The 15,000 delegates, journalists and commercial representatives to the 14th International AIDS Conference in Barcelona, Spain, July 7-12, 2002, departed for their 194 home countries with the first glimmers of belief that the world may finally be ready to take on the global AIDS pandemic, 21 years after the disease emerged seemingly out of nowhere.

AIDS Pandemic to Decrease Life Expectancy in 51 Countries

The conference opened with a sobering statistical account of the deadliest epidemic in human history. A new report from the United Nations AIDS program projects that at current infection rates, AIDS will kill 68 million people in the 45 most affected countries over the next 20 years. In fact, the AIDS pandemic will cause a decline in life expectancy in 51 countries in the next two decades, a demographic effect essentially without precedent in modern times.

By the end of this decade, 11 countries in sub-Saharan Africa will have life expectancies of less than 40 years instead of the 60s and 70s without AIDS, a level they have not experienced since the end of the 1800s. Longevity is also in decline in some nations in the Caribbean (the region second only to Africa in HIV prevalence). In Haiti, life expectancy is now 51 years instead of 59; in the Bahamas it is 66 instead of 74.

In Africa, about 55 percent of infected people are women, and the number of female cases is increasing. Among teenagers, girls are more likely to be infected than boys. In a survey in the Kenyan city of Kisumu, for example, the rate of infection among teenagers ages 15 to 19 was 23 percent in females, while it was 3.5 percent in males. AIDS is eroding decades of increasing child survival. In Botswana, Zimbabwe, South Africa and Namibia, more infants will die from human immunodeficiency virus (HIV) infection in 2010 than from all other cause.

The increasing likelihood that AIDS will kill more women than men has potentially worrisome implications. Noting similar statistics at a pre-conference press briefing yesterday, Stephen Lewis, U.N. special envoy on HIV/AIDS in Africa, said, "This pandemic has become a war on women. AIDS has become the ultimate symbol of gender inequality." Lewis predicted that in a decade or so "we're going to have a demographic rupture. . . . We're going to have all kinds of men without partners, wandering the landscape on a continent where there is already substantial instability."

Hopeful Signs of Global Resolve Emerge

This global tragedy need not happen. HIV prevention campaigns work, and there is overwhelming evidence that the AIDS epidemic can be controlled, but only when governments make fighting AIDS a priority.

A handful of developing countries are proving this. Uganda, devastated by years of dictatorship and war, has also been ravaged by one of the highest HIV prevalence rates in Africa. But after infection rates in the capital city of Kampala reached more than 30 percent in 1990, leaders in Parliament, urban neighborhoods and villages began to talk frankly and publicly about HIV and AIDS. Community groups started education and prevention programs. Today, Kampala's HIV prevalence rate is 11 percent and falling.

Zambia may become the second African nation to reverse its epidemic with education and prevention campaigns mounted by government and local communities. The prevalence of HIV has fallen among young women in cities to 24 percent in 1999 from 28 percent in 1996 and in rural areas to 12 percent from 16 percent.

In Cambodia, large-scale education and prevention programs (including steps to counter the stigma of HIV and AIDS have led to a decline in adult HIV infection rates to 2.7 percent at the end of 2001 from 4 percent in 1997. And in Brazil, where access to antiretroviral treatment is constitutionally guaranteed, the number of AIDS deaths is plummeting and prevention programs are succeeding in some of the groups that are at highest risk for infection.

Furthermore, over the next few months, programs that seemed inconceivable, and even foolhardy, a few years ago will commence. They will include efforts to massively increase AIDS prevention; to bring AIDS drugs to hundreds of thousands of people living in the world's poorest countries; to create a global arbiter of AIDS spending; and a global declaration to extract, year after year, billions of dollars from the wealthy nations of the world.

Hope comes with concrete progress. Progress is a 90 percent decline in the prices of antiretroviral drugs destined for use in the developing world. It includes greatly improved epidemiological information about the disease's toll, and the toll of its toll, such as the number of children now orphaned, or expected to be over the next 20 years, by AIDS. It includes the United Nations General Assembly Special Session on AIDS, held in June 2001, that set targets for increases in prevention services and decreases in disease transmission through 2015.

In the past two years, there has also been a huge addition to the body of knowledge about which AIDS prevention strategies work (and a much smaller one for treatment strategies) in high-prevalence areas. Guidelines for using three-drug combinations of antiretroviral medicines -- the standard of care for the infection -- have been simplified to a point where there is essentially no setting too deficient in resources to use them if they are available.
There are other hopeful signs. Almost 100 countries now have national AIDS strategies. Governments have signed a United Nations declaration pledging to achieve specific global targets in fighting AIDS and creating an international framework for accountability. These efforts are to be applauded, but they are not enough.

Much More is Needed

What's missing? Money, for one thing. A new, independent Global Fund to Fight AIDS, Tuberculosis and Malaria is an important source of funds for development countries, providing roughly $350 million in new money in its first round of grants this year and pledges totaling $2 billion from governments, foundations and individuals. Yet, by 2005, $10 billion will be needed annually to finance a basic response to HIV and AIDS in developing countries alone. To raise $10 billion, an increase of 50 percent a year in funds directed at fighting AIDS is needed in each of the next three years. That will require a collective effort: country-to-country assistance programs, participation by foundations and business, increased government spending in developing countries and international debt relief programs to allow increased spending.

The price of lifesaving HIV drugs has been reduced dramatically for some developing countries. But even at the lowest reduced price, $350 a person annually, the drugs are unaffordable in nations most in need. Last year, 30,000 people in sub-Saharan Africa received antiretroviral drugs; in the same period, 2.2 million people died of AIDS.

Failing to invest in an effective AIDS response undermines every other development goal. At last year's United Nations special session on AIDS, delegates made it clear that the broader development goals agreed on at the Millennium Summit in 2000 on education, literacy, infant mortality and agricultural and economic progress cannot be met if we do not tackle this disease.

Uganda, Zambia, Cambodia, Brazil and other developing nations have demonstrated that AIDS is a problem with a solution. Now the world must match this leadership and commitment with the resources nee ded to get on with the job. Otherwise, the new spirit of hope and vigor in the AIDS fight will be dashed. The costs of that are too devastating to contemplate.

(Editor's note: Exerpted in part from an editorial by Peter Piot, executive director of UNAIDS, the Joint United Nations Program on H.I.V./AIDS (http://www.unaids.org).