World AIDS Campaign 1996
This year's theme - One world. One hope - is that of the 11th International Conference on AIDS, held in Vancouver in July this year. It reflects the fact that HIV and AIDS are global problems affecting all countries, and at the same time it invites us to be optimistic and build on some of the more hopeful trends now emerging. One world. One hope on World AIDS Day 1996 means working together to prevent the spread of HIV, and to build a global society which offers care and support to all those whose lives have been affected by the epidemic.
World AIDS Day has now become an annual event in most countries. Although 1 December is set as the date for the day, in many communities a range of activities are organized during the weeks and days before and after the official commemoration.
World AIDS Day provides an important opportunity to raise awareness of HIV and AIDS in the general public, to carry prevention messages into communities, to improve care for those infected by HIV, and to fight denial and discrimination. It is an opportunity to show solidarity with the over 22 million people who are today estimated to be living with HIV or AIDS and to remember the millions who have died. World AIDS Day can also serve to raise funds for HIV/AIDS projects in your own communities and to support national and international efforts to combat the epidemic.
Some of the kinds of activities that have been traditionally organized on World AIDS Day are:
• candlelight vigils and marches;
• mobile theatre and theatre performances;
• poetry recitals;
• public debates;
• art exhibits;
• marathon runs;
• bicycle races;
• poster competitions;
• media prevention campaigns;
• media briefings and seminars;
• celebrity concerts;
• celebrity sports events.
In however big or small a way, we hope you will join us this year.
World A IDS D ay 1996: One World. One Hope
The theme of this year's World AIDS Day ( 1 December 1996 ) - One World. One Hope - echoes that of the 11th International Conference on AIDS held in Vancouver in July this year. "Improved drugs and drug combinations are bringing hope to infected people - at least those who can afford the new therapies," says Dr Peter Piot, Executive Director of UNAIDS. "On the prevention front, there is also hopeful news. The challenge is to ensure that these hopes extend to all those threatened by the epidemic."
The Day's activities and events aim to capture the upbeat spirit which is just starting to pervade work surrounding the worldwide HIV/AIDS epidemic. For the first time since the epidemic began around 15 years ago, there are cautious grounds for optimism. The prospect of a world in which the spread of HIV and AIDS can be slowed, and the suffering they cause alleviated, is finally dawning.
Under the banner of One World. One Hope , World AIDS Day 1996 is an occasion for focusing public and official attention on the epidemic. The Day has now become an annual event in most countries. It is used by those responding to the epidemic to provoke public discussion of AIDS issues and promote the spread of up-to-date information. On the strength of good news, World AIDS Day 1996 should be a landmark occasion.
According to UNAIDS, the United Nations body coordinating the international response to the epidemic, it would be premature to imply that AIDS is on the run. Over 22 million men, women and children are already living with HIV - the virus that causes AIDS - and others daily join them. More than three-fifths are in Africa and another fifth in Asia , which places the vast majority beyond the reach of the latest drugs and medical technology.
Every day, there are around 8,500 new HIV infections. About 1,000 occur in children under 15. Most of the remainder occur in people in the prime of their economic and reproductive life. An increasing proportion are in women, now representing 42% of HIV infections. Over half are in young people under 25 years old. Altogether, nearly 8 million people, including 1.5 million children under 15, have already developed AIDS since the epidemic began, and nearly 6 million have died. Over 9 million children under 15 have lost their mothers to AIDS.
AIDS is an appalling and continuing tragedy. It is not an outbreak and it is not going to go away. In many countries and societies, the epidemic is just emerging. In some, it is raging out of control. But the good news is that there are now places - both within the geography of the human body and within that of the world - where the AIDS virus has been put on the defensive. Their numbers are few but growing, and they are significant enough to suggest light at the end of a very long tunnel.
The medical breakthroughs: Combinations of drugs that act against HIV have been able to slow the progress of AIDS, even reducing the amount of virus in infected patients. In addition, one such drug - zidovudine (also called AZT) - has been shown to reduce the chances of transmission of the virus from an HIV-positive woman to her newborn child. However, because of their costs and the sophisticated monitoring they require, these medical breakthroughs are only available at present in high-income environments or for high-income patients. This is the downside of technological progress so far.
