The fight continues

Public perception of HIV/AIDS has shifted, and the disease is no longer always fatal, but that has also led to complacency and a lack of funding.

In the three decades since acquired immunodeficiency syndrome (AIDS) emerged as a public-health issue, the illness has changed face several times. AIDS was initially, in the early 1980s, seen as an illness affecting gay men in the rich world. But views quickly evolved, prompting governments in the world’s developed countries to undertake blanket awareness campaigns – after initial hesitation over popular sensitivities. 

Then AIDS began its devastating march through the developing world, in particular Africa, and joined malaria and tuberculosis as a disease that was emblematic of poverty. Rich governments began spending significant amounts on preventing and treating AIDS in developing countries as well as at home, and infection and death rates dropped across the world.

The medical and public- health response to AIDS had a major impact on the disease’s course. Where for the first 15 years or so a diagnosis of the human immunodeficiency virus (HIV), which causes AIDS, was a virtual death warrant, this changed in the mid-1990s with the advent of effective treatments.

Death rates began dropping as increasing numbers of people, initially in rich countries and gradually also across the developing world, gained access to retroviral therapies. An increasing number of people with HIV survived the various illnesses associated with AIDS – although this created new demands on public-health systems, many of which struggled to cope.

In response, the European Commission is now shifting its support away from specific HIV/AIDS programmes – the single-disease approach to global health – towards strengthening health systems more generally. But the move is controversial, precisely because the single-disease approach has been successful in bringing down infection and mortality rates.

Today, some 34 million people worldwide are living with HIV, according to United Nations estimates. Last year, 1.8m people died of illnesses related to HIV/AIDS, down from an annual peak of 2.2m in the mid-2000s. The infection rate has also slowed, after its peak in 1997.

But the drop-off in new infections has also turned HIV/AIDS back into an issue for development aid rather than a generalised worldwide public-health problem. In rich countries, doctors and other practitioners are worried that the drop-off in infection rates, and the transformation of AIDS into a serious but often no longer fatal disease, have bred a sense of complacency. Many prevention campaigns have stopped, and it is estimated that between one-fifth and one-quarter of people infected with HIV are not aware that they are carrying the virus – making them a danger to others.

Financial squeeze

Funding has also become more of a challenge, with the financial crisis squeezing aid budgets. Last week (23 November), the Global Fund to Fight AIDS, Tuberculosis and Malaria announced that it would fund no new projects until 2014 after donors cut their contributions. The fund, a public-private initiative based in Geneva, contributes around a quarter of global spending on HIV/AIDS, and the bulk of spending on TB and malaria – the main poverty-related diseases.

Earlier in the month, the European HIV/AIDS Funders’ Group and Funders Concerned About AIDS, a similar group in the US, reported that private funding for HIV/AIDS action from Europe and the US had declined by 7% in 2010 compared with the previous year. The two groups projected that this year will see an increase – but also stressed that any drop in funding, even if temporary, means more people are infected by the virus or die of AIDS-related illnesses.

The United Nations Programme on HIV/AIDS (UNAIDS) estimates that there is an annual funding gap of around $6 billion (€4.5bn), and that more than 12m new infections and 7.4m deaths could be prevented in 2011-20 if funding were available. The availability of that funding is now highly doubtful.

A renewed commitment?

Last June, the United Nations’ member states adopted a political declaration on “intensifying efforts to eliminate HIV/AIDS”. In the declaration, national governments committed themselves to providing universal access to HIV prevention and treatment by 2015, which is supposed to lead to the complete eradication of HIV/AIDS.

However, that ambition is not new: in 2001, the UN’s member states had agreed, in the form of the sixth Millennium Development Goal, to halt and begin to reverse the spread of HIV/AIDS by 2015 and to achieve universal access to treatment by 2010. That goal remains unfulfilled, with the access rate only just approaching 50% worldwide.

While the 2010 goal remains elusive, the policy environment has changed dramatically, most obviously because of the global financial crisis. According to figures from the European Parliamentary Forum on Population and Development, the EU institutions’ support for population programmes decreased by more than 20% in 2009: support for HIV/AIDS schemes declined by 30% and support for family-planning projects all but ceased. In 2009, the EU institutions provided just 0.04% of their official development assistance to HIV/AIDS and sexually transmitted diseases, compared with more than 3% in the UK and 14.6% in the US.

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