Rallying for action

The XV International AIDS Conference provided a platform to reflect on the missed opportunities of the past decade to safeguard Asia, Africa and other regions against the epidemic, to create a consensus that it has emerged as a global security threat, and to push the leaders of nations to understand the implications of politicking on such a vital issue.

in Bangkok

One out of every four people infected with HIV (human immunodeficiency virus) in the world last year was Asian. One out of every seven people living with HIV is an Indian.

UNAIDS report on the Global AIDS Epidemic, 2004.

TEN years after the earliest warning bells were sounded for Asia at the X International Conference on Acquired Immune Deficiency Syndrome in Yokohama (Frontline, September 23, 1994), the XV International AIDS Conference in Bangkok managed to draw global attention to the massive, smouldering HIV/AIDS/tuberculosis epidemics of Asian countries. The meeting was a reflection on the missed opportunities of the past decade to safeguard the futures of Asia, Africa and other regions in transition. It again foregrounded the need to view AIDS as a global security threat in a globalised world, a crisis moving ahead of traditional threats, such as terrorism and nuclear proliferation. Above all, it underscored the need for assertive leadership from nations to negotiate with one another to shape a safer world for all, not just a few.

The theme of the Conference was `Access for All', a rallying cry not just for anti-retroviral (ARV) treatment but for, as Joep Lange, president of the International AIDS Society, put it: "Access to unbiased information and education about AIDS, access to effective prevention tools, comprehensive medical care, resources and all things that will minimise the impact HIV/AIDS has on human lives." The theme could not have been better chosen; the events that unfolded in Bangkok showed that the global response to AIDS is still being stymied through an obsessive need to control it for narrow ends such as profit or ideology. The direct and indirect controls come not so much from United Nations agencies as from all levels within governments, big business and global institutions that pit the players against one another, when, in fact, each is a vulnerable stakeholder in the pandemic. The controls reach across the spectrum, from funding to prevention strategies to ARV drugs. The most obvious and earliest casualties are those who are already impoverished, marginalised or victimised as evident from the continued concentration of the epidemic among populations in developing countries, drug users, sex workers and women.

Thailand, a leader in the region's response to AIDS, once again displayed its commitment by hosting the conference, which drew the largest number of delegates to any health conference in history. The over 19,000 participants included injecting drug users and Prime Ministers, sex workers and Presidents, physicians and film stars, people living with HIV and multinational pharmaceutical companies, royalty, Miss Worlds, donors and U.N. representatives, non-governmental organisations (NGOs) and a jumbo media contingent of over 1,000 people. Yet it was not excitement but a pall of grim, tired resolve that hung over the meeting from start to finish. The restraint was punctuated with the occasional outburst of anger and demonstration against the United States government for its alleged attempts to protect the interests of pharmaceutical companies rather than those of people living with AIDS and for indirectly withholding funding from crucial prevention programmes that promoted condom use rather than sexual abstinence and fidelity.

That high-power international meetings under the glare of the media can also force commitment for the better became evident from Thailand Prime Minister Taksin Shinawatra's opening speech. The man who waged a `war on drugs' that sanctioned the brutal massacre of over 3,000 suspected drug users and traffickers in Thailand less than 10 months ago announced a new governmental policy of harm reduction for drug users that would reduce their risk of HIV infection. He said: "In the past, drug use was treated like a crime which warranted heavy punishment. At present, our mindsets have changed and we now see drug users as patients who require our support and treatment." And, in what was seen as a particularly pertinent message for Asian leaders, U.N. Secretary-General Kofi Annan stressed that stronger leadership was required at every level to respond effectively to HIV/AIDS. "We need leaders everywhere to demonstrate that speaking up about AIDS is a point of pride, not a source of shame. There must be no more sticking heads in the sand, no more hiding behind a veil of apathy." he said.

SPECTATORS were treated to a replay of the events at Barcelona two years ago during the XIV International AIDS Conference (Frontline, August 16, 2002). Activism and apathy, foreign aid and advice evoked passion and despair through the discussions, against an increasingly dizzying backdrop of escalating HIV rates in Africa, Asia, Eastern Europe and - of all places - North America.

The year gone by notched up 5 million new HIV infections, the maximum number in any one-year period, which takes the global total to 38 million people with HIV by the end of 2003. Increases in HIV infections were reported from every region of the world. Africa's tale is the most chilling: over 25 million are infected and 60 per cent of Africa's 15-year-olds may not live to be 60 years, if the epidemic is not slowed down. If the overall HIV prevalence rate in Africa - the total snapshot of new and old infections present in the population at the moment - appears stable, it is not because there are no new infections, but because the number of the dead is simply replaced by the number of new infections.

Over a million people were infected in Asia last year and there have been an explosive increase in HIV infection rates in Vietnam, Indonesia and China. Central Asia and Eastern Europe are the stage of major HIV epidemics among drug users, with over 80 per cent of those infected below the age of 30.

The vital reminder that the response to HIV/AIDS is going to be a long haul and that no country can afford to rest on past successes came from the U.S. and western Europe, where 50,000 and 40,000 new infections have been added to their 2001 pool of 900,000 and 540,000 respectively. Last year, AIDS became the leading cause of death among African American women between the ages of 25 and 34 years in the U.S.

One out of every two people living with HIV in the world today is a woman and the trend towards the feminisation of the epidemic seems set to continue. Already, women account for nearly 60 per cent of the HIV infections in Africa and women between the ages of 15 to 24 constitute three-fourths of the infections among young people.

Asia's epidemic is primarily driven by sex work, needle sharing and same-sex behaviours, according to epidemiologist Tim Brown of the MAP (Monitoring the AIDS Pandemic) Network. Prevention efforts focussed on drug users in the form of needle exchange programmes or on sex workers and clients through condom promotion programmes are critical to slowing down the spread of HIV in Asia. However, the coverage of such programmes needs to be large enough to have any measurable positive outcome. According to Brown, over 60 per cent of all contacts of sex workers in a country must use condoms in order to actually roll back the epidemic.

"HIV infections in the so-called general population will not balloon into huge epidemics. This means our prevention efforts must stay focussed on populations where infections are actually occurring," he said.

India has about 821 such targeted intervention programmes on the ground, barely a fraction of the numbers required to deal with the situation. The Bill and Melinda Gates Foundation's $200 million will begin to close that gap, as it is poised to carry out focussed prevention among especially vulnerable populations in the six high prevalence States in the country, according to Ashok Alexander, Director of Avahan, the Gates AIDS India initiative.

If India fails to implement aggressive prevention education and condom promotion and work for empowerment among sex workers and their male clients, it could end up sacrificing the lives of millions of India's ignorant, powerless, married monogamous women: the double standards of sexual morality for men and women in Asia may actually ensure that the chains of HIV transmission will stop once they reach traditional Asian households as faithful Asian wives die of AIDS-related illnesses, without spreading the infection.

THE inequitable response to AIDS has led to a situation where only one out of five people in the world has access to HIV prevention services and less than one in 10 people in developing countries have access to anti-retroviral treatment. But people need to know their HIV status in order to know whether they require treatment. The overwhelming majority of people living with HIV worldwide are unaware that they are infected.