The Politics of Life and Death: Global Responses to HIV and AIDS.

• Author: Caron, Mary
• Position: Statistical Data Included

If effectively fighting HIV means openly getting condoms to teenagers or clean needles to addicts, or candidly discussing the prevalence of prostitution in their communities, many politicians would rather avoid the subject altogether even if it means allowing an epidemic to flourish. Where leaders have lifted their heads from the sand, however, millions of lives have been saved.

Both Rajesh and his wife - who prefers not to give her name for fear of being ostracized by neighbors in their Bombay community - are infected with HIV. With the help of money quietly contributed by relatives, they are among the few families in India who can pay for life-prolonging anti-viral drugs - but only for Rajesh. Other couples in India are finding themselves in a similar situation. "It is the woman who is stepping back" so her husband can get treatment, said Subhash Hira, director of Bombay's AIDS Research and Control Center in a recent Associated Press story. "She thinks of herself as dispensable."

In Zimbabwe, where 200 people are dying every day from AIDS, life insurance premiums have quadrupled to keep up with rising costs. It would take roughly two years for the average Zimbabwean to pay for one month of treatment at U.S. rates.

In the United States, of course, incomes are much higher - about 74 times those in India, and 46 times those in Zimbabwe. Yet, even here, nearly half of HIV positive patients in a recent national study had annual incomes less than $10,000, whereas the annual costs of their care and treatment came to about $20,000. Two of every three patients in the study had either no insurance or only public health insurance - which may not adequately cover their needs.

And then there is the Central African Republic, where I worked as a Peace Corps volunteer a few years ago. The five-bedroom house where I lived was owned by my neighbor, Victor, who rented it to me while living in a more modest mud-brick house next door. He used the income from rent, plus whatever his eldest daughter could earn selling food in the market, to support ten people. One of them was a little girl of five or six, who used to come over and sing me songs. I didn't realize that Victor was her uncle, not her father, until someone explained that her mother and father had died following "a long illness." There arc many households like Victor's. Worldwide, more than 41 million children will have lost one or both parents by 2010, mostly as a result of AIDS. The grandparents or other surviving family members, who often have their own difficulties making ends meet, may find themselves taking care of up to a dozen children.

Clearly, AIDS is a disease that the world cannot afford. And yet, the relentless spread of the virus forces us to confront painful life-and-death choices about allocating resources. Communities, nations, and international donors are all struggling to care for a growing number of the sick; to invest in prevention that can avert millions of future infections; to fund research that can yield life-prolonging treatments; and ultimately to develop a vaccine. To do all of these things at once seems an almost impossible task. But experience in the field demonstrates that there are reasons for hope, even in relatively poor countries where HIV is already a serious problem.

While other diseases target children or the elderly, HIV often strikes otherwise strong and healthy people - those most likely to be taking care of children and contributing to the economy. And it does so in a way that has repeatedly caught societies unprepared. HIV does not kill within a matter of days or weeks, like other infectious diseases; rather it gives death a kind of "rain check." The asymptomatic period may last 10 years or longer in a country like the United States, though the infection can progress to AIDS in as little as two to three years in a country like Zimbabwe or India, where the percentage of people who can get full treatment and care is much smaller. An infected person may be iii off and on for years, requiring extended care from family or community members. And HIV, while relatively slow to develop in the body, can spread rapidly within a population. About 75 percent of HIV transmission worldwide is through unprotected sex. The rest occurs mainly through sharing of unsterilized needles, through childbirth or breastfeeding from an infected mother to her child, and from the use of infected blood in transfusions.

AIDS now rivals tuberculosis as the world's most deadly infectious disease. Every day last year, 16,000 people were infected with HIV - 11 people per minute. Women now account for 43 percent of all adults with HIV/AIDS. And about half of all new infections are in 15- to 24-year-olds. Since AIDS was first recognized in 1981, more than 47 million people have become infected and nearly 14 million have died. The epidemic has taken its heaviest toll in Africa, which has just 10 percent of the world's population but 68 percent of the HIV/AIDS cases - most of them in the sub-Saharan region. In some southern African countries, one in four adults are HIV positive. Thus, the world's poorest countries arc staggering under the burden of the world's most unaffordable disease.

As HIV wears down the body's defenses and the infected person becomes increasingly iii from opportunistic infections, the costs of providing care and treatment mount. Worldwide, about 63 percent of the $18.4 billion spent on HIV/AIDS in 1993 went to care, according to a 1996 study by Harvard researchers Daniel Tarantola and the late Jonathan Mann.(*) Another 23 percent was spent on research and just 14 percent on prevention. Moreover, only 8 percent of global spending took place in "low economy" countries of the developing world, yet more than 95 percent of all HIV-infected people live in developing countries.

Preventing an HIV infection costs much less than caring for an infected individual. And the benefit of prevention is compounded, since preventing one person from getting HIV keeps that person from spreading it to others. If a man has sex with three different women in a year, shielding that man from infection also shields his three partners and any children they may have.

However, global resolve to protect the uninfected may be overwhelmed by the challenge of providing for the staggering number already infected. AIDS already rivals the horror of the smallpox epidemic which decimated Native American populations in the 16th century, and the Black Death which wiped out a quarter of Europe's population in the 14th century. If one of every four adults is already infected in Botswana and Zimbabwe, what hope is there for those countries and their neighbors? Many people may now be under the impression that Africa is a continent essentially lost to AIDS, and that the rest of the developing world may soon follow.

Look more closely, however, and two signs make it clear that the situation is far from hopeless.

First, more than half of the populations of developing countries - about 2.7 billion people - live in areas where HIV is still low, even among high-risk groups. Another third live in areas where the epidemic is still concentrated in one or more high-risk groups, yet "HIV prevalence" - the proportion of a population infected at a given time - is still below 5 percent in the general population. Even in hard-hit Africa, there are at least a few countries - such as Benin, Senegal, Ghana, and Guinea - where adult infections arc still under 3 percent. These areas of relatively low HIV prevalence present a one-time opportunity - and one that will not last long - for policy makers to implement solid strategies for keeping HIV at bay.

Second, even in places where the epidemic has taken hold, campaigns to stop further escalation have proven successful in both the early and the later stages of an epidemic. It's instructive to see how that was done in each case - first in Thailand, where an effective campaign was able to ward off an incipient epidemic and to keep prevalence relatively low in the general population, and then in Uganda, where a high percentage of the population was already infected.

By taking action relatively early, Thailand was able to keep HIV infections...