The Perils of Ignoring AIDS

Following the 20th anniversary this summer of the HIV/AIDS epidemic, we spoke with Kenrad Nelson, MD, about the current global situation of the disease and what needs to be done. Nelson is professor and director of Infectious Disease Epidemiology in the Department of Epidemiology.

It was recently announced that the U.S. is putting an additional $200 million into the international fight against AIDS. Will this be enough?

No. The World Health Organization [WHO] has said that an additional $7-8 billion per year will be needed. Other European governments and private foundations will help, but the U.S. needs to do more. The control of HIV in Africa certainly is in the vested interests of the U.S. and Europe. If the countries in Africa and Asia become politically unstable, that certainly will affect us. If new HIV viruses recombine, and emerge, it may complicate the development of a preventive vaccine even further.

Is more money the answer?

I suspect no matter how much money is spent, it will not be possible to fully equalize the situation between poor African communities and the U.S. In many African countries, there are very few doctors, clinics, and nurses, outside the large cities. Nonetheless, I think at least in the cities it would be possible to establish some specialized clinics and train clinicians to identify, treat, and monitor HIV-positive people.

Despite all we've learned about HIV and its transmission in the past 20 years, 36 million people are estimated to be HIV-infected, almost 90 percent of them in developing countries. Why haven't prevention efforts been more successful?

When there isn't agreement among the political and religious leaders that this is a serious problem and how it should be addressed, it becomes more difficult to deal with.

I understand that several religious leaders in Africa have recently opposed the promotion of condoms to prevent HIV. This type of confused leadership contributes to the problem. So politicians may believe it politically easiest to just ignore the epidemic. AIDS is different from malaria and tuberculosis and many other infectious diseases in that it involves marginalized populations and issues of sexual behavior, drug use, commercial sex, and rape.

What makes some programs successful?

Only when countries have decided that HIV/AIDS is a preeminent health problem that they must deal with have they been successful. Thailand is one example. The prevalence of HIV among 21-year-old military conscripts has decreased from 12 percent in 1991-92 to about 2 percent in 2000. And, less than 5 people per 1,000 per year now are becoming infected. Uganda, Senegal, and Zambia also have effective prevention programs. But these countries are exceptions.

The HIV/AIDS epidemic has exploded in the last five years in southern Africa. In Botswana over 35 percent of the entire adult population is infected. Similar rates of infection are seen in populations in South Africa, Namibia, Zimbabwe, and Malawi. The WHO has estimated that, if the epidemic continues, the likelihood of a young man in Zimbabwe dying from AIDS before he reaches the age of 50 is 60 percent.

Given those statistics and the fact that one in 10 sub-Saharan Africans between the ages of 15 and 49 is infected with HIV, what's going to happen in the next few decades?

Without effective intervention, it probably will have the same devastating effect it now has. Or worse.
I think the choice is really clear. We need to move on this. There are really effective prevention techniques that have been shown to work in developing countries, and there are therapeutic advances that would really make a difference. I think as health professionals we need to be in the forefront in educating politicians and the public about the severity of the current problem and what the outlook is if we don't act now.