Making AIDS history
In the last three decades, HIV/AIDS, a disease first reported in humans in 1981 in the United States, has spread across all continents and claimed millions of lives. It has posed one of the biggest public health threats known to man, and changed the course of history. HIV proved to be a formidable enemy, resisting drugs quickly and evading potential vaccines. But the story of HIV/AIDS is also a tale of triumph of human ingenuity, determination and commitment. Infection with HIV was once considered a death sentence.
But now progress achieved in the global response over the last decade has resulted in a 15 per cent reduction in new infections. Today, we are close to overcoming the HIV/AIDS epidemic, as we aim for “zero new infections, deaths and discrimination due to HIV/AIDS”. The World Health Organisation (WHO), along with United Nations Programme on HIV/AIDS (UNAIDS), UNFPA, Unicef, and countries in the Asia-Pacific region, has also launched an initiative for elimination of new paediatric HIV infections and congenital syphilis by 2015.
How did we reach this point? Initial technological progress was rapid. In 1983, HIV was first isolated and by 1985, the first test kit to detect HIV was approved by the United States Food and Drug Administration (USFDA). In 1987, the drug zidovudine (AZT) — the first drug to treat people infected with HIV — was approved by the USFDA. However, the virus soon began to develop resistance to the drug. With the arrival of other antiviral drugs and “combination therapy”, approved in 1992, the disease finally showed signs of abatement.
Over the years, more effective and less toxic drugs have made their way to the market. “Combination therapy” is changing the profile of the disease to a chronic one and is the cornerstone of HIV/AIDS treatment today. In June 2010, the UNAIDS secretariat and WHO launched Treatment 2.0, an initiative designed to improve the efficiency and impact of HIV care and treatment programmes. It also aims to bring a realistic and sustainable solution to reducing illness and premature death from HIV.
Effective treatment is one of several prongs to successfully fight the epidemic. Sustained access to treatment is important. But along with treatment, prevention of the disease is vital. People need to know their HIV status, and need to have access to proper facilities for testing and counselling. Experiences from across the world have shown that political commitment and will, financial investment, widespread awareness and community involvement play a crucial part in preventing the disease.
Countries in Southeast Asia, like Thailand and India, have shown how developing countries can effectively fight HIV/AIDS. The first case of HIV/AIDS in Southeast Asia was reported in Thailand in a sex worker in 1984. By 1993, the government increased the budget for HIV/AIDS twenty-fold. A massive information campaign was launched, with anti-AIDS messages aired every hour by more than 400 radio stations and six TV networks. The Thai government's determination to enforce 100 per cent condom use in brothels and to ensure wide access to HIV prevention campaigns through schools, mass media and workplaces have been key factors in lowering HIV infection rates in the country.
Reported condom use in brothels in Thailand increased from only 14 per cent in 1989 to over 90 per cent by 1994. Over the same period, the number of new cases of sexually transmitted infections (STI) among men treated at government clinics plummeted by over 90 per cent. Regular surveys among young male recruits in the Thai Army revealed similar changes in sexual behaviour and infection rates. HIV infection rates among 21-year-old military conscripts peaked at four per cent in 1993 before falling steadily to below 1.5 per cent in 1997. By 1995, fewer recruits were visiting sex workers (down from almost 60 per cent of recruits in 1991 to about 25 per cent by 1995) and condom use had increased.
These changes in sexual behaviour were paralleled by a decline in HIV infections and other STIs. By 2009, Thailand had come close to eliminating perinatal (mother-to-child) HIV transmission. This was possible due to the dedication of public health workers, a strong health infrastructure as well as strong political leadership and commitment.
India, too, is a similar success story in spite of the size and diversity of the country. With strong political and administrative commitment and strategic focus on high-risk groups, India has the world’s largest HIV prevention programme. The first case of HIV in India was identified in 1986. India responded to the HIV/AIDS challenge by setting up an AIDS Task Force under the Indian Council of Medical Research and a National AIDS Committee. In 1990, a medium-term plan (1990-1992) was launched in selected states. The plan facilitated targeted awareness campaigns, establishment of surveillance system and safe blood supply.
The National AIDS Control Organisation (Naco) was established in 1992. Currently nearing the completion of its third phase, Naco has used a network of HIV-positive people and NGOs, as well as secondary and tertiary health facilities, to successfully and rapidly scale up access to antiretroviral treatment. Epidemic projections reveal that the number of annual new HIV infections have declined by more than 50 per cent during the last decade as a result of persistent efforts.
Countries like Sri Lanka and Bangladesh, with a low prevalence of HIV, have also managed to keep infections low. In Sri Lanka, this has been achieved through strengthening of public health services while in Bangladesh the government has worked closely with civil society organisations to provide community-based services.
Such determined efforts in Southeast Asia and other parts of the world have ensured that progress made in providing access to treatment for people living with HIV/AIDS is unprecedented in global public health history.
Today, people with HIV, on regular therapy, are living longer and better lives, changing the profile of the disease to a chronic one. With regular treatment, more than four out of five people with HIV are alive in the Southeast Asia region 12 months after the start of therapy.
However, this is not the time for complacency. Despite the progress, there are challenges. The majority of people in Southeast Asia do not know their HIV status. Almost half of the people living with HIV, who are in need of treatment, have yet to start therapy. Poor adherence to treatment is resulting in resistance to first-line drugs. Poor access to prevention and treatment services of HIV-positive pregnant women continues to pose challenges for curbing transmission to newborns.
As HIV becomes a chronic infection, it also poses new challenges for our health systems. Destigmatisation and decriminalisation of the disease still remain big challenges.
In order to overcome HIV, we need to address the underlying social determinants, such as poverty, women's empowerment and gender equity. Finally, it is essential that investment in the disease, both political and financial, is maintained and scaled up where needed, so that HIV can be relegated to the history books in the next 30 years.
December 1 is World AIDS Day
The writer is deputy regional director, WHO, Southeast Asia