[hivaids-twg] AIDS: lessons learnt and myths dispelled

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Date: Sun, Nov 15, 2009 at 7:39 PM
Subject: [AIDS ASIA] AIDS: lessons learnt and myths dispelled
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AIDS: lessons learnt and myths dispelled

The Lancet, Volume 374, Issue 9702, Pages 1675 - 1676, 14 November 2009.
doi:10.1016/S0140-6736(09)61988

Prof Peter Piot MD a b, Prof Michel Kazatchkine MD c , Mark Dybul MD e,
Julian Lob-Levyt MB d

Nearly 30 years into the AIDS epidemic, we are able to assess our progress
in tackling the disease with both increased knowledge and the benefit of
hindsight. This Viewpoint examines what we—the international community—got
right, what we got wrong, and why we need to urgently dispel several
emerging myths about the epidemic and the global response to it.

When HIV was emerging in the early 1980s, we clearly underestimated the
global effect that the disease would have, and that in only a few decades,
tens of millions of people worldwide would become infected. The epidemic
nowadays is the result of what 30 years ago was an unpredictable—but
tremendously potent—combination of intimate personal behaviours (notably,
unprotected sex and needle sharing) and socioeconomic factors (including
poverty, gender inequity, social exclusion, and migration) that have
affected nearly every country worldwide.

We also underestimated the extent to which stigma and discrimination—against
people living with HIV and those most vulnerable to it—would remain
formidable obstacles to tackling AIDS. Although the introduction of
antiretroviral treatment in developed countries 12 years ago and its
dissemination to developing countries in recent years has largely changed
the perception that AIDS is a so-called death sentence, people living with
HIV/AIDS in many countries continue to experience ostracism, violence,
eviction, loss of employment, and restrictions on their ability to travel.

Stigma and fear of discrimination still prevent many people from accessing
crucial prevention and treatment services, including HIV testing. Roughly 60
countries worldwide continue to deny or restrict entry to people living with
HIV/AIDS, showing how differently HIV infection is perceived and treated
compared with other diseases.

Notwithstanding these challenges, we can also say that, after years of
inadequate action, we underestimated the sense of urgency and solidarity
that would eventually develop in the global AIDS movement, leading to an
unusual convergence of political will, money, and science.

Since the UN General Assembly Special Session on AIDS in 2001, the
international community has substantially increased resources available for
AIDS by creating the Global Fund to Fight AIDS, Tuberculosis and Malaria.
The USA has launched the US President's Emergency Plan for AIDS Relief
(PEPFAR). As a result, more than 3 million people have now gained access to
antiretroviral treatment, which was unimaginable only 5 years ago. People
living with and affected by HIV, non-governmental organisations, civil
society groups, and the private sector are more engaged in the response than
ever before.

However, in an unstable global political and economic environment, we will
all have to work even harder than previously to ensure that this momentum is
expanded and sustained.1

Some aspects of HIV/AIDS were also overestimated in the early years of the
epidemic—notably, the pace with which HIV would spread in regions other than
sub-Saharan Africa.

For example, in the early 1990s, many were concerned that, left unchecked,
HIV in Asia would spread quickly outside concentrated epidemics of sex
workers, men who have sex with men, and injecting drug users, and that the
disease would take on the proportions of the devastating generalised
epidemics occurring in southern Africa.

Fortunately, this scenario has not yet happened, other than in Papua New
Guinea, which now has a serious AIDS epidemic. Nevertheless, the Asian
epidemic is showing its own worrying trends.

A growing proportion of people with HIV in the region are women—notably
married women. In Vietnam, women now account for a third of people
infected.2 At the same time, HIV prevalence in men who have sex with men is
growing across Asia—eg, the proportion of men who have sex with men in
Bangkok who are living with HIV increased from 17% to 28% between 2003 and
2005.3

Because the continent of Asia has a very large population—more than 2•5
million people are living with HIV/AIDS in India alone—it will continue to
demand substantial resources and intensive efforts to improve HIV prevention
strategies and provide treatment to people who need it.

Meanwhile, our ability to estimate the number of people living with HIV/AIDS
has become increasingly advanced. Estimates from UNAIDS/WHO are based on all
relevant data available, including surveys of pregnant women attending
antenatal clinics, population-based surveys, sentinel surveillance in
populations at increased risk of HIV infection, case reporting, and
registration systems.

Different combinations of these approaches, and the consensus reached by
leading experts nationally and internationally, are producing both improved
data from country surveillance and steady advances in modelling methods. The
overall result is increasingly accurate estimates.

