"In Latin America, the epidemic's most recent target is women who are infected by male partners who may be having sex with other men. But the chain stops there."—Fernando Zacarias, PAHO

Zacarías explains the difference citing genetic as well as social and cultural factors: "There are currently two major groups of HIV circulating in the world, HIV1 and HIV2. We already know of 10 subtypes of HIV1 and five subtypes of HIV2. It so happens that in the Americas, the strain that is circulating is the same one that is circulating in Western Europe—HIV1, subtype B—and it is apparently less virulent than the HIV2 strains that are circulating in Africa."

Not only are the African strains of HIV more pathogenic, they are also more easily spread heterosexually, which partially explains the accelerated pace of Africa’s epidemic, says Zacarías. However, the virus mutates so readily that the relatively favorable scenario in the Americas could easily change in the coming years.

Zacarías notes with approval that many countries of the region took the threat of this "new disease" very seriously as early as the beginning of the 1980s. "In Brazil, for example, there were from the outset clear decisions at every level—ministerial, public health, in the communities," he says.

"Through effective campaigns and interventions they were able to slow the progress of the epidemic. Also, in Cuba, they took drastic measures, which were strongly criticized, but they managed to keep the virus out of the island during the first years of the epidemic." In today’s world of travel, tourism and globalization, however, he and others insist that such "epidemiological fences" will no longer work.

The UNAIDS report for 2002 notes that one factor favoring the spread of HIV in Latin America and the Caribbean is the combination of inequality and a highly mobile population. For Zacarías, it is behavior that has most influenced the evolution of HIV in the region. "Heterosexual transmission is emerging as a major mode of infection. And the most recent target of the epidemic is women, particularly monogamous women who are infected by their own partners, who in many cases are having sex with other men. What happens is that the chain of contagion stops there, in the wife or girlfriend." In other words, what is slowing the epidemic is basically a cultural phenomenon.

Two years ago, the slogan for UNAIDS’s world campaign called on men to "make a difference." Far from endorsing male control over sexual relations, the campaign was instead appealing to men to be conscientious about using condoms to protect themselves as well as their partners. Using a condom was in a sense assuming personal responsibility in the battle against AIDS.

This is no arbitrary approach; condom use continues to be critical in preventing infection. But it is also something over which many women have little control. "In some countries women are not given the status to be able to make their own decisions about safe sex," says Fauci. "We have to continue to educate everyone from the leaders of the countries down to the people who are the community leaders in order to make the changes that we need."

In South Africa, where one out of four people is infected, a tribal king can have dozens of children and several wives. Will a king use a condom? Will a Latin American truck driver who delivers goods in several countries? Or the small farmer from China's Jilin province who donates blood once a month for his only steady income?

Zacarias shares Fauci's belief in the importance of education but adds that, to educate, one must do it in the language and culture of the target group. "In Haiti, we've done campaigns where a voodoo priest explains, in his own language and rituals, how to properly use a condom. Interventions should be aimed at new cohorts, the newly vulnerable groups, mobile populations—there are many in our continent—sex workers, assembly plant workers and indigenous groups, where the virus has expanded dramatically. The Garifuna population of Honduras has from 15 to 20 percent prevalence of HIV."

So where on the AIDS road map do we now stand? The experts agree: We are at a crossroads. It is the perfect time to do things right, to take the correct path to make sure that the epidemic does not explode.

Fauci believes that a clear political and economic commitment is most decisive. "If you look at the U.S., we are putting an extraordinary amount of resources in HIV/AIDS. In my institute, 50 percent of the budget is for HIV/AIDS. We would not have that commitment if it were not for the President, who put that into his budget, and Congress, which approved the budget. The political leaders of the country were committed to putting a lot of effort on HIV."

Zacarias' main concern is, what will happen when HIV stops being a problem in the rich countries?

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