World AIDS Day

For nearly three decades, the world has struggled to manage the vast human, social, economic and political impact of the emergence of HIV/AIDS.

The history of the global HIV/AIDS pandemic is broadly divisible into two phases — before and after the introduction, in 1996, of effective antiretroviral therapy (ART).

The first phase of the pandemic — from the earliest reported cases of HIV/AIDS in New York in October 1982 until treatments became available in 1996 — constituted nothing less than a public-health catastrophe. In many countries, notably the United States and South Africa, political leaders responded to the appearance of HIV/AIDS with a toxic combination of ignorance, prejudice and political cynicism directed at those in whom the disease had first appeared in industrialised countries — gay men, sex workers and injecting drug users.

Only a few countries, including Australia, moved decisively during the 1980s to control HIV/AIDS and to prevent its spread into the general community. These pragmatic prevention strategies were based on rapidly accumulating evidence that simple changes in sexual and needle-sharing behaviour among young people, complemented by access to condoms and clean needles, dramatically reduced HIV transmission rates. By the mid to late 1990s, there was clear evidence from published studies that such strategies were effective in containing new HIV infection rates,1,2 and their success in Australia and a small number of other countries was undeniable.

Yet almost none of these strategies were implemented on a sufficiently large scale or in time to reduce the impact of HIV/AIDS in regions and countries then largely unaffected by the problem. To put it mildly, an epic failure of leadership and political will to accept and act on scientific evidence turned a potentially containable problem into a pandemic that, by the late 1990s, was beyond control.

Nature created HIV, but anti-prevention politicians and their associates created the HIV pandemic.3

The human consequences of the HIV pandemic, and the failure to contain the problem in the mid 1980s, are shocking. Since 1982, HIV has infected 60 million people, and there have been 25 million deaths from AIDS caused by HIV infection.4

The second, and much more encouraging and enlightened, phase of the HIV pandemic dates from 1996, with the development and introduction of highly effective ART. In almost all industrialised countries, access to this lifesaving treatment quickly became virtually universal. From the late 1990s, deaths from AIDS declined and HIV became a more manageable chronic condition. This in turn led to an abatement of the worst excesses of fear-mongering and a perceptible decline in HIV-related stigma and discrimination.

The international response to HIV/AIDS was galvanised by two highly significant developments.

Firstly, in 1996, the United Nations (UN) established UNAIDS, a specialised UN agency set up to provide strategic direction and to develop and oversee a coordinated international response to HIV/AIDS.

Secondly, in 2002, the G8 countries (United Kingdom, US, France, Germany, Italy, Japan, Canada and Russia) established the Global Fund to Fight AIDS, Tuberculosis and Malaria. The Global Fund was charged with funding and supporting the large-scale distribution of ART in developing countries, especially African countries, which have been most grievously affected by the uncontrolled spread of HIV/AIDS.

These two institutions — one handling strategy and politics and the other raising and disbursing money — have brought about tremendous improvement in the international management of HIV/AIDS.

Since 2002, the Global Fund has sourced nearly US$20 billion from public and private donors,5 of which about US$10 billion has been applied to the subsidised distribution of HIV/AIDS treatment, care and prevention services in some 140 poor and developing countries. The Global Fund is now the major international financer of programs to eradicate mother-to-child transmission of HIV and to support harm reduction among injecting drug users. At the end of December 2009, programs financed directly by the Global Fund were providing ART to 2.5 million people.6

Together with ART distribution financed by the US under the President’s Emergency Plan for AIDS Relief, more than four million people in low- and middle-income countries now have access to ART, representing about 40% of those in urgent need.

Sensible HIV strategies backed with large funding have begun to stabilise the spread of HIV/AIDS in most high-burden African countries. In Ethiopia’s capital, Addis Ababa, for example, the rollout of ART has led to a decline of about 50% in adult AIDS deaths over a period of 5 years.6

As the number of global deaths from AIDS has fallen, the number of those living with HIV has increased. There are now some 33.4 million people living with HIV infection.4 But, despite these advances, each year about 2.7 million people acquire HIV and about two million people die from AIDS, mostly within the developing world.4

Other regions have not responded as well as Africa.

In Eastern Europe and Central Asia,* many national governments reject the lessons of how the spread of HIV can be contained through education and behavioural change. They oppose the widespread availability of condoms and the introduction of needle and syringe programs for those at highest risk of HIV infection. Consequently, rates of HIV infection in these countries are increasing at an alarming rate. In Eastern Europe and Central Asia, an estimated 110 000 people were newly infected with HIV in 2008, bringing the number of people living with HIV in the region to 1.5 million, compared with 900 000 in 2001 — a 67% increase over this period.7 Ukraine and the Russian Federation are experiencing especially severe and growing national epidemics. With an HIV prevalence of over 1.6% in adults, Ukraine has the highest infection level reported in all of Europe.4

So, as we mark the recent occasion of World AIDS Day 2010, the best that can be said about the state of the global fight against HIV/AIDS is that our successes have been relative.

The world supported care and treatment for people with HIV/AIDS when effective therapies became available. During the boom conditions of the 1990s, it was relatively easy for the largest donors to put real financial resources behind the distribution of ART that saved millions of lives in the poorest countries.

But economic times have changed. In October 2010, the Global Fund went to donors seeking some US$20 billion for the period 2011–13 so that the most urgent unmet need for ART in the developing world could be met.8 But, instead of US$20 billion, donors provided only US$11.7 billion. (Australia was one of the few countries that increased its support for the Global Fund.)

In summary, the first phase of the HIV/AIDS pandemic was chaotic and lamentable. The second phase was encouraging and hopeful.

We are now entering the third phase of the response. At a critical moment, transient economic difficulties in the donor countries threaten to jeopardise the great progress that has been made since the late 1990s. It would be appallingly callous and retrograde to take HIV treatments away from those whose lives have been saved thanks to the efforts of donors working through the Global Fund. We must not falter in our determination to provide universal access to care and treatment to all who still require it.

The costs of ensuring universal access to ART by 2015 are, in the scheme of things, trivial compared with overall global development assistance budgets, not to mention expenditure on armaments and weapons, while the benefits are abundantly obvious. The third phase of the global response to HIV/AIDS must be dominated by a renewed commitment to behavioural prevention as the surest and most sustainable way to contain the pandemic.

We can contain HIV by improving access to treatments and providing care to people with the disease. But HIV will only be defeated and eradicated when the lessons of behavioural prevention that we developed and applied in Australia two decades ago become the basis of the global response.