The prevention breakthroughs: Where vigorous efforts have been made to change social attitudes which pave the way for HIV, campaigns to encourage people to take self-protective action are showing definite results. These results include increased condom use in a variety of settings. They include postponing first sexual intercourse. For men in particular, they include having fewer partners and visiting prostitutes less often. They include declines in the number of sexually transmitted diseases (STDs) - a key achievement because a person with an STD is much more likely to contract HIV.
More important still: these efforts are managing to reduce the spread of HIV. This is happening not only in high-income environments such as Australia and Northern Europe , but in cash-strapped African countries such as Uganda . And it is happening in such countries in spite of the fact that a lower level of development inhibits both the spread of correct understanding about AIDS and the spread of services. When coupled with political determination to make the social and economic environment antipathetic to HIV, preventive strategies can and do work. In Thailand , a pioneer of AIDS action in Asia , HIV infections today are running at one-quarter of their 1990 level.
One World. One Hope
Today, neither One World nor One Hope is the reality for many of those living with HIV. Often the contrary is true. The need to remedy this is an important inspiration of the World AIDS Day message.
Many of those living with HIV still experience stigma and rejection, even in places where infection is commonplace. HIV can still precipitate a person's relegation to an isolated, marginalized and discriminatory "world", in addition to one dominated by pain, illness and impending mortality in a hostile climate where elementary health care is absent.
Nor is One World the experience of many fighting the epidemic as preventers and carers. In different settings the epidemic has different characteristics. All too often, it concentrates its damage on those whose state of disadvantage or way of life already often carries social, cultural or economic penalty. But beyond this constant lies infinite diversity. The primary method of HIV transmission, the number, age groups and sex of the majority infected, their occupations, lifestyles and family status, the likely response of those around them, their chances of support and care, the prospects for their dependants and family members: all these vary widely. So the epidemic occupies many different "worlds".
The same contradiction surrounds One Hope . For many of those living and coping with HIV, today's new optimism is coupled with a bitter truth. Hope for medicines to repress HIV does not apply to them but only an elite few. Treatment with the latest drugs can cost as much as US$ 20,000 a year. The health services of most countries hard-hit by the epidemic will not be able to afford this within any imaginable future.
Worse, many thousands of today's AIDS patients, especially in Africa , do not even receive care for the illnesses associated with their immunodeficiency. They do not have basic drugs - aspirins, pain-killers, anti-diarrhoeal and anti-fungal preparations - to ease their suffering. Nor can they or their families rely on benefits and income support services familiar in industrialized societies.
At the International AIDS Conference in Vancouver , some people were sceptical that One World. One Hope could be a meaningful message for everyone affected by the epidemic. UNAIDS believes that World AIDS Day 1996 should be used to demonstrate solidarity between the infected and the uninfected, between individuals and organizations within countries and between countries together fighting HIV and AIDS. HIV must not be allowed to tear apart families and communities. Nor must it be allowed to tear the world apart into those who can hope for care and support, and those who cannot.
The contribution of UNAIDS
UNAIDS exists to reinforce that message, in word and deed. UNAIDS both coordinates the responses to the epidemic of its six cosponsoring organizations - UNICEF, UNDP, UNFPA, UNESCO, WHO and the World Bank - and supplements these efforts with extra initiatives. Its purpose is to lead and assist an expansion of the international response to HIV on all fronts: medical, public health, social, economic, cultural, political and human rights.
Says Dr Peter Piot: "Our task in UNAIDS is to help countries build on the hopeful trends we are hearing about, and make them materialize worldwide." UNAIDS helps all kinds of partners - governmental and NGO, scientific and lay - share knowledge, skills and best practice across boundaries. It exemplifies the principle of "one world" and offers not "one hope" but a multiplicity of hopes applicable in different contexts.
UNAIDS also has a global mission to hold aloft the banner of equity in response to AIDS. The concentration of resources in most industrialized regions tends to skew research and other HIV-related agendas in the direction of certain groups and away from the less powerful, less vocal, and less well-informed. Since HIV often targets the disadvantaged, and since the huge bulk of the AIDS caseload is in lower-income regions, the role of UNAIDS in trying to redress such imbalances is a vital one.
