Almost 20,000 people attended the 15th International AIDS Conference in Bangkok July 11-16 to discuss the numerous fronts in the battle with HIV/AIDS, most of which continue to worsen as infection rates keep rising.
About 40 million people around the world are now living with HIV, with almost 5 million people acquiring the virus in 2003 - the greatest number in any one year since the epidemic's beginning, according to the "2004 Report on the global AIDS epidemic," which was released in July by the Joint United Nations Program on HIV/AIDS. Sub-Saharan Africa is home to about two-thirds of all people living with HIV as well as about 12 million children who have lost one or both parents to the virus. Experts also warn that HIV numbers could explode in Asia if leaders don't address the growing epidemic immediately, the report stated.
Women are increasingly becoming the face of HIV, accounting for about half of all HIV infections globally and 57 percent of infections in sub-Saharan Africa. Women and girls also bear the brunt of the HIV burden, as they are often the most likely to care for sick relatives, drop out of school and lose income. Women also continue to face discrimination and cultural inequalities that significantly affect their ability to stay HIV-free, UNAIDS reported. Women were the focus of "Women and HIV/AIDS: Confronting the Crisis," a report released by a host of United Nations agencies during the Bangkok conference. The report emphasized that curtailing HIV's spread cannot be accomplished without addressing women's rights, including reproductive rights, and gender-based violence.
The women's report also took issue with the "ABC" - or Abstain, Be faithful, use Condoms - approach to HIV prevention that is often hailed by U.S. officials. Those three approaches ring empty to women who have little control over their reproductive life and little legal status in comparison to men.
"Abstinence is meaningless to women who are coerced into sex," said Thoraya Obaid, executive director of the United Nations Population Fund. "Faithfulness offers little protection to wives whose husbands have several partners or were infected before marriage. And condoms require the cooperation of men."
The ABC approach to HIV education attracted much debate during the conference, especially as large sums of U.S. HIV/AIDS funds are earmarked for abstinence-only programs. In May 2003, President Bush signed the U.S. Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 2003, providing $15 billion over five years to African and Caribbean countries, with a third of the act's prevention funds going to programs that promote abstinence until marriage. In a speech interrupted by protestors in Bangkok, Randall Tobias, head of the Office of the Global AIDS Coordinator within the U.S. State Department, defended U.S. policy, saying the United States is not against condom use. He cited a Uganda HIV program as an example of a campaign where abstinence played a role.
Uganda has been quite successful in reducing HIV infection rates through efforts that include encouraging teenagers not to have sex, according to the World Health Organization. In Uganda's capital of Kampala, HIV infection among pregnant women fell from 31 percent in 1993 to 14 percent in 1998, while rates for pregnant women younger than 20 beyond Kampala dropped from 21 percent in 1990 to 8 percent in 1998. WHO stated that Uganda's success was the result of many aspects, including sustained political commitment, community collaborations, social marketing of condoms and upgraded HIV testing services.
U.S. funding policy also garnered criticism for its stances on generic drugs and funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria. The law Bush signed in May 2003 created the President's Emergency Plan for AIDS Relief, a five-year strategy to combat HIV/AIDS. Unfortunately, emergency plan funds cannot be used to purchase generic antiretroviral drugs that may have been pre-qualified by WHO but have not been approved by the U.S. Food and Drug Administration, according to Human Rights Watch. Generic drugs will play a key role in WHO's "3x5" initiative, which aims to bring antiretroviral treatment to 3 million people by 2005. Currently, only about 400,000 people in developing nations have access to treatment.
The United States also took criticism for setting annual contributions to the global fund at $200 million - a sum that advocates say is woefully inadequate. Currently, the United States is the Global Fund's largest donor. However, according to UNAIDS, although global spending on HIV/AIDS was up to $5 billion in 2003, it is still less than half of what will be needed by developing countries by 2005. UNAIDS predicts that about $12 billion will be needed by 2005 and $20 billion by 2007 for prevention and care in low- and middle-income nations. Some advocates, such as APHA member Leonard Rubenstein, executive director of Physicians for Human Rights and an attendee at the conference, said more U.S. money should be directed toward the global fund, as it has a more global reach when compared to the president's program, which is directed at 15 specific countries.
"Bilateral assistance should be accompanied by a major ratcheting up in the level of multi-lateral assistance to the global fund, which is the world's mechanism for fighting AIDS, TB and malaria," Rubenstein told The Nation's Health. "The global fund has the worldwide reach and mechanisms for accountability, technical assistance, participation by people living with AIDS and scientific integrity that give it credibility and force."
In fact, a July report from the U.S. Government Accountability Office, Congress' investigative arm, found that among the difficulties of expanding and implementing antiretroviral treatment in resource-poor settings was, among other things, "U.S. government policy constraints." Another constraint named was shortages of health workers. The issue was the topic of a July report from Physicians for Human Rights that chronicled "brain drain," which is defined as the "exodus of health care workers from developing nations to the wealthier countries of the north." The issue presents a major obstacle to expanding and sustaining AIDS treatments in the developing world, according to "An Action Plan to Prevent Brain Drain: Building Equitable Health Systems in Africa."
According to the report, about 38 of 47 sub-Saharan African countries do not meet WHO recommendations of 20 physicians per 100,000 population. And in addition to health workers being lured away by better health care systems, higher salaries and more stringent safety conditions, many workers are dying because of AIDS or must stay home to care for family members with HIV, the report stated. The report offered an action plan to slow and prevent "brain drain," such as using donor funds to increase worker salaries and asking the United States and other nations to stop active recruitment of health professionals from developing countries. In fact, a recent report from the Institute of Medicine found that expansion of HIV/AIDS treatment and prevention in the developing world "will require tens of thousands of health care workers with the experience and training to treat millions of people who have a disease that requires a complicated and long-term regimen of care."
"Infrastructure is key, and unless the health systems can be strengthened sufficiently to have the capacity to provide counseling, treatment and also health services on many other conditions related to AIDS, the effort to treat people with AIDS can't succeed," Rubenstein said.
For more information on the 15th International AIDS Conference, visit www.unaids.org . For a copy of the Physicians for Human Rights report, visit www.phrusa.org .