Perspectives in Health Magazine The Magazine of the Pan American Health Organization Volume 8, Number 1, 2003

Like a volcano in permanent eruption, the epidemic is advancing slowly but steadly throughout the world. Will the Americas escape the next explosion?

"An increase of just 1 percent in incidence in a country like China or India means you’ve added 20 million people."—Anthony Fauci, Director, National Institute of Allergy and Infectious Diseases, USA (All photos ©Armando Waak/PAHO)

Anthony Fauci sits in his spacious office at the National Institute of Allergy and Infectious Diseases in Bethesda, Maryland, USA. He glances out the window but doesn’t seem to focus on the scene outside.

Fauci has been director of the prestigious institute for the past 18 years, and his office wall is a tapestry of academic titles and honors. As one of the leaders in the global fight against AIDS, he has a vision that encompasses countries, regions and entire continents.

With his hands on top of his head and a somewhat distant look, he describes in clear terms what he calls the "new wave of AIDS." Like a volcano in permanent eruption, the epidemic is spreading throughout the world, but most notably in five countries—China, India, Russia, Nigeria and Ethiopia—that are home to more than 2.5 billion people.

"If you have a country that has a billion people, like India or China, all you need is to increase the incidence by 1 percent and you’ve added 20 million people," says Fauci. "I’ve been in India, China … my feeling was exactly what the [September 2002] report from the National Intelligence Council said, that it is an epidemic waiting to happen, waiting to explode."

Fauci insists, in reaction to an interviewer’s line of questioning, that he leaves personal emotion out of his professional work. Certainly his daily confrontation with the reality of AIDS could otherwise be overwhelming. Some 42 million of the world’s people are living with HIV/AIDS, according to December 2002 estimates by the United Nations Program on HIV/AIDS (UNAIDS). The same year, there were 5 million new infections and 3.1 million deaths from the disease.

Five years ago, scientists declared that a preventive vaccine would be available by now. Today, however, they are much more cautious. The AIDS virus constantly mutates, making it exasperatingly evasive and complicating the search for a vaccine. Many now believe that the most effective tools for dealing with the epidemic are other forms of prevention and treatment with the potent antiretroviral drug "cocktails" that restrain viral replication.

To these measures, Fauci adds a third key tool for containing the epidemic: medical research.

A nondiscriminatory virus
HIV has proved itself largely nondiscriminatory, affecting both rich and poor (particularly in the first years of the epidemic), strong and weak, children and adults. Passing through entire continents unseen in the microscopic spaces of cells, it has followed a relentless logic in producing epidemics: Wherever, whenever cracks appear in a system, the virus will seize the opportunity to invade.

"It happens whenever a country’s socioeconomic order is affected, as in the case of many African countries and in the former Soviet Union," says Fernando Zacarías, chief of the HIV/AIDS unit of the Pan American Health Organization (PAHO). "Wars, crises, induced migrations, major breeches in the health system, these generate ideal conditions for HIV to expand."

Will the same laws hold in this hemisphere? In North America, nearly 1 million people are believed to be living with HIV. In Latin America and the Caribbean, an estimated 1.9 million adults and children are HIV positive. This includes 210,000 people who contracted the virus in 2002; it does not include the estimated 100,000 people in the region who died of AIDS the same year.

Zacarías recalls that 20 years ago, when some people referred pejoratively to AIDS as the "pink plague" and the virus itself was a recently solved mystery, the future looked apocalyptic. "There was an international survey of experts, and our vision was terrifying. We imagined a year 2000 completely devastated by the disease."

Time and medical research have demonstrated that the infection can be transformed into a chronic disease, that many can remain HIV-positive without developing AIDS and that the planet will not be decimated. But the battle against AIDS requires clear health policy decision making and political commitments.

"The war is only beginning," Richard Feachem, director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, wrote in a January 2003 op-ed piece in The Washington Post.

"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

In Latin America and the Caribbean, the AIDS epidemic has until now followed a slow but expanding path. Prevalence rates in some Caribbean countries are among the highest in the world after sub-Saharan Africa. In the two decades since the start of the epidemic, Latin America has undergone wars, sociopolitical crises and system breakdowns. Yet the epidemic has not exploded as in other regions.

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?

In the general population the culture of sexuality is changing. Young people today know it is essential to protect themselves.

Behavior change
Many nations of the Americas have accepted the challenge of AIDS head on. One example already mentioned is Brazil. "What Brazil did serves as a model," says Fauci. "They have excellent vision at the top. The country's political leaders and leaders in health realized very early on that it is important to link prevention with treatment, to provide access to treatment throughout the country, to try and overcome in a creative way the obstacles to the availability of very expensive drugs, making those drugs generic and that way available for people with low incomes. They have shown leadership, creativity and concern. They didn't deny the problem; they faced it."

The 2002 UNAIDS report also cites Brazil's policies on intravenous drug users as exemplary: "Brazil has adopted a less punitive approach to dealing with the dual challenge of injecting drug use and HIV infection—to good effect. Prevention programs among injecting drug users have contributed to a substantial decline in HIV prevalence in this population in several large metropolitan areas. In addition, a national survey has shown increasing condom use among injecting drug users (from 42 percent in 1999 to 65 percent in 2000)—a sign that sustained education and prevention efforts are bearing fruit."

Another key element in slowing the region's epidemic has been organized advocacy by self-described "seropositives." The Latin American Network of People Living with HIV/AIDS coordinates seven regional advocacy networks that work closely with governments, nongovernmental organizations and international agencies fighting AIDS. "Horizontal cooperation has made it possible to win many battles, especially against discrimination and high drug prices," says Javier Hourcade Belloq, regional secretary of the network.

Zacarias notes that "with the new antiretroviral therapies, fewer patients go on to develop AIDS, and the number of hospitalizations in the countries has declined significantly."

Then why not step back and rest a bit? In San Francisco, the epicenter of the epidemic in the 1980s, prevention efforts succeeded in dramatically lowering the incidence of infection among men who have sex with men. In those early years, fear was the driving force. Friends and lovers were dying; people had to be very careful. Yet a recent study by the city's Department of Public Health shows an increase in infections over the last six years.

"The new generations of men who have sex with men do not have the same perception of the danger to them," says Zacarias. "They know there is good medication, that the infection can be treated. But we must keep telling them, it is always, always best not to become infected."

Zacarias and Fauci are veterans in this war, and both are competent to forecast the epidemic's future. Zacarias proffers the following: "This process of stabilization of the epidemic, I might not be around to see it myself, but it can be achieved. In the general population the culture of sexuality is changing. Young people who became sexually active in the AIDS era know it is essential to protect themselves. The key words are care, prevention and treatment."

Fauci says: "We are at a critical point right now. If we are not aggressive in prevention and education and behavior modification, if we don't put the resources there to treat people who are already infected and link treatment with prevention, then it could get much, much worse. But if we do it right, we have the opportunity to have a major impact on the epidemic right now."

Paula Andalo is a journalist in Public Information at the Pan American Health Organization in Washington, DC.

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