Despite the remarkable innovations and successes of antiretroviral
treatment, we have also overestimated our capacity to devise technological
solutions to prevent HIV.

Notwithstanding the optimistic projections of the US Health and Human
Services Secretary Margaret Heckler in 1984, that an AIDS vaccine would be
ready for testing in about 2 years, we still seem many years away from
either a vaccine or a microbicide to protect against HIV transmission,
especially after a recent series of disappointing trial results.4, 5

Nevertheless, much has been learned about how HIV enters and acts within the
body, and continued investments in new prevention technology remain a
crucial part of the AIDS research agenda.

Encouragingly, in the past 2 years, studies have shown that male
circumcision reduces HIV infection in men by up to 60%,6 although it does
not reduce transmission from men to women or between men.

One of the most common myths is that HIV prevention is not working.

However, much evidence suggests that, in several countries, prevention
programmes are effective. Between 2005 and 2007, coverage of services to
prevent mother-to-child transmission of HIV increased from 14% to 33%.7 As a
result, in 2007, we noted for the first time a substantial decrease in the
number of children born with HIV.

Prevention is, of course, about not only technology, but also behaviour. In
many countries on several continents, changes in sexual behaviour (such as
waiting longer to become sexually active, having fewer partners, and
increased condom use) have been followed by reductions in the number of new
HIV infections, providing evidence that efforts to change behaviour can and
do work.8

However, sustaining behaviour change in the long term remains a major
challenge. For example, the number of new HIV diagnoses in men who have sex
with men doubled in Germany between 2002 and 2006, and increased by more
than three-quarters in Switzerland.2

These data could be attributable to complacency about AIDS and the sense
that a treatable disease is somehow less threatening than are other
diseases, and to a decrease in HIV prevention efforts in western Europe.

Some developing countries that have previously had much success with HIV
prevention, such as Uganda, have also had increases in rates of HIV
transmission.2

Another major challenge is that, nearly 30 years into the epidemic, only
about half of countries have national HIV prevention targets, whereas nearly
90% have targets for AIDS treatment.

Furthermore, when prevention programmes do exist, they are often
under-resourced and do not have the quality and scale that are needed to
have a real effect in communities. They need to be better targeted to where
the epidemic is, both in terms of populations at risk and geographic areas.
Much has been published about the need for precise targeting of HIV
prevention, especially in concentrated epidemics.

But even saturation coverage of vulnerable groups will have little lasting
effect without concerted and concrete efforts to change social standards and
tackle social factors of the epidemic, such as homophobia and the low status
of women in many societies. Programmes also need to be designed and managed
more efficiently, including increased use of skills and practices from the
business sector.9, 10

An increasingly recurrent myth is that one solution, or a so-called silver
bullet, will comprehensively prevent HIV transmission. Elimination of
concurrent partnerships, circumcision of all men, focusing of prevention
efforts on sex workers, universal HIV testing, and provision of
antiretroviral therapy as soon as possible after infection, have all
received attention as potential solutions for prevention of HIV
transmission.

Scaling up strategies for harm reduction, such as methadone substitution and
the provision of clean needles for injecting drug users, remains neglected
in many countries in which injection drug use is a major means of HIV
transmission.

Although these strategies are all important, no approach will be enough on
its own, and the promotion of one solution is, in our view, irresponsible.

If we have learned one lesson in the past 27 years, it is that effective HIV
prevention depends on customising the right mix of interventions for every
context and ensuring the necessary coverage of them.8 If we are to
successfully increase access to HIV prevention, we have to be prepared to
come to terms with complexity, effectively use all the methods that are
available, include affected communities, engage relevant business expertise,
and foster leadership to help change harmful social norms.

Another prevailing misconception is that heterosexual transmission of HIV is
uncommon outside Africa. Generalised epidemics are occurring in Haiti and
Papua New Guinea, whereas heterosexual transmission drives the epidemic
between sex workers, their partners, clients, and clients' partners in Asia
and elsewhere.

HIV infections in women are rising worldwide. The main method of
transmission in Thailand is no longer between sex workers and their clients
or between injecting drug users: it is between married couples.3

Furthermore, AIDS remains the leading cause of death in African-American
women in the USA.11 To characterise all African epidemics as exclusively
heterosexual is also incorrect.

Methods of transmission and affected groups are many and varied. In Kenya,
for example, HIV infections in men who have sex with men and injecting drug
users are an increasing cause for concern.12

Although such observations neither indicate nor predict extensive or
generalised HIV epidemic spread, they do draw attention to the fact that
heterosexual transmission of HIV occurs in a wide range of settings. They
also show that the HIV epidemic is constantly evolving, and continually
surprising.

