Time to act: global apathy towards HIV/AIDS is a crime against humanity

Lancet commentary:

There are less than 1 million people on antiretrovirals worldwide. Fred Minandi is one of the lucky ones, especially considering Malawi is one of the poorest countries in the world. Like in most African countries per-capita income in Malawi is less than US$1 a day, which is not enough to pay for food and shelter let alone antiretrovirals. People like Mr Minandi and the plight of countless others with HIV living in Africa and elsewhere cannot be ignored.

UNAIDS estimates that more than 60 million people have been infected with HIV and a third of these have died. Last year alone an estimated 3 million people died from HIV/AIDS worldwide. Over the next 20 years, another 68 million people are projected to die prematurely as a result of HIV/AIDS, with the greatest toll in sub-Saharan Africa. Globally, HIV/AIDS is now the leading cause-of-disease burden.

Of the 40 million people currently living with HIV/AIDS, 28 million live in sub-Saharan Africa, 6 million in south and southeast Asia, 1·5 million in Latin America, 0·5 million in the Caribbean, 1 million in eastern Europe and central Asia, 1 million in east Asia and the Pacific Region, 0·5 million in north Africa and the Middle East, 0·5 million in western Europe, and 1 million in North America.

The HIV/AIDS crisis in Africa has received increased attention, particularly after the International AIDS Society sponsored the Durban conference in 2000. But political leadership has failed to recognise that the HIV epidemic is at an earlier stage but equally out of control in other areas. For example, Russia, Nigeria, India, Ethiopia, and China, five nations that make-up more than 40% of the world's population, have yet to mount an effective response to the pandemic.

By 2010 the US National Intelligence Council estimates that between 5 and 75 million people could be infected in these five next-wave countries. Russia promised US$133 million to fight the disease over the next 5 years, but there is little evidence that it has set aside this amount. In Kolkata (formerly Calcutta), India, a sexually transmitted diseases clinic run by the Durbar Mahila Samanwaya Committee as part of an HIV-prevention programme for sex-trade workers has been closed down.

This effective initiative, which provides services to about 60 000 sex workers has been running for nearly a decade. If >effective prevention efforts are not sustained, India could have 37 million people infected with HIV by 2005. This estimate is roughly equal to the total number of HIV infections in the world today. In China, although senior leaders acknowledge HIV as a serious problem, the country's size, lack of money, limited popular knowledge about HIV/AIDS, and cultural taboos make prevention efforts difficult.

"To them we are like bubbles", says Xie Yan, referring to officials in her Chinese village. "They know if they turn away and ignore us, we will soon pop and be gone", says Yan, a mother of three who recently lost her husband to AIDS. Elsewhere, in Latin America, a growing economic crisis, particularly in the southern cone, threatens to reverse the limited but tangible gains of the past decade.

Most persons currently living with HIV/AIDS are in the prime of their working lives. Typically, HIV infects the most sexually active age groups, leading to disease and death over the next 5-15 years. The disease course may be even faster in sub-tropical areas due to poorly characterised ecological pressures.

Life expectancy in sub-Saharan Africa, for example, has already dropped 15 years because of HIV/AIDS. Life expectancy at birth is currently 47 years in this region; without HIV/AIDS it would have been 62 years

If left unattended HIV/AIDS will weaken macro-economic and microeconomic activity by squeezing productivity, adding costs, diverting productive resources, and depleting skills in the countries most affected. All these factors give rise to increased poverty, despair, and lack of hope, and could lead to increased political instability, terrorism and war, and even global instability.

HIV/AIDS has not only become a global epidemic, but it is also regarded as a major impediment to development and a substantial threat to human security, defined not just as the absence of armed conflict but rather as the fundamental conditions that are needed for people to lead safe, secure, healthy, and productive lives (Peter Piot, AIDS and Human Security, United Nations University, Tokyo, Japan, Oct 2, 2001).

The UN recognised this during their special session on HIV/AIDS in New York on June 25-27, 2001. At the same session it was agreed that access to medications is one of the fundamental elements to achieve the right of everyone to enjoy the highest attainable standard of physical and mental health, and that the prevention and treatment of those infected and affected by HIV/AIDS are mutually reinforcing elements of an effective response. It was then estimated that US$9·2 billion a year was needed to turn the tide against AIDS by 2005.

The annual cost has now been revised to US$10 billion a year. At the same forum it was proposed that each country would contribute to this fund using a sliding scale based on gross national product. Unfortunately these commitments have not been met and, as such, the epidemic grows unchecked, despite the fact that on April 23, 2002, US Secretary of State Colin Powell stated that HIV/AIDS is "a catastrophe far worse by orders of magnitude than any problem or crisis we have on the face of the earth right now . . . a catastrophe worse than terrorism"

Against this background, it is disheartening to hear that US Vice-President Dick Cheney, on August 29, 2002, said "what we must not do in the face of mortal threat is to give in to wishful thinking or willful blindness. We will not simply look away, hope for the best and leave the matter for some future administration to resolve". But he was not referring to the real and present danger of HIV/AIDS but to the hypothetical threat posed by Saddam Hussein.

The Global Fund to Fight AIDS, Tuberculosis and Malaria is quickly running out of money.6 The fund has pledges for just US$2·1 billion over the next 5 years, 4% of what UN Secretary-General Kofi Annan called for last year. Just to meet already existing commitments in the next 2 years the fund will need another US$7 billion in donations.

Clearly monies are available. In Canada, the province of British Columbia spent nearly 0Ã?·5 billion Canadian dollars on four fast ferries that will probably never be used. In China, US$25 billion will be spent on the Three Gorges Dam, a controversial project across the Yangtze river which is expected to alter the health and welfare of millions of people. Lastly, if the USA goes to war with Iraq, the estimated cost is between US$50 and 100 billion. 

The situational diagnosis is clear, the need for action is imperative, the crisis is growing. The pillars of an effective response have already been identified: education, prevention, care, and research. Globally 16 000 new infections occur a day,5 about 90% of them in the south of the world. Since most of those infected have no access to effective therapies, for most, HIV infection equals an unnecessary premature death.

The world cannot turn its back on this injustice any longer. Inaction against HIV/AIDS today is a crime against humanity that cannot be tolerated any longer. Immediate action is needed to move this issue forward and must start by ensuring that political leaders fulfil their commitments on a local, regional, and global basis without further delay.

The fate of people like Fred Minandi rests on our actions and the actions of our leaders. The time to act is now.

All the authors have received funding for work in HIV/AIDS. Robert Hogg, Pedro Cahn, Elly T Katabira, Joep Lange, N M Samuel, Michael O'Shaughnessy, Stefano Vella, Mark A Wainberg, *Julio Montaner

*AIDS Research Program, St Paul's Hospital/University of British Columbia, Vancouver, British Columbia V6Z 1Y6, Canada; Department of Health Care and Epidemiology and BC Center for Excellence in HIV/AIDS, University of British Columbia; Fundacion Huesped, Buenos Aires, Argentina; Faculty of Medicine, Makerere University, Kampala, Uganda; Academic Medical Centre, IATEC, Amsterdam, Netherlands; Department of Experimental Medicine, TN DR MGR Medical University, Chennai, India; Faculty of Medicine, University of British Columbia; HIV AIDS Clinical Research, Istituto Superiore di SanitÃ? , Rome, Italy; and McGill University AIDS Centre, AIDS Research Laboratory, Lady Davis Institute for Medical Research, Montreal, Quebec, Canada.