Needed, will to tackle a global scourge

By Peter Piot

Exactly twenty years ago, the first official report of the disease now known as AIDS was made in a nine- paragraph report of the U.S. Center for Disease Control. Five persons were affected.No one reading those nine paragraphs could know that they were looking at what would become the most devastating epidemic in human history. It was inconceivable that HIV would spread so rapidly that within the first 20 years of the epidemic it would infect 58 million people, killing 22 million of them. But from nearly the outset, the warning signs were there.

I will never forget the day in 1983 when I revisited Kinshasa's large Mama Yemo Hospital, a place I had come to know during the Ebola outbreak in 1976. When I saw the large numbers of emaciated young men and women, I instantly realised that the world would face a major new epidemic - one driven by sex. Even so, none of us involved in those early days of AIDS could have imagined the scale of the epidemic that has unfolded.

It is a tale of globalisation; of the rapid global spread of a mainly sexually transmitted virus, of global inequities in health, and of the need for a truly global response and solution. And it is a tale that is still in its opening chapters. HIV is characterised by a relatively long gap between infection and major illness, and its natural dynamic is to show up first among those at heightened risk, while at the same time it gradually moves across the whole of the sexually active population. So one of the hardest lessons is that, for all the destruction the epidemic has already caused, we are still at the early stages of the epidemic.

But that does not mean that we have no choice but succumb to an inevitably growing toll of the disease. The opposite is true. The course the epidemic takes over the next 20 years will be a consequence of the choice the world makes now. The brief history of AIDS is one of evolving understandings and shifting paradigms - from a medical curiosity to a complex health issue with major development, political and human security dimensions.

Less than a month ago, a meeting of 30 of the leading scientific and policy thinkers on AIDS from around the world was convened by UNAIDS, the International AIDS Society and the Bill and Melinda Gates Foundation to advise the U.N. and the international scientific community on the next steps of an effective, achievable global response to AIDS. Perhaps for the first time, this meeting aired a truly global set of perspectives based on a realistic appraisal of the billions of dollars needed for the fight against AIDS and in a context where treatment gains experienced in rich countries through anti-retroviral therapy can be contemplated across the world. For years, the price of drugs seemed to be an impossible barrier. But today, preferential prices for developing countries for AIDS drugs has been widely accepted within both the pharmaceutical industry and by policy makers. In this new context, consensus is growing around a new paradigm.

Five of the meeting's conclusions stand out. First, investment now will prevent tens of millions of new infections and extend the lives of millions already living with HIV. Second, whatever the stage of the epidemic, special recognition of the needs of young people maximises the effectiveness and impact of prevention. Third, prevention, medical treatment and social support are all critical components of effective responses. Their effectiveness is immeasurably increased when they are used together.

Fourth, while the degree to which poor countries are able to extend access to anti-retroviral therapy varies, in every case a beginning can be made. But these treatments have to be used carefully if they are to have lasting benefits, given that even under the best-resourced and most closely monitored conditions, the virus develops resistance to these drugs. And fifth, political commitment and planning exists in many countries around the world to build on existing programmes to greatly scale up prevention and treatment. What they lack are the resources.

The benchmark cost of providing a prevention and care response to the epidemic in low and middle-income countries is between $7 and $10 billion. There is a big gap between this figure and current AIDS spending from private, national and international sources in these countries of under $2 billion. Filling this gap will undoubtedly need a greater level of commitment from national budgets. That is one reason why liberating funds through debt relief is a valuable part of HIV responses. Private sector involvement at the workplace and community responses to HIV is another source of support.

But as well as building up these channels of support, meeting the resources gap will need a new global fund, attracting genuinely new money, from both wealthy countries and from private donors. To this end, an international AIDS and health fund, as called for by the U.N. Secretary- General, Mr. Kofi Annan, is rapidly taking shape. These resources must provide for a wide spectrum of efforts, from supporting prevention programmes to increasing access to care and building the healthcare infrastructure that is sorely lacking in much of the world.

For the first time in the history of this epidemic, we have the opportunity to turn the tide on a truly large scale - the scale that matches the extent of the epidemic. The stars are moving into the right configurations; we know what works, there is a strategy, there is political commitment, and resources are coming. There are still some stars missing - the ones with the vaccine and an effective microbicide that kills HIV on contact, as well as the one with the all-out effort to eradicate the stigma associated with AIDS.

Later this month, the United Nations General Assembly will hold a three-day Special Session on HIV/AIDS. That session will mark the extent to which the world is prepared to demonstrate the resolve and the vision necessary to turn back the epidemic. We know what we need to do to slow new infections, and provide care for those who are ill. The only question, on this 20th anniversary of that first report of the disease called AIDS, is whether we have the will to do it.

(The writer is Executive Director, UNAIDS)

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