Breakthroughs in medical technology will inevitably occur in better-resourced environments. But their benefits need not be permanently confined to a select few if appropriate pressure is exerted. And many of the necessary breakthroughs in care, prevention and support are not tied to technological or scientific advance. The positive impacts of social and behavioural discoveries can be widely spread.
In the early days of the epidemic, everyone thought in terms of "vaccine" and "cure" - the standard big technological fixes of modern public health. Now attention has spread to the multiplicity of caring and preventive fixes - by governments, NGO's, and people living with AIDS - which have occurred in a huge range of fields. Their pioneering work has softened the damage HIV has wrought. It has opened up new avenues, showing what works and what does not. It has helped cultivate political support behind efforts to stop the epidemic. These gains represent hope too. But much more is needed.
Putting the theme to use
How can the theme One World. One Hope be put to use by organizations and individuals undertaking activities for World AIDS Day 1996?
The One World theme invites us to be inclusive. This is a world in which no society, and no group within society, can remain immune to AIDS as the epidemic evolves and metamorphoses. But there are particular vulnerabilities and risks connected to age, sex or lifestyle. Involve women's groups. Involve youth. Involve people living with AIDS or HIV. Involve men having sex with men. Involve the military. Involve others whose occupations take them away from home, including long-distance drivers and seagoers. Involve those in tourism and sexual services. Fight prejudice, stigma, and discrimination, within ourselves and as expressed in social attitudes and regulations.
The One Hope theme invites us to be positive. Spread the message that prevention works. Open up dialogue about sexuality and behaviours which, when hidden, provide HIV with its point of entry. Encourage mutual fidelity. Encourage the use of condoms. Help change attitudes which leave women and youngsters without knowledge of their vulnerability and with little chance of refusing sex or negotiating safer sex. Offer care to those infected with HIV or living with AIDS in their families. Support the extension of care and preventive techniques to those otherwise excluded. Fight divisiveness, denial, and depression.
One World. One Hope
World AIDS Day 1996 means working together for a world able to control HIV, and for a global society which offers care and support to all those whose lives have been touched by the epidemic.
Good news about HIV prevention
New signs of hope in the global campaign to conquer HIV and AIDS are not restricted to glimpses of therapeutic advances. Prevention too is reaping its rewards, even in the absence of the ideal preventative - a vaccine.
For the first time, there are clear signs of a brake on HIV infection rates in a number of developing countries hard-hit by the epidemic. World AIDS Day 1996 is a time to salute the effectiveness of efforts to promote safer sexual and drug use behaviour, and build on their success.
"Ten years ago, we could only speculate about whether our prevention strategies would work," says Dr Peter Piot, Executive Director of UNAIDS, the organization spearheading the international response to HIV and AIDS. "We now have evidence of their effectiveness. There is an important lesson here: We are not powerless against HIV ."
First evidence of slowing infection rates came from Australia and northwestern Europe . But these industrialized settings were at an advantage. Not only are more resources available, but people are generally well educated, the role of viruses in disease is well understood, communications channels reach the entire population, and most people can afford to take protective action. In many developing countries these conditions do not apply. Nonetheless, some have managed to stabilize or reduce HIV spread.
Clear proof of mass behavioural change as a result of a fully-rounded response to the epidemic comes from Thailand . This has entailed the introduction of policies designed to make the social environment antipathetic to HIV: for example, regulations insisting on 100% condom use in brothels coupled with campaigns encouraging respect for women. It has also entailed forceful public education.
Thanks to this comprehensive approach, Thai men have reduced the number of their sex partners and practise more fidelity and abstinence. The number of men visiting sex workers has gone down and the use of condoms gone up. There is less sharing of drug injection equipment by drug users. As a result, there have been dramatic reductions in HIV incidence in young men including military recruits. Nationwide, the annual rate of infection today is one-quarter of what it was in 1990 - an astounding achievement.
Ugandan cities have also seen a reduction in HIV rates. Experts lay credit for this success on the attitude of Ugandan leaders, whose courage in facing the challenge of AIDS is reflected in their own, and society's, willingness to speak out openly and repeatedly about the epidemic. One result is that young people are postponing first sexual intercourse. HIV levels have dropped, even in the 13-24 age-group where a high proportion of infection is concentrated. Says Dr Piot: "If Uganda , one of the poorest countries in the world, can reverse its HIV trends, so can others."
