PERSPECTIVES ON AIDS: OPPORTUNITIES AND CHALLENGES FOR GLOBAL SOUTH NATIONS
Speaking as someone who has been working in the field of AIDS for the last ten years, the attention given to AIDS in the recent Millennium Summit is a refreshing sign of a breakthrough – a breakthrough in the global perspective on what was for long, a much-misunderstood and largely ignored epidemic. Ten years ago, none of us would have imagined that there would be a special session of the Security Council on AIDS, to review the impact of AIDS on the security of nations. Even five years ago, we could not have dreamed that a majority of the world’s leaders, would talk about the devastation caused by AIDS, within the five precious minutes they were given to address the recently-concluded Millennium Summit of the United Nations. The positioning of the AIDS pandemic for discussion in a panel on humanitarian affairs while evaluating this millennium summit is itself a telling, though tragic, comment on the critical importance this pandemic has assumed.
When AIDS emerged two decades ago, almost nobody predicted the dimensions it would take on. It was seen largely as a health problem, which would affect specific segments of the population, often on the margins of society. More so, it touched upon sensitive issues like sex, drugs and death, which most preferred to avoid. I still recall my own reaction, fifteen years ago. Like most others, I dismissed AIDS as largely a Western health problem. A problem that assumed low priority in the developing world, especially with the more demanding issues of poverty, inequity, and oppression faced by millions in countries in the South, and the major health problems that followed as a result. I soon began to be horrified by my own realization of the overarching impact of this problem. But many in positions of greater power and influence than I, continued to be sceptics for long. It is this very scepticism and what is worse, denial of the impact of AIDS, which today has caused AIDS to assume staggering proportions - proportions which now call for treating it as a global emergency, not on the fringes of society but at its very core.
What is so special about AIDS that it merits this universal attention? Is it the exponential growth of the epidemic across all segments of society and nations? Is it the fear and stigma with which it is associated, which lead to denial and silence blocking an effective response? Is it because the pandemic evolves and is influenced by a host of factors that go way beyond health? Or is it because AIDS has multiple effects on diverse sectors of national economies? The answer lies in all of these.
Peter Piot, who leads the UN effort to fight this pandemic, recently ranked AIDS as one of the key issues shaping the world, ranking as high on the list of human concerns as globalization, peace and the environment. The Secretary General, Kofi Annan expressed similar sentiments, defining it as an unprecedented crisis, demanding an unprecedented response. In his report to the Millennium Assembly, ‘We the Peoples: the role of the United Nations in the 21st century’, he chose to focus on AIDS above all other issues, as a health crisis that threatens to rapidly reverse a generation of accomplishments in human developments and become a social crisis on a global scale. Today, there is ample and growing recognition that AIDS is a development issue – one that wipes out hard-earned gains made so far by countries in the South, affects every sector of society, and challenges us to veer away from the business-as-usual approach.
But what is the evidence underlying this new understanding about AIDS ?
Numbers often hide the pain and human aspects of a problem but the statistics of AIDS are staggering and tell a story from which you cannot turn away. HIV is now the single largest infectious killer and the fourth leading cause of death in the world. Since this epidemic began, nearly 19 million have died of AIDS, of which as many as 3 million died in just one year - 1999. Today there are over 34 million people living with HIV/AIDS. But bear in mind that as many as 5.4 million of these were infected in 1999 alone.
A particularly grim statistic is that half of these new infections consist of our young, our hope for tomorrow – those under the age of 25 years. The rates among young girls in particular, are alarming; in 7 of 11 studies in Africa reviewed by UNAIDS in its latest report, it was found that more than one woman out of every five in the early 20s is infected with HIV. A large proportion of these women will not see their 30th birthday. AIDS thus, is a disease that strikes at our productive age group, debilitating economies, and depriving families of breadwinners and loved ones; it robs us of our future, by disproportionately infecting the young, especially girls, and affecting many other young people by depriving them of their parents; it affects the most vulnerable of populations hardest -- rates among women now exceed those among men in some parts of the world; and its worst impact is seen in poor countries: 95% of the 34 million infected with HIV globally live in less developed countries. If this is not a grim situation, I do not know what is.
Africa in particular, is reeling under the impact of AIDS. More than 23 million of the 34 million infected live in sub-Saharan Africa where adults and children are acquiring HIV, the virus that causes AIDS, at a higher rate than ever before. In 1999 alone, 4 million people became newly infected. According to UNAIDS, in seven African countries in the southern cone, at least one out of every five adults is living with this virus. In the worst hit cities of southern Africa, it is estimated that as many as 40 percent of pregnant women are infected. 90% of the 11 million orphans of AIDS live in Africa alone.
