AIDS: Winning the Fight, Losing the War

A nurse boils water in the procedure unit of a regional medical AIDS center in Rostov-on-Don city. It was reported in May that AIDS is spreading in North Caucasia as a result of the ongoing Chechnya war since doctors are unable to fight the epidemic due to a shortage of proper medical equipment and the reluctance of the local population to go to medical center. (Photo: Kazbek Basayev / AFP-Getty Images)

The fight against H.I.V./AIDS is throwing up an unlikely scenario whereby steady progress made in the fight against the epidemic may not translate into significant gains in the long-term war against the global epidemic. How is it possible to be on a winning streak in the fight against H.I.V./AIDS in the short term and yet be in danger of losing the long-term battle to contain the epidemic?

It is important to begin with a summary of the known impact of H.I.V./AIDS in the last 25 years. According to the United Nations agency coordinating response to the epidemic, UNAIDS, 65 million individuals have contracted H.I.V. since 1981. At least 39.5 million people live with H.I.V. In the last 25 years, 25 million people have died of AIDS. In 2006 alone, 4.3 million individuals contracted H.I.V. and 2.9 million died of AIDS. Countries with a huge AIDS burden face contracting economies and work force shortages.

Winning the Fight and Losing the War Against H.I.V./AIDS

I briefly discuss how we are winning the fight and yet are in danger of losing the long-term battle against H.I.V./AIDS.

The international resolve to fight AIDS reached unprecedented momentum in 2001 when the United Nations General Assembly, in a special session, adopted the Declaration of Commitment on H.I.V./AIDS and Millennium Development Goals, explicitly recognizing the need for a strong political will in the fight against the epidemic. The declaration also highlighted the need for coordinated resource mobilization in fighting and reversing the impact of the epidemic by 2015. The General Assembly reaffirmed its commitment to the fight against AIDS with the 2006 Political Declaration on H.I.V./AIDS, urging universal access to H.I.V. prevention, treatment, care, and support by 2010. The 2006 declaration emphasized the role of stable and adequate long-term financing strategies. The creation of the Global Fund to fight AIDS, Tuberculosis, and Malaria to finance remedial efforts is a testament to the global resolve on AIDS. The United States government program against AIDS (PEPFAR) committed $15 billion over five years, making it the largest bilateral program of its kind. The European Union and the Gates Foundation also significantly increased their support of global AIDS efforts. The United Nations reports that at the end of 2006, 90 countries had set national H.I.V./AIDS remedial targets and 25 countries had developed costed, priority national plans.

An unequivocal evidence of the steady progress in the fight against H.I.V./AIDS is the level of financial support available worldwide. The UNAIDS indicates that funding for global H.I.V./AIDS rose from $300 million in 1996 to $8.9 billion in 2006. Funding for H.I.V./AIDS programs worldwide is expected to reach $10 billion in 2007.

However, in long-term war plans, the dramatic increase in financial support is less than half of what is needed to fight the epidemic. At least $18 billion is needed in 2007 and another $22 billion in 2008. The UNAIDS estimates that to achieve universal access to H.I.V./AIDS services by 2010, $32 billion to $51 billion will be needed. Today, there is no credible evidence that needed financial resources will be available by 2010.

Steady progress is also evident in access to lifesaving antiretroviral therapy. In 2004, about 300,000 individuals were on antiretroviral therapy worldwide. By the end of 2006, 2.2 million individuals were receiving antiretroviral medication. The increased access to treatment is remarkable. However, the impressive numbers of individuals on treatment belie five ominous concerns, with grave implications in the long-term battle against AIDS.

First, individuals currently receiving treatment represent less than 30 percent of the 7.1 million people clinically qualified to receive antiretroviral medications. These individuals will likely die without treatment. Second, the scale-up of antiretroviral therapy is not keeping pace with clinical need, leading to an increase in the number of AIDS deaths. In 2006, 2.9 million people died of AIDS compared to 2.2 million in 2006. Third, for every one person on antiretroviral therapy, six new people contract H.I.V., signaling a losing battle in the long term. Fourth, only 10 percent of pregnant women with AIDS receive treatment to prevent H.I.V. transmission to their newborns. Every year up to 500,000 pregnant mothers transmit H.I.V. to their newborns. Fifth, a recent study indicates that more than one-third of individuals on antiretroviral therapy in Africa die or discontinue treatment within two years. These individuals die or discontinue treatment for a number of reasons, including commencing treatment very late in their illness, and dying shortly thereafter; inability to travel long distances to receive medications in health facilities; inability to pay for treatment; and the difficulties of juxtaposing struggle for daily survival with the logistics of keeping up with treatment schedules and protocols.

The prevention of new H.I.V. infections has received considerable planning and implementation attention in the fight against the epidemic. Innovative information, education, and communication campaigns have been introduced, focusing on the needs and priorities of target populations. Scientists are working in an unprecedented collaborative effort to produce H.I.V. vaccines. A very promising weapon in the battle to prevent new H.I.V. infection is the preliminary result that male circumcision can reduce new heterosexual infections by up to 60 percent. A recent study in South Africa suggests that exclusive breastfeeding for the first six months of life can reduce the risk of pregnant women transmitting H.I.V. to their babies.

However, the battle to prevent new H.I.V. transmission faces long odds. A credible, clinically effective, and deployable H.I.V. vaccine is 7 years to 10 years away, removing the scenario of a potential quick fix. As earlier noted, six new infections occur for every one person on antiretroviral therapy. More than 90 percent of individuals living with H.I.V. are unaware of their status and may unwittingly continue to transmit the virus. The UNAIDS estimates that only 15 percent of individuals at risk of H.I.V. transmission in some countries are benefiting from appropriate preventive strategies. H.I.V. prevention programs also suffer from inadequate funding. In addition, preventive programs are spread thinly among at-risk groups, with insufficient program attention directed toward behavior modification among target populations.

Although H.I.V./AIDS has multisectoral consequences, most current programs lack linkages to other health and social risk factors that can facilitate H.I.V. transmission. Today, H.I.V./AIDS programs are not adequately addressing the needs of AIDS orphans and street children. Ongoing AIDS programs are rarely integrated with initiatives that prevent childhood and maternal deaths. In most AIDS hard hit countries, programs are not tightly coordinated with national initiatives on poverty alleviation, education, gender equality, and human rights. Fragmented and dysfunctional health systems in countries with a heavy AIDS burden remain long-term concerns. Lack of a qualified health workforce is another long-term threat.

Perhaps, the most fundamental threat in the long-term battle against H.I.V./AIDS is the current lackluster community-based response to the global epidemic. As the emergency response phase of the global epidemic slowly gives way to the phase of leveraging resources, mobilizing target populations, and sustaining successful programs, the long-term battle against the epidemic will be fought at community levels where individuals infected and affected by H.I.V./AIDS live and die. A strong community-based response to H.I.V./AIDS should include sustained information, education, and communication campaigns directed at specific target populations or cohorts; timely access to quality clinical care and support programs; and the availability of comprehensive social services.


The H.I.V./AIDS epidemic continues to challenge the collective will of the international community. The last six years has witnessed unprecedented short-term wins in the fight against the epidemic. Financial, technical, and logistics resources have increased significantly. However, we are in the danger of losing the long-term battle to prevent new H.I.V. infection, to provide timely antiretroviral therapy and support care, and to deal with health and nonhealth facilitative factors that help sustain the epidemic. We are also yet to begin the long battle against H.I.V./AIDS in the communities where the global epidemic is wrecking its most havoc.

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