As we approach the fourth decade of the AIDS epidemic, new global challenges
are competing for the attention of political leaders and donors at the same
time as they face the present financial crisis.

Alarmingly, a myth has begun to emerge that too much money is spent on AIDS.
But AIDS remains the leading cause of death in Africa and the sixth highest
cause of mortality worldwide.13 It is fitting that investment in fighting
AIDS has finally begun to increase substantially, rising from a paltry
US$250 million in 1996 to around $14 billion in 2008.14

Even so, UNAIDS estimates that available resources at present fall well
short of what will be needed to reach coverage targets for 2010.14

Moreover, mobilisation around AIDS has increased available resources for
tuberculosis and malaria (largely through the Global Fund) to unprecedented
amounts and generally contributed to an increase in global funding for
health.

Increased resources are beginning to have an effect, as are antiretroviral
treatment programmes, which have been established in developing countries
for less than 5 years.

Among the first was in Malawi, which recorded a 44% reduction in mortality
in workers at the national electricity company—one of the country's largest
employers—after the roll-out of antiretroviral treatment.15 In Botswana,
where HIV prevalence has reached 30%, mortality has begun to fall in the age
groups most affected by AIDS since the introduction of antiretroviral
treatment.16

Another major myth that needs to be dispelled is that investments in AIDS
are being made at the expense of health systems that are chronically
underfunded. Although AIDS has exposed weaknesses in health systems, funds
for this disease are making a major contribution to the strengthening of
health systems.

The Global Fund and PEPFAR are now among the biggest investors in health
systems, joining other funders such as the GAVI Alliance.

Although drugs and other commodities account for nearly half of Global Fund
spending (figure 1), 35% of the Fund's financing for AIDS, tuberculosis, and
malaria contributes directly to supporting human resources, infrastructure
and equipment, and monitoring and evaluation: all key components of health
systems.

Overall, the Fund has committed more than $4 billion in these three areas.
>From 2004 to 2009, on the basis of conservative estimates, PEPFAR will
commit more than $4 billion to health systems, including more than $1
billion in 2009 alone (figure 2).


Figure 1 Full-size image (25K)
Direct funding of health systems through Global Fund grants


Figure 2 Full-size image (37K)

PEPFAR planned investments in health-systems-related programmes and
bilateral programme support in 15 countries in 2009
The results of these investments are clearly noticeable on the ground, where
AIDS resources are contributing to the refurbishment of health centres, the
hiring of new health workers, and the establishment of local schemes for
national health insurance.

In Ethiopia, resources from the Global Fund and PEPFAR are strengthening the
health system and enabling the rapid scale-up of diagnostic and treatment
services for AIDS and tuberculosis.

AIDS programmes have other benefits for health systems. In many African
countries, AIDS services and treatment keep health workers alive, healthy,
and able to work.

A study in Rwanda,17 for example, showed that within 2 months of starting to
provide antiretroviral treatment in PEPFAR-supported sites, the average
number of new admissions at seven sites dropped by 21%, freeing up health
workers and enabling valuable resources to be dedicated to other health-care
needs.

AIDS resources have greatly strengthened overall laboratory capacity and
systems for distribution of drugs. In Nicaragua, new equipment financed by
the Global Fund for the National Reference Laboratory enables not only
processing of HIV tests, but also processing and storage of blood samples
taken for other purposes.

A further myth that has emerged suggests that strengthening health services
alone will solve the world's health problems, including AIDS. Improvements
to health infrastructure and measures to tackle the human resources crisis
for health are long overdue in many countries and deserve much support,
especially since they will be essential for the further roll-out of
antiretroviral treatment.

At the same time, what might have happened to the 4 million people on
antiretroviral therapy in developing countries if we had waited until health
services had been strengthened before launching HIV treatment programmes is
a sobering thought.

Improved health systems alone are not enough to end the AIDS epidemic. We
have known since the early 1990s that, although the health sector has a
major role in provision of HIV treatment, it cannot and does not meet the
full range of needs.

Whereas well functioning health and community services will be key to
provision of antiretroviral therapy for decades to come—as well as services
for the prevention of mother-to-child HIV transmission, blood safety, and
male circumcision—most other HIV prevention activities are happening largely
outside the health sector. This tenet is especially true in the case of
programmes that reach populations at high risk and at the margins of
society, youth, and injecting drug users, and programmes promoting social
change.