Just look at South Africa, a country which came out of an era of apartheid and suffering only recently, and which showed promise of a brighter future in the coming Millennium.
Two years ago, 13 % of its population was infected with HIV. Today, this percentage is nearly 20%, with South Africa achieving the dubious distinction of having the largest number of people infected by this virus in the world.
Is Asia doing any better? While the rates of prevalence in Asian countries are lower than those in Africa, the sure and steady rise of these rates continue to be disturbing. Four million people live with HIV in India alone. Even more disturbing is the finding that in Mumbai, in 1997, the prevalence of HIV among sex workers reached 71%, a situation not unknown in parts of Africa. In Cambodia, Myanmar and Thailand, over 1% of the population between 15-49 is now infected with this virus.
Rates in Latin America, on the other hand, may perhaps not appear as high as elsewhere but the epidemic is firmly established in this region. In countries like Honduras, Guatemala and Belize, between 1-2% of the adult population is HIV positive. And these percentages are on the rise. Recent trends in the Caribbean indicate that AIDS is ravaging the populations of several Caribbean island countries; Haiti has over 5% of adults living in HIV, with the Bahamas following with 4%.
In economies in transition in Eastern Europe and Central Asia, drug-injecting practices appear to be largely driving the epidemic. In Ukraine for example, after 1996, around 20,000 new infections are being reported each year, 80% of which are in injecting drug users.
While high-income countries are showing longer survival rates due to availability of anti retroviral drugs, it appears that risk behaviour is on the increase. A sense of complacency is causing resurgence in the epidemic in some populations. This is a warning sign of what would happen, globally, if, we are lulled into a false sense of security due to wider availability of antiretroviral drugs.
But it is not just these statistics that tell the whole story. Figures on falling life expectancy, increasing adult and child mortality, rising numbers of orphans, numbers of impacted sectors are sobering in terms of the implications for resource-constrained countries. Just a few samples may give you an idea of what this means.
In the last decade, many countries in the south have made steady, even if slow, progress in fighting early mortality and raising life expectancy. AIDS is eroding this progress, dramatically. Life expectancy in countries like Cote d’ Ivoire and Zimbabwe today, is 10-20% lower than it would have been without AIDS. The average child born in Botswana has a life expectancy of 41 years – without AIDS, this age would have been 70 years. Countries like Kenya and Zambia, with high rates of HIV, are now seeing a particularly steep rise in child mortality, often associated with mother to child transmission. What is most distressing is that in some countries over a third of 15 year olds are expected to die of AIDS.
AIDS means more than early death for children and young people – the impact on them is multi-faceted. They will be denied education, deprived of food, forced into early labour, exploited and lose their right to enjoy childhood. More than one child in every 10 has lost its mother to AIDS in sub Saharan Africa. It is estimated that a decade from today, there will be 40 million orphans in this part of the world, largely because of AIDS. In a study of commercial farms in Zimbabwe, 48% of the orphans of primary school age interviewed, had dropped out of school, and not one orphan of secondary school age was in school. Many affected children will be heading households in the absence of adults, often in situations where their economic and social situation, exposes them to HIV infection.
Households with a family member with AIDS are also showing marked signs of diminished resources to go around. In studies in Thailand and Cote d’ Ivoire, food consumption is reported to drop drastically, with expenses on health care rising disproportionately. Household savings are also dropping considerably.
Sectors, such as education, are most dramatically hit by AIDS, both due to loss of students as well as teachers. In Cote d’Ivoire, one teacher dies of AIDS every school year. In the first 10 months of 1998 alone, Zambia is reported to have lost 1300 teachers – the equivalent of around two-thirds of the new teachers trained annually.
Businesses are being ravaged by the impact of AIDS, threatened by losses in production and markets. Data is pouring in from countries heavily affected by AIDS, showing the drop in production, high rates of absenteeism due to ill health and care of sick family members, and attending funerals, and higher overtime costs for workers who have to work longer hours to make up for the work of their sick colleagues. A recent study in South Africa shows that as many as 20% of coal miners and 30% of gold miners are infected. This industry, like many others, is expected to lose 5-10% of its workforce in five years, leading to a productivity loss of 20% -- a loss ill afforded by countries striving to boost their national income. Tragically, the only businesses, which may prosper in many, such economies, are those related to funerals.
Government projections in Zimbabwe suggest that HIV will take up 60 % of the inadequate national health budget by 2005. Think of the situation in countries where many other health problems like malaria and TB already make high demands on the budget. Think of the many countries in Africa living through repeated famines and natural disasters. And think of the resources available when many of these countries are in situations of perennial conflict, instability and wars, which further enhance their peoples’ vulnerability to AIDS.
