Scientific American, 7/98, Jonathan M. Mann, Daniel J.M. Tarantola, page
62
HIV 1998: The Global Picture
Worldwide, the populations most affected by the AIDS virus are often the least empowered
to confront it effectively.
In 1996, after more than a decade of relentless rises, deaths from AIDS
finally declined in the U.S. The drop appears to have stemmed mainly from the introduction
of powerful therapies able to retard the activity of HIV, the virus responsible for AIDS.
Other economically advantaged nations, including France and Britain, have documented
declines as well. But the trend in industrial countries is not representative of the world
as a whole.
Further, the international pandemic of HIV infection and AIDS-composed of thousands of
separate epidemics in communities around the globe-is expanding rapidly, particularly in
the developing nations, where the vast majority of people reside. Since the early 1980s
more than 40 million individuals have contracted HIV, and almost 12 million have died
(leaving at least eight million orphans), according to UNAIDS, a program sponsored by the
United Nations. In 1997 alone, nearly six million people-close to 16,000 a day-acquired
HIV, and some 2.3 million perished from it, including 460,000 children.
This grim picture reflects some other unpalatable facts. Over the years, resources devoted
to battling the pandemic have been apportioned along societal lines. Although more than 90
percent of HIV infected people live in developing nations, well over 90 percent of the
money for care and prevention is spent in industrial countries. This disparity explains
why the new HIV taming therapies, costing annually upward of $10,000 per person, have had
no impact in the developing nations; by and large, these countries lack the infrastructure
and funds to provide the medicines. In a few locales in the developing world, notably in
parts of Uganda and Thailand, public health campaigns seem to be slowing the rate of
infection. Yet those are the exceptions: in most other places, the situation is worsening.
HIV is spreading especially quickly in sub-Saharan Africa and in Southeast Asia. The
region below the Sahara now houses two thirds of the globe's HIV infected population and
about 90 percent of all infected children. In areas of Botswana, Swaziland and several
provinces of South Africa, one in four adults is afflicted; in many African countries,
life expectancy, which had been rising since the 1950s, is falling. Unprotected
heterosexual sex accounts for most of HIV's spread in sub-Saharan Africa, but the problem
is compounded by contamination of the blood supply. At least a quarter of the 2.5 million
units of blood administered in Africa (mostly to women and children) is not screened for
the AIDS virus.In Southeast Asia the epidemic is dominated by India (with three to five
million HIV infected individuals) and Thailand. It is now also raging in Burma and is
expanding further into Vietnam and China.
Mirroring the dichotomy between the developing and the industrial nations, certain
populations within nations are suffering a disproportionate number of infections.
Epidemiologists have been dismayed to uncover a societal-level factor influencing the
distribution: groups whose human rights are least respected are most affected. As
epidemics mature within communities and countries, the brunt of the epidemic often shifts
from the primary population in which HIV first appeared to those who were socially
marginalized or discriminated against before the epidemic began.
Those who are discriminated against - whether because of their gender, race or economic
status or because of cultural, religious or political affiliations - may have limited or
no access to preventive information and to health and social services and may be
particularly vulnerable to sexual and other forms of exploitation. And later, if they
become infected, they may similarly be denied needed care and social support.
Stigmatization therefore pursues its course unabated, deepening individual susceptibility
and, as a result, collective vulnerability to the spread of HIV and to its effects.
As a case in point, 10 years ago in the U.S., whites accounted for 60 percent of AIDS
cases and blacks and Hispanics for 39 percent. By 1996, 38 percent of new cases were
diagnosed in whites and 61 percent in blacks and Hispanics. Further, between 1995 and
1996, the incidence of AIDS declined by 13 percent in whites but not at all in blacks.
Social marginalization, manifested in lack of educational and economic opportunity, also
magnifies risk in the developing world. In Brazil, for example, the bulk of AIDS cases
once affected people who had at least a secondary school education; now more than half the
cases arise in people who have attended only primary school, if that. Moreover, in much of
the world, women (who account for more than 40 percent of all HIV infections) have low
social status and lack the power to insist on condom use or other safe-sex practices; they
will be unable to protect themselves until their social status improves. Recognizing the
societal-level roots of vulnerability to HIV and AIDS, UNAIDS has incorporated advancement
of human rights in its global-prevention strategy.
What will the future bring? In the short run, it seems likely that the international
epidemic will become even more concentrated in the developing countries (that is, mainly
in the Southern Hemisphere), where it will expand. Explosive new epidemics (as in southern
Africa and Cambodia) will coexist with areas of slower HIV spread, and HIV will enter
areas where infection has not yet been detected. And the already overwhelming burden of
care will increase enormously.
In the industrial nations the epidemic will slow, at least for some populations, but it
will take a higher toll on socially marginalized groups. The cost of care will rise
substantially, as more and more infected individuals receive aggressive therapy. In both
the Southern and Northern hemispheres, efforts to address societal forces that enhance
vulnerability to HIV infection and AIDS will most likely proceed slowly, countered by
significant resistance from social elites.
Control of the pandemic will require the extensive broadening of prevention programs. But
given the large numbers of people at risk for infection and the difficulty of effecting
behavioral change, the expansion of prevention programs will have to be coupled with
greater efforts to develop HIV vaccines. The research establishment-both governmental and
private-and international organizations must give highest priority to finding a vaccine
and making it available to those who need it most: the marginalized populations who are
bearing the brunt of the global HIV and AIDS pandemic.