to be checked against delivery

IXth International Conference on AIDS

Berlin

7-11 June 1993

The HIV/AIDS Pandemic: Global Spread and Global Response

by Dr. M.H. Merson Director Global Programme on AIDS

Berlin 7 June 1993

It is often said that public health interventions arrive after the epidemic has done its damage. The major challenge now facing us is how we can get ahead of, rather than trail behind, the AIDS pandemic, and this is my topic today. I will first give a broad overview of the pandemic and then outline the global response to date, good and bad. Lastly, I will attempt to show how we can get ahead of the pandemic - how with an adequate and realistic response we can cut the number of new infections in half by the turn of the century and save milions of lives, bilions of dollars and immeasurable pain and suffering.

The first thing that strikes me about the pandemic today is the growing burden of illness. Since we met last in Amsterdam, half a million people with HIV infection have gone on to develop AIDS. The cumulative world total as of early 1993 stands at more than 2.5 million AIDS cases - 20% higher than in early 1992. And the curve is set to go much higher: WHO projects than between 1992 and the year 2000, the annual number of new AIDS cases will at least triple.

During the past year, we have also seen the relentless advance of the human immunodeficiency virus. As of today, WHO estimates that more than 13 million adolescents and adults have been infected since the start of the pandemic. And these are conservative estimates. The largest number of infections is still in sub-Saharan Africa - more than 8 million - but the biggest increase in the past year has been in Latin America and South and Sout-East Asia, each with 1.5 million or more infections. What has not changed is the basic transmission pattern. Wordwide, about three-quarters of cumulative HIV infections have been acquired through unprotected sexual intercourse. And heterosexual transmission is still on the rise. Five out of every 11 newly infected adults are now women. Mother-to-child transmission is also growing in importance. So far, about 1 million infants have been infected via this route, up to half of them through breast-feeding. Adding the infant and adult infections, we get a cumulative total of over

14 million. Just a year ago, the figure was 11 to 13 million.

What about regional trends? The growth of the epidemic in South and South-East Asia can only be decribed as explosive. In Thailand, for example, in early 1990 there were over 50 000 infected people in the country. By late 1992 there were an estimated 450 000 - almost ten times more. In South Asia, there are today at least 1 million infected adults, most of them in India. There has been a steep rise in infection among drug injectors in Myanmar, Thailand and north-east India. In just 3-4 years, prevalence has risen from zero to 50%. These infections acquired through needle-sharing are in turn fuelling heterosexual transmission among adults who do not use drugs, Indeed, infection through unprotected intercourse is the dominant route of transmission throughout the region.

Turning to Latin America, the Caribbean has some of the highest per capita AIDS rates in the world, and infection is occurring at ever-younger ages, primarily through heterosexual intercourse. In South America, the number of infections is greatest in homosexual and bisexual men, but transmission among heterosexuals and drug injectors is increasing. How big the epidemic will become is still uncertain. Much will depend on what happens in Brazil, where the Ministry of Health has warned that there could be half a million cumulative AIDS cases by the turn of the century. The situation in parts of Central America, particularly Honduras, is worrying, too. In the past two years, 4% of pregnant women in San Pedro Sula and one-third of female sex workers close to the Guatemalan border were found to be infected.

The epidemic in sub-Saharan Africa, once focused on the central and eastern part of the continent, is extending southward and westward. Sentinel surveillance data from Nigeria tell us that by 1992 HIV had spread throughout the country, with prevalence reaching as high as 22% in STD patients and nearly 6% in pregnant women. Zimbabwe has over 600 000 infected people. In Abidjan, Côte d'Ivoire, between 10% and 12% of the adult population is infected.

HIV has also continued to spread in North Africa and the Middle East. For example, in southern Sudan, infection rates as high as 40% have been found in female sex workers. Now, HIV is advancing in the north, as shown by the tenfold increase in seropositivity among blood donors in Khartoum since 1987. Clearly, the epidemic in this region is evolving rapidly.

The situation has moved on in the industrialized world, too. The welcome downturn in incidence among gay and bisexual men appears in general to be holding, but infections among injecting drug users continue to increase, especially in places where there are no needle-exchange programmes. In Europe as a whole, needle-sharing accounts for almost a third of recent AIDS cases, 50% more than in the mid 1980s. And heterosexual transmission is on the rise, particularly in urban populations with high STD or drug injecting rates. Up to one-third of newly infected people in some cities of Scotland have acquired HIV from heterosexual intercourse.