And other countries are trying. Pakistan , a country practising strict religious norms, broadcasts almost daily TV messages about AIDS. In Viet Nam , sales of condoms nearly tripled between 1991 and 1995, to 117 million. Brazil has cancelled its import duties on condoms - imposed by many countries to protect local economies - in a bid to reduce the price to consumers and help create an environment in which HIV prevention, instead of HIV, can flourish. Hopefully, others will follow suit.
Prevention takes many forms
The first prerequisite for prevention is open dialogue about HIV transmission and acknowledgement of the reality that no one engaging in a sexual life is impervious to HIV. People also need to know the facts about HIV transmission through unclean needles. Silence surrounding the essential facts of the epidemic is tantamount to complicity in the spread of HIV.
In some parts of the world, even where HIV infection is common, denial, rejection and superstition still characterize public and official attitudes towards AIDS - and towards people with AIDS. As the experience of Uganda and Thailand shows, when efforts are made to dispel this hostile climate, prevention has a chance to work.
People with AIDS (PWA's) are playing a major part in challenging both silence and false assumptions by talking out publicly about who contracts HIV, how, and what life is like with the virus. The International Community of Women Living with HIV/AIDS is one network committed to educational action and mutual support. It now reaches women in 70 countries.
If HIV is still too often taboo, so are other sexually transmitted diseases (STDs). But the presence of an existing STD - of which there are hundreds of millions of cases every year - increases the chance of infection with HIV by 5 to 20 times. So efforts to combat all forms of STD should reduce HIV transmission. And they do. A recent study from Tanzania showed that where better management of STD was introduced in addition to the promotion of self-protective behaviour and condoms, the number of new HIV infections was significantly lower.
Targeting certain groups of people who, because of their occupation or lifestyle, are specially exposed to HIV does carry a risk of labelling and stigmatization. But prevention strategies must give priority to those most likely to become infected or they are guilty of reverse discrimination. These include sex workers and their clients, men having sex with men, injecting drug users, truck drivers and others spending time away from home.
More countries now conduct education plus condoms programmes for the military. Some armies have rates of HIV infection well above 20%. Military forces depend on youthful manpower, and recruits often frequent bars, massage parlours and sex workers during recreation. Studies show that their rate of STD infection is typically 2 to 5 times higher than among civilians. Since a 1995 regional seminar for African military leaders on HIV and AIDS, many are conducting HIV education programmes in the ranks.
Other forms of prevention include the protection of the blood supply, and close attention to hospital practices including sterilization of needles. These need to be governed by technically sound methods of management, according to norms advocated by UNAIDS. Progress is being made: between 1993 and 1995, the number of African countries screening virtually all blood for HIV more than doubled.
Creating a social environment friendly to HIV prevention
The need to combat the spread of HIV has led to an exhaustive enquiry into aspects of the social environment which collude with the virus' capacity to infiltrate human defences. Whole communities are vulnerable because of social norms that have become deadly with the advent of HIV, especially social taboos on discussing sex and the inferior status of women.
This is conspicuous in the way the virus attacks women. Women with only one lifetime sexual partner have contracted HIV. This is because, tacitly, societies may accept or even approve men having other partners than their wives. But wives may not be at liberty to protest about their involuntary exposure to possible infection or even to discuss it. In many cultures, women are expected to be passive and subservient to men in sexual matters. They cannot abstain from sex or insist on a condom.
Similarly, some societies frown upon AIDS education in school, believing this encourages promiscuity among the young. (Studies show that, if anything, it does the opposite.) But unless youngsters, especially girls, are taught about the risks of infection and how to insist on no sex or negotiate safer sex, they are vulnerable to HIV. Ultimately, success in the prevention of HIV depends in large part on attitudinal and social change. Higher rates of female school attendance would increase women's capacity to take their own decisions in life and practise self-protection.
In the meantime, UNAIDS is promoting research into technology that would put better protection directly into women's hands. The female condom is proving perfectly acceptable to many women who have tried it, but it remains expensive. Even more promising in terms of women's capacity to protect themselves without male permission or even knowledge is the prospect of microbicides - vaginal creams or foams which would kill HIV-infected sperm. Their development is under way, but availability will have to await a proven record of safety.
