Lessons from the Global HIV/AIDS Epidemic
Foreword to the Encyclopedia of AIDS
by Peter Piot, M.D., Ph.D.
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The global HIV/AIDS epidemic has taught, or retaught, us many important lessons. It has confirmed the importance of socioeconomic and cultural factors in health. It has shown that when human rights are not protected, people are more vulnerable to disease. And it has reminded us that, although infectious diseases once seemed to be on the wane, a new worldwide epidemic can break out at any moment.
Perhaps the most sobering lesson of the past 15-plus years is that the HIV/ AIDS epidemic has not turned out to be a disease outbreak that science can quickly bring under control. Both a vaccine and a cure remain elusive. There are no quick fixes, technological or otherwise, to prevent new infections or eliminate the lingering societal impact of millions of AIDS deaths among individuals in their peak productive and reproductive years.
The most hopeful lesson is that, even though our approaches are imperfect, we are not powerless against the epidemic. Communities in the developing world, and even some industrialized nations as a whole, have managed to stabilize or reduce the rate of new HIV infections, provide care and support for those infected or affected, and combat fear and rejection of people living with HIV and AIDS.
Scientific advances hold out even greater hope for the future. Combined antiviral drugs promise longer and higher quality survival for HIV-infected people. Antiviral treatment for women and their newborn babies has been shown to reduce mother-to-child transmission. Progress is being made in developing vaginal creams and other "barriers" to HIV that women can apply. Insights for both vaccine and drug development are emerging from the study of individuals who appear resistant to HIV infection or who remain remarkably disease-free years after becoming infected. Yet with more than 20 million HIV-infected people alive and facing an unpredictable and generally fatal course, and with more than 7,500 new HIV infections occurring each day, it is premature to claim that we have turned the corner.
Difficulties and obstacles abound. Denial has diminished since the early years of the epidemic but continues to block political commitment and individual action. Those most affected-the people who are infected with or at risk of HIV-still often have no voice in designing and planning action and services. Harm reduction measures, such as access to condoms or sterile needles, continue to be controversial despite their effective track record. In countries with resource-starved or poorly managed health services, people with HIV/AIDS suffer for lack of the simple drugs that could ease their pain, itching, or nausea, not to mention a total lack of access to antiviral drugs.
Prevention is still divorced from care and support, and measures are geared to outbreak control instead of lifetime HIV risk management. Moreover, in the context of people's lives, many key prevention messages are irrelevant. Where homosexuality is criminalized or heavily stigmatized, gay men may have no realistic way of obtaining condoms to prevent HIV infection or health care once they have HIV or AIDS. To take another example, mutual sexual fidelity may protect from HIV, but it is something over which many married women have no control. The lack of realistic options for self-protection- whether because of poverty, power imbalances, or denial of human rights- results in appalling vulnerability for billions of men, women, and children.
Only an expanded response to the epidemic gives us a chance of grappling with these problems. The response needs to be of greater duration, in keeping with the permanent nature of the AIDS challenge; of greater quality, bearing in mind the ineffectiveness of technically inappropriate and poorly managed action; and of greater scope, encompassing but reaching far beyond the health sector.
The fact that HIV and its repercussions will be with us for generations implies the need for a sustainable response, one that encourages openness about the epidemic among individuals and communities and that builds up their coping capacity. Among other things, coping means lifelong acceptance and inclusion of people with HIV/AIDS in the household or community and the adjustment of personal behavior to the lifelong risk of HIV infection.
But while the action required must always be viewed through the lens of human needs, it cannot be limited to the personal or individual level. We must act on the broad structural context of prevention, care, and impact alleviation. At one end of the spectrum, we need to tackle the underlying socioeconomic and structural factors that make people vulnerable to HIV/AIDS by giving them few realistic options for self-protection. Empowerment for action is one obvious remedy. To return to the example of women, vulnerability could be lessened through increased education, access to credit, and equitable rights in the event of divorce. Clearly, such action could simultaneously diminish women's vulnerability to other ills with similar socioeconomic roots, including violence and unwanted pregnancy.