeably absent: leaders of the world's richest nations who pledged

them significant help five years ago.

The continued ambivalence - even as public health experts are

heralding the first tentative signs of a slowdown in the growth of

Aids since it was identified in 1981 - reflects both the enormity of

the task ahead and the political and ethical sensitivities that

underpin it.

To consign Aids to history will require not only a big injection of

cash over the long term. It will also demand a consensus on how best

to distribute resources between prevention, diagÃ‚Ânosis and

treatment - and a new boldness in tackling the issues that debate will

throw up.

Piot, head of UNAids, the United Nations' co-ordinating body,

reflects the mood of cautious optimism that has taken hold among

experts in recent months. " There has been more progress in the last

two years than in the previous 22, " he says. " In 1996, even working on

Aids was stigmatising, let alone having it; 2005 was the least bad

year yet. "

On the positive side, science has made considerable progress in

treating Aids through the development of antiretroviral medicines, and

politicians have mobilised strong support to secure additional

funding. Last July, the leaders of the G8 leading industrialised

nations pledged at Gleneagles to achieve " as close as possible " to

universal treatment for those who needed it by 2010.

Spurred on by the previous UN General Assembly on Aids in 2001, the

Global Fund to Fight Aids, Tuberculosis and Malaria was created. It

has since become the biggest channel for multilateral support.

Feachem, its head, says: " It's quite remarkable. Since our

creation in 2002, we have committed $10bn [£5.3bn, €7.8bn] to projects

in 130 countries and the impact is now starting to be seen. "

Total support has risen substantially to more than $8bn a year,

swollen further by the World Bank, bilateral programmes led by US

President W. Bush's Pepfar and redoubled efforts by individual

countries.

There has also been a sharp drop in the price of drugs, through a

mixture of discounts and donation programmes by pharmaceutical

companies, price competition from copycat generic manufacturers and

political leverage from groups such as the Clinton Foundation.

Mr Piot can point to findings in the latest UNAids report published

yesterday showing more than 1.3m HIV-positive people in low- and

middle-income countries are now on treatment, up from 240,000 five

years ago.

But it is far too soon to claim victory. Aids remains one of the

world's greatest health threats, responsible for 25m deaths since

1981. It has attacked teachers, doctors and all parts of the

workforce, while creating hundreds of thousands of orphans,

undermining economic development and even threatening global security.

While 700,000 people are on treatment in the developed world - a high

proportion of those who need it - the 1.3m in the developing nations

represents only one-fifth of those with advanced HIV who should be on

drugs. Nearly 3m people died from Aids last year, including hundreds

of thousands of children unable to gain access to little-researched

paediatric drugs.

More worrying still, the number of new HIV cases was at its highest

level ever in 2005 at 4m, while the life-prolonging effect of drugs

means that a record 40m people are now living with the infection.

Against such a background, there is no doubt that more money is

required. " The world is on a trajectory that will fall significantly

short of the interÃ‚Ânationally endorsed universal access goal for

2010, leaving millions without life-saving care, " warns the

International Treatment Preparedness Coalition, one advocacy group.

The failure of the World Health Organisation's goal of " 3 by 5 " - or

3m on treatment by the end of 2005 - highlighted the challenges.

Meeting the goal of universal treatment would mean placing and keeping

up to 10m people on treatment by 2010. UNAids estimates that that will

cost $23bn a year for at least a generation, orthree times current

spending levels.

" We are at a real turning point in the balance between optimism and

despair, " says the Global Fund's Mr Feachem. " Without full funding,

the G8 pledge is just pie in the sky. "

He is forced to seek fresh support from donor countries every few

months, with the latest " sixth round " recently launched with support

from the UK, which is keen to see follow-through from the Gleneagles'

G8 summit it hosted last summer. Other countries were more hesitant

and little of the money has been raised so far.

" Up till now, it has been about haphazard crisis management, " says Mr

Piot. " Now we are starting to have a critical mass, we need a more

sustainable, strategic, long-term response. The reality of dealing

with Aids is it is not something we can run year by year. We need to

count in decades. "

Business could do much more. For Jim Kim, the former head of the WHO's

3-by-5 programme, that includes drug manufacturers. He believes they

should sub-contract antiretroviral production to low-cost producers.