In Eastern Europe, the situation is volatile. Economic crisis, ethnic and religious conflicts, the displacement of civilian populations are not only hindering health promotion. They are also encouraging risk behaviour such as drug injecting and unprotected commercial sex. Even changes brought about by freedom and democracy could turn today's low transmission rates into an epidemic of major proportions.

Before concluding this look at the global pandemic, I want to say a few words about the vulnerability of youth to HIV infection, especially through unprotected intercourse. Here are the facts. There has been a worldwide drop in median age at first intercourse. In many parts of the world, half of all young people have had intercourse by the age of 15 or 16, and millions of youngsters are already sexually active at 12 or 13.

Young girls are especially vulnerable to STDs, including HIV infection. They tend to marry or have intercourse with older men who have had more sexual esposure. As the receptive partner, females run a greater risk to begin with. This risk is magnified in teen-age girls because their immature cervix and limited vaginal secretions put up less of a barrier. To make things worse, sometimes young girls are physically forced at first intercourse, resulting in genital trauma.

Given these facts, it is not surprising that the conventional STDs are highly prevalent among young people worldwide. In Botswana, a quarter of young sexually active males report at least one STD in the past year. In the USA, at least 1 out of 4 sexually active teenagers has had an STD by age 21. In Thailand, two-thirds of patients diagnosed with an STD in medical clinics are under 25. And in Uganda, STDs are most common in teen-age girls.

What about the HIV situation among youth? WHO is currently condcting a study of age-specific HIV infection rates which will provide precise information. At present, we estimate that about half of all HIV infections so far have occurred in youngsters under 25 years old. In other words, since the start of the pandemic, at least 6 million young people have been infected with HIV through unprotected intercourse or needle-sharing. And there is enormmous potential for further spread among youth, particularly since 800 million live in developing countries, where the pandemic is expanding the fastest. Looking at it the other way around, we can even say that it is HIV spread among youth that is driving the pandemic.

Such is the HIV/AIDS pandemic today. How well are we responding to it?

Forgive me for using the ambiguous "we" with an audience such as this. By "we" I mean the world at large, not the thousands of committed AIDS workers in this room. There can be no question about your response to AIDS - if you have travelled to this conference, it is because of your commitment and concern.

In fact, you represent all that is best about the global response to the pandemic. Community workers leading efforts in prevention and supporting those who are infected and ill, often in the face of discrimination too outrageous for words. Social scientists studying the dynamics of society in an attempt to strengthen our approaches to behaviour change. Biomedical researchers urgently seeking better treatments and developing vaccines that we all hope may someday prevent infection and forestall progression to AIDS.

So there are impressive examples of the right kind of response. In some parts of the world, a strong commitment to prevention by political leaders and communities is paying off in safer sex, inclunding greater condom use. More countries are letting HIV-infected people pass freely through their borders, recognizing that HIV does not spread through passports and visas. In some quarters, it is finally being acknowledged that mass testing of certain population groups is the wrong way to go. A resounding declaration along these lines was adopted three months ago not far from here by the health and finance ministers of central and eastern Europe - the Riga Statement.

In Africa, people are learning to work with, and not against, prostitutes in getting clients to use condoms. Some excellent needle exchange projects - especially in Australia and northern Europe - are bringing down HIV infection rates in drug users. People with HIV and AIDS, the pioneers of community care, continue to be the mainstays of innovative projects as far afield as San Francisco and Kampala. Some developing countries - and here I would single out Ethiopia and Thailand - are putting impressive national resources into the fight.

But, overall, I would have to say that the global response to the pandemic is still inadequate and unrealistic.

For one thing, we are still knee-deep in denial and complacency. Africa staggers under the burden of AIDS, and yet we hear the media claiming that the African pandemic is a myth! Can you imagine how this sound to Noerine Kaleeba whose TASO project in Uganda has provided support to about 14 000 people living with AIDS, or to Sister Margaret Mensah who has seen hundreds of AIDS patients in her small clinic in Ghana? Can you imagine how this feels to the countless Africans who have lost their loved ones to AIDS? Denying the African epidemic is an outrage: it is an insult to the memory of the millions who have died.

