Governments as facilitators or obstacles in the HIV epidemic

The current trajectory of the HIV/AIDS epidemic is unlikely to change quickly. Five million people will become infected each year despite decades of research that has discovered every preventable means of HIV transmission—via sex, intravenous drug use, blood transfusion, breast feeding, and perinatal transmission.¹ We could try to blame science for having failed to perform research that affects international public health. But the transition from successful clinical research to implementation of public health rests in the hands of governments.

Faced with a crisis of enormous proportions, how do we motivate governments to mount a vigorous public health response? Initially, in the early 1980s, the US government was slow to act, but with constant prodding by activists over $9.7bn is now spent annually for research, education, prevention, and treatment. New HIV infections in the United States have fallen from a peak of about 150 000/year in the 1980s to 40 000/year currently.² Here then is the first ingredient. Activism must be used to keep public health issues continuously in the political forefront.³,⁴

The second ingredient is government acknowledgement of the severity of the epidemic. Several developing countries are recognised for their successful public health response to HIV/AIDS. Thailand's ministry of health established a policy that all pregnant women should be provided with voluntary counselling and testing for HIV. Those who are positive are offered zidovudine; and infants born to HIV-infected mothers are given zidovudine, infant feeding formula, and clinical care.⁵ Brazil provides zidovudine free of charge to HIV infected mothers and infants in public hospitals and combination antiretroviral treatment to HIV infected women, children, and men. Brazil also successfully challenged international drug pricing laws when they seemed to hamper the treatment of this life threatening disease.⁶

A third ingredient is national commitment to prevention. Compare, for example, the different commitment shown by Uganda and South Africa. Uganda's blunt public HIV prevention campaign, coupled with political commitment that extended to all government offices, resulted in greater than a 50% reduction in HIV seroprevalence over four years.⁷ In contrast, facing one of the highest rates of HIV infection in the world, the South African government determined last year that antiretroviral therapy for perinatal HIV prevention was too expensive—a decision that will cost over 70 000 infant lives each year. Months later the government announced spending of $3bn-4bn to refurbish military weapons.⁸ Its leaders now stand accused of violating fundamental human rights.⁹

The fourth ingredient is rapid implementation of prevention methods. India's first documented case of AIDS in 1986 resulted from a blood transfusion.⁹ A two year delay in implementing testing of blood donors is estimated to have resulted in over 350 000 HIV infections. India and South Africa now vie for being the single country with the most people infected with HIV.¹⁰,¹¹ China reported its first HIV infection in 1985. Epidemiological studies then showed that all transmission vectors for HIV were expanding rapidly—large numbers of people were migrating to the cities, and there were increases in the sex trade, in sexually transmitted diseases, and in the number of intravenous drug users. China also has a poorly regulated blood donor system. Pleas to implement prevention measures went unheeded. As a result of the delays China forfeited the chance to play an international leadership role in prevention. It could have been the first nation to avert a major HIV/AIDS epidemic.¹² Instead, in the first quarter of 2001 there was an 67% increase in new HIV infections, and the number of HIV infected individuals in China is expected to reach over 10 million in the next decade.¹³

The fifth ingredient is a change in how resources for public health are determined, along with a reinterpretation of the national and international laws that govern the use of resources for public health. Globalisation creates international trade laws that determine the cost and availability of lifesaving drugs. Nowhere is this more sharply seen than in the antiretroviral drug “price war.” However, when the public health of entire nations is at risk, the basis of these laws cannot be mired in economics.¹⁴

What is a solution to getting governments to move more quickly? Nothing short of a new paradigm. The availability of public health measures must be seen as an issue of justice rather than economics. Patents may protect individuals economically, but if life saving drugs are out of the reach of the poor has justice been served? If governments proceed as usual the relentless spread of HIV throughout the world will ultimately disrupt the social and economic structures that governments say they are out to protect.