AIDS funding is often used to lend support to the establishment of quality
sex-education programmes in schools, efforts to eliminate violence against
women, and care for orphans. The benefits of such activities extend far
beyond an effective AIDS response.

A last myth is that AIDS has somehow been solved. However, we have only just
begun to see a return on the investments of the past decade in the form of
falling rates and fewer deaths, indicating a new phase in the AIDS response;
it by no means suggests that the problem is anywhere near solved. This new
phase is characterised by a new set of challenges that could well prove more
difficult than any that we have encountered so far.

We need to recognise that AIDS is a long-term event. Tackling it is complex,
but our successes so far indicate what is possible. In the future, we should
pay far greater attention to epidemiological trends and to the social
factors driving them. We have to identify now how to finance a sustained
response to AIDS for another several decades, and develop longlasting links
with broader efforts to strengthen health systems and health workforces as
well as other development efforts, such as in education and food security.

At the same time we have to continue to invest in research and development
to produce improved diagnostic tests and less toxic and more effective
drugs, in addition to microbicides and vaccines.

A serious and concerted effort is also needed to tackle stigma and
discrimination, ensuring that people most at risk actually receive the
services that they need. Only when we have met all these aims will we be
anywhere close to the point at which we can truthfully say that the fight
against AIDS is being won.

Contributors
PP and MK jointly drafted the article, MD provided significant editorial
input to the draft, and JL-L provided editorial input to the draft.

Conflict of interest statement

We declare that we have no conflict of interest.

Acknowledgments
We thank Sarah Russell, Ian Grubb, and Rebecca Affolder for their assistance
in the preparation of this article.

References
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2 UNAIDS/WHO. AIDS epidemic update, 2007. Geneva: UNAIDS/WHO, 2007.

3 Commission on AIDS in Asia. Redefining AIDS in Asia: crafting an effective
response. New Delhi: Oxford University Press, 2008.

4 Buchbinder SP, Mehrotra DV, Duerr A, et alfor the Step Study Protocol
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6 Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A.
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| PubMed

7 WHO/UNAIDS. Towards universal access scaling up priority HIV/AIDS
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5, 2009).

8 Merson MH, O'Malley J, Serwadda D, Apisuk C. The history and challenge of
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9 Piot P, Bartos M, Larson H, Zewdie D, Mane P. Coming to terms with
complexity: a call to action for HIV prevention. Lancet 2008; 372: 845-859.
Summary | Full Text | PDF(635KB) | CrossRef | PubMed

10 Bertozzi SM, Laga M, Bautista-Arredondo S, Countinho A. Making HIV
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11 US Centers for Disease Control and Prevention. Revised recommendations
for HIV testing of adults, adolescents, and pregnant women in health-care
settings. MMWR Morb Mortal Wkly Rep 2006; 55: 1-17. PubMed

12 Gouws E, White PJ, Stover J, Brown T. Short term transmission estimates
of adult HIV incidence by mode of transmission: Kenya and Thailand as
examples. Sex Transm Inf 2006; 82: 51-55. PubMed
13 WHO. The global burden of disease: 2004 update. Geneva: World Health
Organization, 2008.

14 UNAIDS. What countries need: investments needed for 2010 targets. Geneva:
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15 The Global Fund to Fight AIDS, TB and Malaria. Partners in impact:
results report. Geneva: The Global Fund to Fight AIDS, TB and Malaria, 2007.


16 Stoneburner R, Montagu D, Pervilhac C, et al. Declines in adult HIV
mortality in Botswana, 2003—2005: evidence for an impact of antiretroviral
therapy programs. Sixteenth International AIDS Conference, Toronto; 2006
(abstr THLB0507).

17 Price JE, Micomyiza E, Nyeimana V, Tchupo J. Integrating HIV clinical
services in primary health care centers in Rwanda: effect on the quantity on
non-HIV services delivered. HIV Implementers Meeting; Kigali, Rwanda; June
17, 2007.

a Institute for Global Health, Imperial College, London, UK
b Bill & Melinda Gates Foundation, Seattle, WA, USA
c The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva,
Switzerland
d GAVI Alliance, Geneva, Switzerland
e O'Neill Institute for National and Global Health Law, Georgetown
University Law Center, Washington, DC, USA

Correspondence to: Prof Michel Kazatchkine, The Global Fund to Fight AIDS,
Tuberculosis and Malaria, Chemin de Blandonnet 8, 1214 Vernier, Geneva,
Switzerland
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