But is the situation as hopeless as these figures may suggest to some? I would argue that there are islands of hope.
There is much that we have learned and achieved since AIDS first appeared on the scene. More countries are shedding their denial around HIV and taking bold steps to combat it, more than ever before. What is more impressive that countries are actually starting to turn the tide. Thailand and Uganda are quoted most frequently as examples. In Uganda, there is a decline in HIV rates among pregnant women in urban as well as rural populations. Condom use is going up among young people in the region, and there are indications that among the better educated, sex with casual partners may be less frequent and starting later – not enough, but a good beginning. Such decline is evident in pockets of several other countries.
We also have today more tools to protect ourselves from this infection than we did in the early years of the epidemic. Consistent and correct use of condoms –both female and male, treatment of sexually transmitted infections, reduction in the number of partners, non-sharing of needles and syringes in injecting drug use, and medication to prevent mother to child transmission are a few of the tools currently available to us. But we also know that all of these tools can be used when there is a safe and supportive social, economic, political and legal environment which promotes their use. What is the use of condoms if they are inaccessible or of poor quality? What is the use of condoms if religious groups continue to chastise those who use them? What is the use of condoms if they continue to be associated with only some forms of sexual partnerships? What is the use of condoms if women continue to lack power to demand their use, even in situation when they know that their partners may be infected? What is the use of condoms if sex workers must have sex without condoms for economic survival? And what is the use of all these tools if women do not have access to their own methods to protect themselves and their loved ones from HIV, like access to existing female condoms or to the vaginal gels called microbicides, still under development? Clearly, creating a societal climate where these tools are easily accessible, affordable, socially acceptable is critical. And this is lacking even in many countries in the North.
Such a climate is more likely to be available when social policies and laws support if not promote these tools. This means social policies and laws which foster availability of needle exchange programs, non-criminalization of prostitution and homosexual behavior, and accessibility to all means of protection, including rapid development of those under development such as vaccines and microbicides. It also means social policies which combat gender inequity and poverty alleviation, since HIV disproportionately affects the poor and increasingly, women especially girls. Furthermore, it means, legal protection against discrimination and stigmatisation for those infected or affected by HIV or suspected to be vulnerable. In addition it necessitates the search for new tools. The range is vast and the challenges many, especially since many of us hesitate to face squarely the bold approach needed, involves going beyond the prevalent cultural norms and deep-seated prejudices which surround us.
The United Nations was one of the pioneering organizations to acknowledge the multi-faceted nature and impact of AIDS and to initiate some bold steps. I quote the ECOSOC report of 1995 which says ‘Inevitably many different sectors are affected by the epidemic, given its selective impact on the most productive age group in society, and its destructive ripple effects on families, communities, and economies.’ It chose to develop the Joint United Nations Programme on HIV/AIDS as the UN’s coordinated response to AIDS as there was a strong commitment to a multi sectoral approach. Through several events and collaborative efforts including the G8 summit, OAU summits, other inter-regional and regional summits, and most recently through the Millennium summit, UNAIDS with other UN partners, has sought to underscore the linkages between AIDS and development, and to seek the commitment of different governments and key agencies in the fight against AIDS. However, the UN’s efforts, laudable as they are, are just not enough if the member states do not show the political will and commitment needed and take bold steps to curb this epidemic.
What are some of these steps, which resource-constrained countries can take to stem the tide?
Clearly, the major responsibility of responding to this epidemic, lies with national governments, even if each and every segment of society has a role to play. Martha Ainsworth and Waranya Teokul in a thought provoking piece published in the Lancet (Lancet, 2000; 356: 55-60) argue that only governments can provide public goods such as information, epidemiological and behavioural surveillance, sectoral coordination for an effective response, and incentives to people to adopt safe behaviour, for example through subsidized condoms, improved health information, STD treatment, or needle exchange programs. Governments must take on their responsibility to make these available, while doing more. Much more.
For example, governments and leaders in particular, need to break the silence around AIDS and the taboo subjects seen as related to it. Jonathan Mann, a leader in this field, said that denial is the worst enemy of this epidemic. It only drives underground the behaviours, which we need to address to respond to this epidemic, and disables the swift response, which is needed from all sectors. What occurs in fact is a worsening of the epidemic. The effect of Museveni or Mahathir or Mandela talking about AIDS in public forums both in the country and outside, is dramatic as it injects a sense of political commitment and urgency of action among all parts of the national government and civil society within the country, and creates a sense of global solidarity in the fight against AIDS. A policy and legal environment which is open about AIDS and supportive of those infected and affected, will also help fight the stigma around AIDS – a major barrier to an effective response.