The need for a vaccine
The scientific research agenda for medical interventions against HIV has been dominated by the quest for a cure. Understandable pressure from people with AIDS in industrialized countries, and the commercial prospects in the pharmaceutical industry for profitable drug treatments, have skewed the agenda in this direction. But 9 out of 10 infections occur in places where sophisticated drugs are way beyond economic reach. In Africa , Asia and other lower-income regions, people are desperate for a vaccine.
"The time has come to turn the global AIDS research agenda on its head," says Dr Piot of UNAIDS. "Ignoring the research needs of 90% of the epidemic is not just unethical. It is irrational." When it comes to the danger of HIV, everybody is living in one and the same world - a world characterized by demographic and economic fluidity, and in some places by politically induced mass migration too. Given humanity's awesome degree of mobility, a vaccine against HIV would be a boon for everyone, not just those who could not afford expensive drug treatments if infected. The need to move ahead quickly with vaccine trials is an important message for World AIDS Day 1996.
AIDS : The right to care
Ever since AIDS was identified as an untreatable and fatal condition, people with HIV and those close to them have prayed and clamoured for a cure. Today, over 22 million people are living with HIV, including 2 million with AIDS. So desperate do some become that they sell everything they own to buy a potion claiming miracle properties against the virus, or travel long distances in the hope that a rumoured cure will work.
Today, medical science is finally coming up with combination drug therapies which offer hope of arresting the AIDS virus.
HIV - the human immunodeficiency virus - is a 'retrovirus'. Drugs that attack the virus itself are known as 'antiretrovirals'. Recent trials with combinations of new and existing antiretrovirals have shown that they can halt HIV's remorseless attack on the immune system, and even reduce the presence of HIV in a patient.
Exciting as this breakthrough is, there is one huge problem: cost. Treatment with a cocktail of antiretroviral drugs costs up to US$20,000 a year. In some countries of sub-Saharan Africa , public expenditure on health services totals no more than US$10 per head a year. Altogether, prohibitive costs currently exclude around 90% of those with HIV worldwide from any treatment with the new combination drug therapies.
Redressing inequities in caring for people with HIV
The rich-poor divide in terms of access to care for HIV infection and its related illnesses is the most difficult challenge facing those fighting the epidemic on a worldwide front. Inequities extend far beyond access to antiretroviral drugs. The need to combat these inequities within and between countries was an important reason why One World. One Hope was chosen as the theme for World AIDS Day 1996.
In some places, the pre-condition of humane care - respect for those living with AIDS - is lacking. Where stigma still dominates the social climate, people hide their HIV status and get no care at all. One way to combat rejection is for people in leadership positions to speak out about losses and heartbreaks they, too, have experienced because of AIDS. Another is to provide visible support for those living with HIV. Where this is given, it helps conquer popular terrors, and more people ask for care and receive it.
When people with HIV seek treatment for the opportunistic infections stemming from their immunodeficiency, the health care response varies enormously from setting to setting. In some African environments, pills and lotions to relieve pain and treat the rashes, nausea, diarrhoea and respiratory infections typically associated with HIV are often unavailable. Economic crisis has damaged fragile primary health and hospital services. There are cuts and there are fees. In Zimbabwe, a course of treatment for thrush, a fungal infection of the mouth or throat that can make it too painful to swallow or eat, costs a month's pay for a government clerk and four times that of a domestic worker.
A disease making a serious comeback thanks to HIV is TB - tuberculosis. Many people carry the TB germ in their bodies without suffering any consequence. But if their immune system is undermined by HIV, the TB then becomes active. Not only do AIDS patients with TB need proper antibiotic treatment to cure them. Active TB is contagious, so without treatment they may pass on the TB germ to those around them.
In Kenya , a recent study showed that around 30% of AIDS patients die without ever being in contact with the health care system. In many African households where one partner has died and the remaining one is sick and unable to work, the only carers are children. An aspirin, a bar of soap, a clean cloth for a sheet may be beyond their purchasing power.