" We've got to get serious about establishing a humanitarian corridor, "

he says. " There is no way discount programmes will meet the target of

8-10m people on treatment by 2010. "

Holbrooke, president of the 215-strong Global Business

Coalition on HIV/Aids, called this month for support from many more

companies. They can help not only through donations, but by enhancing

their own activities in offering education, testing, counselling,

treatment and a pledge of non-discrimination to employees and their

families.

Beyond new money, however, a second issue in the fight against Aids is

how the funds should be spent. The G8 leaders, the WHO and the UN

assemblies have focused primarily on accelerated treatment. They have

been far less vocal about prevention and HIV-testing programmes, which

lack the dramatic appeal of " saving lives now " .

Yet both drugs, and the infrastructure required to ensure people

receive them consistently, mean that treatment is costly and risks

diluting other health initiatives in poor countries. Prevention and

testing may prove cheaper, less disruptive and more effective in

tackling the causes of the epidemic.

" An increased emphasis on prevention is something that is sorely

needed, " says Tedstrom, president of Transatlantic Partners

Against Aids, a charity working in the countries of the former Soviet

Union to raise the profile of the issue at this year's G8 summit in St

sburg.

While there are some indications from UNAids that infection rates may

have begun to fall in parts of Africa where they had reached

saturation point, he stresses that in other regions of the world -

notably Russia, China and India - the situation remains parlous. The

prospect of treatment may have induced complacency that has in turn

led to new infections in the US and western Europe.

Treatment on its own in any case does little to address the

longer-term problem of stemming the rate of infection. The more

survive thanks to antiretroviral drugs, the larger the pool of

HIV-positive people. That, in turn, risks further spread of HIV -

including a drug-resistant form of the virus - to others.

" If you have treatment but it's inÃ‚Âeffective and generating

resistance, you are building up a problem for the future that is going

to be almost insoluble, " warns Coker, reader in health at the

London School of Hygiene and Tropical Medicine. " Personally, I would

be more cautious than the international community in advising that

'antiretrovirals for all' is feasible and will achieve the claimed

benefits. If this doesn't work, we won't get another opportunity to

revisit it with the same sense of urgency and support. "

Most health officials are reluctant to argue for a reallocation of

scarce resources. " The great lesson of the last couple of years is

that there are no choices, " says Mr Feachem. " We need prevention,

testing and treatment: all three, all big, all together. They feed off

each other. "

Experience in the field certainly suggests that the best way to ensure

people are tested for HIV is to offer them the incentive of treatment.

Testing also provides an opportunity to reinforce prevention messages.

Yet if prevention and testing have been underplayed, even more

neglected has been research into what works. Information on the extent

and spread of drug-resistant HIV virus in the developing world is

scant, for instance. The Global Fund is only now scrambling to

commission a five-year evaluation of its own work and cannot even

detail how its money has been split between prevention, treatment and

testing.

" We don't have the evidence of the effects on the rest of the public

health system of HIV treatment, and for every prevention programme,

the evidence is pretty muddled, " says Murray, professor at

Harvard's School of Public Health.

However, studies conducted in recent years point to a third barrier to

enhanced Aids support. Many of the most effective methods clash with

the values of countries struggling to fight the epidemic and with

important funders and influences, such as the White House and the Vatican.

Research suggests the role of condom distribution in cutting infection

far outweighs any resulting rise in promiscuity and that free

needle-exchange and substitution programmes for hard drug users reduce

transmission without creating new addicts. But the US

administrationemphasises abstinence and loyalty over condom use. Grant

recipients must condemn sex workers and refrain from offering abortion

advice. Critics say such policies risk undermining organisations best

placed to tackle the epidemic, while handing funds to inexperienced

religious groups.

Other challenges lie ahead: curbing violence against women,

encouraging circumcision and fighting prejudice against high-risk

groups such as homosexuals, prostitutes, drug addicts and prisoners.

If they are serious about turning their Aids rhetoric into reality,

political leaders will need not only the financial resources to make a

difference abroad but also the moral courage to defend controversial

policies at home.

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June 1, 2006