OPINION (Spotlight Weekly)

HIV, AIDS And Politics

By Dr John Dickinson

It was both appropriate and unfortunate that the main millennial AIDS conference, AIDS 2000, was held in Durban. Appropriate, because 4.2 million of the world’s 43 million HIV positive people are in South Africa. Unfortunate, because her President, Thabo Mbeki, shows a great reluctance to accept HIV, the Human Immunodeficiency Virus, as the cause of AIDS.

In May, Mr Mbeki set up a Presidential Advisory Panel on AIDS. Nothing objectionable in that; except that half his appointees do not believe that HIV causes AIDS. To appreciate the significance of this, you need to know that these people, are only a tiny fraction of those working in the field. Dr Peter Duesberg, whose views have been refuted all around the world, is typical of these advisors.

Why has Mr Mbeki, otherwise considered a worthy successor to Nelson Mandela, taken this extra-ordinary step? It is hard to tell. He has emphasised the role of poverty as a root cause of AIDS and few would disagree that there are many economic, social and cultural factors that play a large part in the spread of the HIV virus. But we need to follow the old advice "know your enemy", and HIV is undoubtedly the enemy.

There has been a strong reaction to this step, and also to letters written by Mr Mbeki to Bill Clinton, Tony Blair and other world leaders expressing the same views. Over 5000 scientists from around the world signed the "Durban Declaration" in the prestigious scientific journal "Nature". This was highly unusual in that the declaration was published a week before the conference even began! It made clear all the reasons why no further proof is needed to establish HIV as the cause of AIDS. Among them are:

¤ In all parts of the world, AIDS patients are infected with HIV

¤ People who receive blood transfusions from HIV positive donors eventually get AIDS. Those who receive screened, negative blood do not.

¤ Drugs that block HIV multiplication in a test tube also reduce viral load in AIDS patients. They also reduce AIDS mortality by more than 80% in the relatively few countries that can afford them.

¤ Untreated, people with HIV show signs of AIDS in 5-10 years.

Mr Mbeki’s opening address at the conference did little to placate his critics. The issue rumbled on throughout the week. It was not until Nelson Mandela’s masterly closing address that morale was restored to any extent. He focused on the fact that 90% of those with HIV and AIDS are in poor countries, where there is no money for anti retroviral drugs or even for basic care of the AIDS patient.

In Botswana, the country with the highest HIV prevalence in the world, 33% of the population between 15 and 49 years are HIV positive. In 7 other African countries, the prevalence is over 20%. Because of the effect of AIDS on the work force, businesses are going bankrupt, schools and hospitals are disrupted for lack of staff. Increasing numbers of children are orphaned or forced to leave school to care for parents.

¤ Life expectancy, previously rising, has dropped by as much as 20 years.

Notice the vicious circle. AIDS is most rife in countries where there is the most ignorance, the most poverty and the fewest resources. The result is further hindrance in development due to more sickness and disability, greater dependency, hampered education and reduced manpower. Many at the conference cried out on behalf of those whose lives are being ruined; has anybody heard?

So what lessons can be learnt? This was a depressing and unedifying spectacle of politicians and scientists in conflict. They need each other if progress is to be made. Though some of the pharmaceutical companies have offered to reduce the prices of their anti retroviral drugs for developing counties, even the reduced prices would not bring these drugs within the reach of the 90% of patients who live in these countries. A vaccine against HIV is at least 8 years away.

The only hope is to combat the social evils that allow the HIV virus to thrive:

¤ Poverty; the poverty that drives men away from their own homes to seek work; the poverty that leads girls and women into the sex trade.

¤ Ignorance; the ignorance that causes people to have unprotected sex with others of unknown HIV status; to inject addictive substances with used needles.

¤ Crime and greed; the crimes of drug trafficking and girl trafficking.

¤ Oppression of women; the oppression that does not allow them freedom of choice in their own health and fertility.

¤ Selfish attitudes; "It is OK for me to do anything that I desire at the time".

¤ Inadequate infrastructure to care for and nurture the poor and the sick.

Of course this is political. Without strong political will, both nationally and locally, advances can be made in none of these areas. It also costs money; in Kenya a programme of voluntary testing and counselling was estimated to prevent 1104 HIV infections per year, but the cost was US$ 249 per case prevented. In Tanzania, the equivalent cost was $ 346. The Director of UNAIDS has estimated that US$ 4 billion are needed world wide for educational and preventive programmes. Such programmes cannot be implemented without international funding and national and local commitment.

These issues are both political and personal. Sahayog, an NGO working in AIDS in Uttarakhand in Uttar Pradesh, published a report on prevalent sexual practices in the area. They described people having more than one sexual partner, cases of incest, low awareness of risk factors for HIV infection, migrant labour, unsterile injections and untested blood transfusions. They were probably absolutely correct, though perhaps undiplomatic. The result was that their offices were attacked and many workers put in prison.

So what about Nepal? So far, we are well behind the African countries in the development of the epidemic, but Nepal has been re-classified by WHO as having a "concentrated epidemic". This means that HIV is not firmly established in the general population, but there is high prevalence in certain sub- populations. For example, in the Kathmandu Valley, prevalence among intravenous drug users is 40% and among commercial sex workers it is almost 18%. Unfortunately, there are "bridging populations", such as the clients of sex workers and migrant labourers, who are already carrying HIV to their own homes. This brings a strong risk that the epidemic may become generalised in the next few years.

Though the reported number of HIV positives at the end of July is only 1616, WHO estimates at least 33 000 in Nepal. An independent estimate was as high as 60 000.

¤ Can you imagine the effect of 60 000 AIDS cases on the health services of Nepal?

Twenty years ago, no-one realised that a disease was developing in Africa which would threaten whole nations and communities. Though we now know more about it, we have few weapons with which to combat it. There have been some successes, using what we have; Thailand, for example, seems to have made good progress by means of strong programmes of education and harm reduction.

¤ The time to prevent an AIDS catastrophe in Nepal is NOW.

It cannot be done by scientists or doctors alone, or by politicians alone, but needs a united approach involving schools, colleges, workplaces, social services, NGOs and INGOs, local authorities and police. There are already government and NGO initiatives in various places. They need to be brought together in an effective whole.

HIV most generously and indiscriminately opens up the human host to a whole variety of other infections and diseases. We must co-operate together at least as well if we are to overcome it.

Dr Dickinson, Director, UMN Sakriya HIV and AIDS Unit