Since the 11th International Conference on AIDS in Vancouver in July 1996, more attention is being focused on the problem of access to simple drugs for HIV-related illness, and on advice to those managing and nursing such illness, especially tuberculosis and pneumonia. With good care, patients can recover and lead healthy lives for years - even with HIV.
Access to care and support is more than medicines
Providing elementary treatment for the sick is not only a moral and health-promoting obligation. It also reduces other HIV damage. Parents whose life is prolonged by medical treatment can continue to raise their children, see to their education, pass on their own wisdom and practical life experience, and make provision for the children's future.
A patient's ill-health rebounds on family members, particularly on wives and daughters who shoulder the burden of nursing. Where a young girl leaves school and tends a dying mother alone and unaided for months on end, the experience leaves a permanent psychological mark. A home visit, some drugs and human kindness will make a world of difference. And if ways can be found of helping child carers make up lost schooling, then their own chances in life will be restored.
Those affected by AIDS need support that health care workers cannot provide. Women, children and dependent partners may need legal help to prevent the loss of pension benefits or inheritance. They need employment opportunities to replace income earned by a sick breadwinner.
Nine million children under 15, over 90% of them in Africa , have lost their mothers to AIDS. The traditional extended family cannot cope alone. Some grandparents are trying to raise as many as 20 or even 30 children of their prematurely dead sons and daughters. They need help with food, farming, shelter, blankets, school fees and clothing.
Integrating care and support with prevention
"In the past, we have often made an artificial distinction between prevention on the one hand, and care and support on the other," says Dr Piot of UNAIDS. "But for individuals and their families, coping with HIV infection is part of the challenge of living in the AIDS era - a challenge that includes self-protection. We should be integrating prevention and care in a way that exploits the rich interface between them."
Many NGO's which came into being to respond to the epidemic did so because an exceptional human being experienced the pain of losing someone to AIDS and wanted to help others in a similar plight. The exhortation and skills such NGO's have offered for "living positively with HIV" have brought hope and longer life to countless thousands. These community groups have enabled those with HIV to come to terms with their condition and to take action to avoid spreading the virus to others.
Tackling the problems
• In Uganda , people with AIDS are using their collective strength to improve access to care. Through TASO, one of the developing world's first AIDS service organizations, they are giving greater visibility to the issue of needless pain and other suffering that could be relieved with simple remedies. For example, they are pushing for a change in government regulations so that effective painkillers can be given to AIDS patients treated at home, and lobbying the donor community for funding not only for HIV prevention but for basic drugs needed by AIDS patients. Activism of this kind has enabled people with AIDS in other parts of the world - including North America and Western Europe - to push for faster action on drug licensing and availability.
• In Venezuela , a buyers' club was launched in 1994 to purchase drugs and medical supplies for people living with HIV and AIDS. Under the general coordination of ACCSI (Citizens' Action Against AIDS), the bank uses a health care facility run by the religious group Accion Ecuménica as the distribution and resource centre, and relies on the NGO called United Against AIDS International for procurement and transport.
• In South Africa 's KwaZulu Natal province, a project is successfully integrating both AIDS prevention and TB treatment into the community. Local shopkeepers and vendors distribute AIDS information and condoms, provide antibiotics to TB patients and watch them take their pills to ensure that the entire course of treatment is completed and patients are cured.
When people with HIV are looked after and treated with respect, they feel more confident about speaking out and giving a human face to AIDS. They can play a very important role in helping others overcome their fears and prejudice. This in turn facilitates community acceptance of the presence of the virus, and support for measures to deal with it.
Levelling the field
Meanwhile, the search for better ways of ensuring a longer and higher-quality life for people with HIV must go on. Inevitably, scientific research agendas in the AIDS field, as in others, are influenced by market and popular pressures in settings where the resources exist to finance complex research. But the claims of the resourceless, powerless and voiceless who represent the majority of people with HIV are equally valid.
Ways need to be found of reducing costs of treatment with antiretroviral drugs. At the same time, new initiatives must be launched around the priority health problems faced by those with HIV in poor-income regions to make essential drugs and care available for HIV-related sickness. Imbalances in access to all forms of support - including pain relief - must be remedied.
The impact of hopeful news surrounding treatment for HIV and AIDS must not be confined to a select and exclusive few. Ways must be found of making One World. One Hope apply to all.
