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)

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.

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