Another form of denial is the so-called lifestyle theories of AIDS. They were disproved years ago, but some individuals still confuse our youth by telling them that HIV is not the cause of AIDS.

And, in one of the strangest denial theories ever to raise its head, heterosexuals in some countries are now claiming that they are not at any risk of HIV - never mind their high rates of conventional STDs! If this is not magical thinking, what is?

The global response is also stymied by the king of blaming and finger-pointing that mankind has always engaged in when confronted with a frightening new disease. The stigmatized groups have changed. Back in the sixteenth century, for example, neighbouring countries routinely blamed each other for syphilis, as we can tell from the old French term le mal italien and the Italian one, morbus gallicus. Today, it is the prostitutes, the foreigners, the homosexuals, the truck drivers who are to blame.

And because AIDS is still perceived as a problem that other people are responsible for, not oneself, there is still a Knee-jerk reflex to "solve" the problem by testing and identifying these "others". Instead of applying universal precautions in infection control, hospitals try to identify infected patients and put them on special wards. Instead of encouraging all clients to use a condom, city authorities try to identify infected prostitutes. We have got to keep on repeating that the "test and identify" approach may make sense for diseases that spread through everyday contact, or when, as with syphilis, there is a way of curing infected people and making them uninfectious to others. But when it comes to AIDS prevention, mandatory testing is at best pointless, at worst dangerous - and, I need hardly remind this audience, a violation of human rights.

Given this irrationality, it is not surprising that there is still needless controversy over HIV prevention policies, stategies and interventions. The day are long past when there could be any doubt about the effectiveness of condom promotion, AIDS education in school, and harm reduction programmes for drug injectors. The data are in: these interventions reduce HIV transmission without encouraging risk behaviour. Yet life-saving information is still being withheld, especially from young people - and they are the ones who need it most because, yes, they have sex. In some places, even the word "condom" is still taboo, and adults are often shocked at the idea of talking about non-penetrative forms of sex - which I am told by my son is what many young people do anyway. It is clear that in responding to AIDS, we need to see the world as it is, not as we would like it to be.

How are we responding to the underlying societal factors that make HIV spread so easy and AIDS prevention so hard? Not well. Far too little is being done to improve the status of women, to reduce the disparities in investment that encorurage massive migration, to ensure that countries undertaking structural adjustment maintain a social safety net.

Above all, the financial commitment to defeating AIDS is still grossly inadequate. Even where budgets are growing, the increases are only incremental - at a time when we need a quantum leap in investment.

This brings me to my final point: what kind of a global response do we really need, and what could it achieve?

To begin with, we need to respond with the greatest possible urgency to the people now living with HIV infection and AIDS. Their human rights must be respected, and no discriminatory measures must be tolerated. People with HIV and AIDS should receive dignified, humane care and have access to currently available drugs at affordable princes. This is the least we can do - call it basic human decency, call it just plain solidarity.

At the same time, we need to refocus and prioritize our research agenda. Along with better drugs, I see two outstanding needs. One is to come up with a vaccine appropriate for use in developing countries. It is clear that this will not be easy, and that is why we need to explore all scientifically reasonable options and find ways of addressing sagety and potential liability concerns. For example, just last week, scientists and experts in medical ethics met at WHO to look into the feasibility of a live attenuated HIV vaccine. They found the results from monkey protection trials so convincing that they recommended that the development of live attenuated HIV vaccines should be "intensively explored", to use their words. Clearly, more animal studies will be necessary before human trials could even be considered, but given the millions of lives at stake in this pandemic we must leave no stone unturned.

The other need is for barrier methods under the control of women. Experience has repeatedly confirmed what women have been saying all long - they are less able than men to protect themselves from HIV infection by a simple act of will. In many settings, they cannot control or even negotiate sager sex, including condom use. In many settings, the ideal of mutual fidelity is just that - an ideal. It is hardly something a woman can trust with her life. That is why a vaginal microbicide, active against HIV and, ideally, against other STD pathogens too, could revolutionize AIDS prevention. If the scientific community and the pharmaceutical industry put their minds to it and make the needed invesments, i find it hard to believe such a product could not be rapidly developed.

