Prescriptions for combating the HIV/AIDS pandemic in Africa, Latin America, and Eastern Europe include increased funding, focus on local disease drivers, and reassertion of public health goals over political concerns.
We should be a lot more humble about what we know.
Panelists at a spring 2007 conference on Global Dimensions of the HIV/AIDS Pandemic told some 130 participants that public health responses to the worldwide crisis need urgently to shift. Today, some 40 million people are infected with HIV, the virus that causes AIDS.
Paula Tavrow, director of the Bixby Program at the UCLA School of Public Health, questioned whether some current approaches to combating the pandemic were compatible with public health goals.
For example, an underlying message of the "ABC" approach to AIDS prevention (Abstinence, Be faithful, use Condoms) is, "If you can't be a moral person, use condoms," she said. In regions with epidemics, condoms should instead be seen as a necessity, and discordant couples (where only one partner is HIV positive) in particular should be educated on how to "eroticize" the condom during sex.
Tavrow also recommended that funds be set aside to retain and motivate nurses, who have left Africa at an alarming rate.
"We never use AIDS money for this," she lamented.
The May 18, 2007, conference provided a platform for expert perspectives on the growth and management of the pandemic in Africa, Latin America, and Eastern Europe. It was sponsored by six UCLA units: the International Institute, the Latin American Institute (LAI), the African Studies Center (ASC), the Center for European and Eurasian Studies, the UCLA/Pacific AIDS Education and Training Center, and the Center for Health Promotion and Disease Prevention. The recently renamed and restructured LAI and the ASC took the lead in organizing the conference.
Stephen Lewis, former United Nations Special Envoy for HIV/AIDS in Africa, in his keynote address (podcast) linked the pandemic to issues of gender inequality, sexual violence, and social injustice. He said that the international community showed a stunning passivity in the face of the disease, with rich countries regularly failing to deliver promised funding.
Disease and Dictatorship
With conditions and infection rates that vary in the East, West, and South, the African continent has suffered 71 percent of the total deaths from AIDS over the course of the pandemic, according to Tavrow. Still, other regions have endured much, and this conference served as an opportunity to view localized epidemics and public health responses in a comparative light.
Keith Hansen, a World Bank official responsible for health issues in Latin America and the Caribbean, looked at diverging approaches to fighting the disease in Brazil and the Caribbean, where AIDS is the leading cause of death for adults. One of the weaknesses of the responses among Caribbean island nations has been poor surveillance of the disease's progress, he said. To his knowledge, these governments have no official epidemiologists.
In Brazil, by contrast, the government took on the disease from the beginning, Hansen said, balancing prevention and treatment and building relationships with groups in civil society. Brazil gets treatment to a high proportion of those afflicted (85 percent) and has been tough in negotiating prices of antiretroviral drugs with manufacturers. Its efforts "coincided with the movement against dictatorship," he observed. The military lost its grip on the country in 1985.
For all that, however, Hansen said in response to a question from the audience that it was impossible to specify which pieces of Brazil's strategy had worked well. He said that the next generation of AIDS specialists in public health and population studies would bear a great burden in understanding the disease.
"We should be a lot more humble about what we know."
Hansen also warned that the increasing "pauperization" of AIDS in Latin America could make the disease politically more difficult to combat over time. More than half of Latin Americans living with HIV/AIDS in 1985 had high school degrees, he said, a proportion that has since fallen dramatically.
Hansen and other speakers at the conference observed that AIDS is not "one global enemy," but a group of epidemics that have spread and developed differently in varying social, cultural, and political contexts. In her speech (podcast), the World Bank's leader in the AIDS fight, Debrework Zewdie, urged colleagues to concentrate on local causes of transmission and, crucially, on "fundamental drivers" such as poverty, gender inequality, and sexual violence.
Adriana Baban, a visiting UCLA professor from Babes-Bolyai University of Romania, laid out some complexities of the virus's progress in former Soviet states in Eastern Europe and Central Asia.
In recent years an "explosive situation" has developed in the neighboring regions, where an estimated 1.7 million people were living with AIDS by the end of 2006, she said. But the drivers of the disease have not been uniform. For example, heterosexual sex is the primary means of HIV transmission in Romania. In Poland and much of Central Asia, injected drug use ranks as the leading cause. Sex between men is the primary disease driver in several Eastern European countries, including the Czech Republic, Hungary, and Slovakia, and also in Western Europe.
"The new epidemic is in Central Asian countries," said Baban, referring to Uzbekistan, Kazakhstan, Kyrgyzstan, and Tajikistan. Infection rates in many Eastern European countries peaked in 2001.
Focusing on Central America, Evelyn Gonzalez-Figueroa of the AIDS Project Los Angeles discussed the importance of public education campaigns against homophobia and of prevention.
"For every life saved through HAART [antiretroviral treatment regimen]," she said, "28 could have been saved through prevention."