| Fall 2001;
Volume 2, Number 2|
Confronting the Global HIV Epidemic: A Call for EquityLaura Tarter and Paul Farmer, MD
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The dimensions of the global HIV crisis are such that predictions
termed alarmist a decade ago are now revealed as sober projections.1 In 2000, HIV overtook tuberculosis as the worlds leading infectious cause of adult death. HIV has, in fact, overtaken the 1918 influenza epidemic as the most devastating communicable cause of adult death since the bubonic plague of the 14th century.2 With each passing year, HIV is becoming increasingly concentrated among the poor; at this writing, HIV incidence is declining in wealthy countries and more than 95% of new infections occur in the developing world (Figure 1).3
Figure 1: Adults and children estimated to be living with HIV/AIDS as of the end of 1999.
Close to 80% of cumulative AIDS deaths to date have occurred in Africa, the worlds poorest continent.4 While the virus is tearing through poor communities at a frightening pace, life-saving therapeutics are not following suit. At the same time that AIDS mortality has dropped precipitously in affluent countries, in large part because of access to highly-active antiretroviral therapy (HAART), the death toll mounts in the so-called developing world, where treatment is deemed unsustainable. 5 ,6 ,7 We argue that it is not the treatment of the destitute sick that is unsustainable, but rather the ever-widening global outcome gap that prohibits the fruits of science from reaching those most in need of them.
Here in rural Haiti, where we have been treating people infected with HIV/AIDS for several years, it wasnt long before patients began asking for one of the latest scientific developments, antiviral cocktails. Adeline Merçon did not ask for the medications, even though more than a decade of battling with HIV had worn her down to less than 80 pounds; her father asked instead for money for a coffin. He could see by November 1999 that Adeline wasnt going to last much longer (Figure 2).
Figures 2 (l) and 3 (r): Adeline Merçon in November 1999 (left) and in January 2000 (right).
Instead of a coffin, however, we gave Adeline a three-drug cocktail of anti-HIV drugs. And between November 29th, when she began therapy, and January 2000, she gained 26 pounds (Figure 3). Adeline is aware of the debates surrounding the use of these agents in what are euphemistically termed resource-poor settings. She is now devoting her time to the HIV Equity Initiative based not far from her home village.
If the drugs cost a lot, there must be a reason, she commented in a recent meeting. Science made them, so science will have to find a way to get them to poor people, since were the ones who have AIDS.
Examining global trends in confronting the epidemic might not bolster Adelines optimism. And no wonder: globally, billions of dollars have been invested in AIDS prevention and treatment, but the epidemic marches on. AIDS-prevention efforts have failed in precisely those areas where they are needed most. And yet in these very areas - poor communities in developing countries - we are encouraged to restrict our AIDS-related activities to prevention alone. Take, as an example, the worlds largest pot of AIDS funding targeted to the developing world. The hundreds of millions of dollars disbursed by USAID through Family Health International have until now gone almost exclusively for prevention, even though the efficacy of these interventions is difficult to demonstrate.8 The exception more recently has been to fund palliative care (sometimes under the euphemism community-based care) or low-cost prevention of certain opportunistic infections.
By this point, readers may conclude that we are making an attack on prevention or public-health approaches to HIV, but this is simply not true. We are calling instead for a redoubling of our efforts to improve prevention, including vaccine development and educational tools. Prevention, however, will be most effective as part of a comprehensive plan to meet widespread demands for treatment and health equity in general. It is high time to admit the limitations of existing prevention strategies.
Prevention is cheap, compared to therapy for people already infected with the disease. But what is the cost of focusing solely on prevention, given our current limitations? First, we fail to represent the aspirations of those already infected or sick. They will number, soon enough, more than 100 million.9 This large number represents parents, farmers, doctors, teachers, factory workers - the very fabric of a society as we know it. Second, letting HIV disease run its course in high-burden countries will mean - and has already meant - significant reductions in life expectancy with many drastic social consequences, even if new infections were to cease immediately.10 The number of AIDS orphans grows, with sober projections of 40 million orphans by 2010 on the continent of Africa alone (Figure 4).11
Figure 4: Cumulative number of children estimated to have been orphaned by AIDS at age 14 or younger, as of the end of 1999.
Many children left to fend for themselves will eventually turn to sex work, crime, or will perhaps become soldiers in local conflicts. They will almost certainly live out their lives in poverty. And if little is done, they too are likely to die of AIDS, which is already causing ten times as many deaths in Africa as war.12 Third, other diseases will emerge. Throughout sub-Saharan Africa and beyond, HIV is driving the frightening rise in tuberculosis incidence. The wealthy country of South Africa shows rates of TB to be two or three times higher than those registered in far poorer countries where HIV is not a ranking problem.13
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