Above all, we must waste no time in scaling up the interventions that we know work. There is a consensus that a basic HIV prevention package would include at least the following interventions: condom social marketing, that is, the promotion and distribution of condoms in the general population; treatment of the conventional STDs, because of their role in faciliting HIV transmission; AIDS information and education in schools and through the mass media; promotion of condom use by prostitutes and their clients; the maintenance of a safe blood supply; and needle exchange programmes for injecting drug users.

We are often asked how much these interventions would cost. We can now tell you the answer, based on an analysis of the costs of existing programmes. WHO estimates that, in 1990 US dollar terms, implementing the entire prevention package in the developing countries would cost between $1.5 and $2.9 billion a year. The most expensive components are condom social marketing and STD treatment, and the cost range shown here depends on factors such as STD and condom use rates in each setting.

Let me quickly emphasize that WHO is not advocating a standard blueprint for prevention. The global pandemic is a mix of diverse epidemics, each driven by different factors and forces. The best mix of interventions must be chosen, adapted to the local context, and adjusted for local constraints, such as the societal forces operating locally. I want to be perfectly clear, though. AIDS is essentially a sexually transmitted disease, and preventing sexual transmission has to get priority everywhere.

But the really important question is, how much of a difference could such a package make to the course of the pandemic? WHO is about to publish a research study showing that if comprehensive prevention were carried out in all developing countries starting now, it could cut the number of new adult infections during the rest of this decade in half - from almost 20 million to 10 million. This means preventing over 4 million in Asia and about 1 million in Latin America. so many lives saved, so much suffering averted.

But can the world afford the necessary $2.5 billion? After all, this is about 10-20 times what was spent on AIDS prevention in the developing countries last year. Well, $2.5 billion is scarcely one-twentieth of the $49 billion spent on Operation Desert Storm. It would hardly buy one can of Coke for every person in the world.

The answer is simple. The world can find this kind of money when it wants to. And it does not have to come from just one pocket. Some can come from individuals and communities, even in the developing counties - after all, if you can afford a beer, you can afford a condom. Let us not forget that communities are a rich source of manpower for prevention campaigns. Some money can come from a reordering of domestic spending priorities by developing countries. A great deal can come from a more realistic stance by donors. And much can come from the private sector - they have a lot at stake.

In any case, an annual investment of $2.5 billion must not ve regarded as current spending. It is an investment on which the returns would be huge. In purely financial terms, preventing AIDS means averting enormous costs - not only the direct costs of health care, but the fare greater indirect costs, especially the income lost because of illness and death. WHO estimates that investing $2.5 billion a year would save close to $90 billion in direct and indirect costs by the turn of the century. This is a return any company would be happy to achieve. But the yield will actually be greater, because the main impact of prevention will be seen later, well into the twenty-first century. Again, a return in financial terms - but above all in the incalculable yield of diminished human suffering.

In conclusion, we have the know-how to respond realistically to the AIDS pandemic and save millions of lives in this decade alone. Now it's time to act.

It's time to overcome the denial and fear. Accept that people with AIDS are people that were infected winth HIV. Make them partners in prevention; give them humane care and support; ensure that they enjoy the same rights as the rest of the human race, including the freedom to travel.

It's time to stop doing what doesn't work. Accept that the best way to get uninfected people to stay uninfected is to make them allies. Do not alienate them with coercion and threats of testing.

It's time to face the facts about harm reduction. Give young people especially the whole range of options for safer behaviour - this is the key to keeping them alive and well.

It's time to make the world a better place for AIDS prevention. Empower women: ensure schooling for girls, change discriminatory inheritance and property ownership laws, and strengthen credit facilities for women. Help men and women find a fairer, and sager, way of relation to each other.

In summary, AIDS is a grim reality, not a myth. Magical thinking will get us nowhere. It's time to do what works, not just in pilot projects but countrywide, worldwide. To respond to AIDS in the developed worl, we must commit ourselves to realistic prevention programmes and a true partnership with people living with HIV and AIDS. Combating the pandemic in the developing world will take exactly the same commitment - plus an annual investment of $2.5 billion starting this year. I appeal to world leaders to make this commitment and help mobilize the resources neede - from national fudgets, nongovernmental organizations, the private sector. We can afford AIDS care and prevention. We cannot afford to neglect it. AIDS must not be allowed to join the list of prblems that the world has learned to live with because the powerful lost interest and the powerless had no choice.