MEXICO CITY – Unprecedented advances in treating and controlling HIV/AIDS on a global level in recent years has some activists worried that success is breeding a new culture of complacency in Central America and throughout the rest of the world.
From a resurgence of new infections among certain populations at risk to fading activism and a lack of government planning in countries with low HIV prevalence, AIDS experts warn that a lack of sustained prevention efforts could jeopardize advances made in past years.
Unlike the macabre scenario that characterized the first 20 years of the epidemic, recent news on HIV/AIDS has been notably more positive. In fact, the United Nations’ 2008 Report on the Global AIDS Epidemic, released earlier this month, was called “the most positive report” thus far by U.N. AIDS chief Peter Piot.
The advances have been substantial. Last year, more than 1 million people were put on life-saving antiretroviral treatment (ARV), which has proven successful in lowering the viral load in infected people to almost undetectable levels, allowing them to live healthy lives and making them less likely to transmit the virus to others. As a result, incidence rates have dropped among certain populations, such as mother-to-child transmission in developed countries.
But the battle is far from won, and activists worry that success will numb the sense of urgency that once compelled the world to declare a war on AIDS.
“We must categorically reject any attempt to so-call ‘normalize’ AIDS or treat this epidemic as just one of many medical problems,” says Piot during his opening address at last week’s International AIDS Conference in Mexico City. “Now, more than ever, we need an exceptional response.”
In many parts of the world, however, the response has been less than exceptional. In Central America, where the epidemic has yet to reach alarming proportions among the general public, governments and civil society have become increasingly demobilized in recent years.
In Nicaragua, the country with the lowest HIV prevalence in Central America – less than 0.2 percent of the population – the government has not prioritized the HIV/AIDS as an important health issue.
“Nicaragua is a special case; it’s one of the fortunate countries that has a low prevalence rate, but it’s been slow to respond to HIV/ AIDS,” Vivian López, HIV/AIDS advisor for UNICEF Latin America, told The Nica Times. “Nicaragua needs to catch up.”
Instead, the Sandinista government appears to be heading backwards. Earlier this year, the government eliminated its national HIV/AIDS program, absorbing all AIDS efforts into the Public Health Ministry’s department of epidemiology. Nicaragua’s National Commission on AIDS has since been reduced to a lobby group without any administrative authority.
Nicaraguan AIDS activist Ivo Rosales says that despite Nicaragua’s “wonderful legal framework” to deal with the HIV epidemic, including a specific law (Ley 238) to protect the rights of people living with HIV/AIDS, the government’s commitment doesn’t go much beyond paper. In addition to having no AIDS program, strategy or funding, the government has also failed to implement a surveillance program to test people and determine how many are living with HIV in Nicaragua. As a result, the government’s statistic of 3,275 infected Nicaraguans is thought to be as much as five times less than the actual number of those living with HIV, Rosales says.
“The government says we don’t have a problem, but if it doesn’t have a surveillance system in place, we could have a huge problem and we just aren’t aware of it,” Rosales says. “And if we aren’t aware of our problem and we don’t have a national budget, there is very little we can do about it.”
In Costa Rica, which boasts a greater than 95 percent access rate to ARV medications, leaders in the AIDS community are concerned that activists have let down their guard.
“Unfortunately, nearly universal access in Costa Rica has also led to complacency in the activist community of people living with HIV/ AIDS, and this is a very dangerous trend,” says Richard Stern, director of Agua Buena Human Rights Association in San José.
Stern claims that the number of people living with HIV/AIDS in Costa Rica has put increasing strain on the Costa Rican Social Security System and that deteriorating health services are unlikely to be fixed without activists applying “outside pressure to correct these problems.”
Problems in the U.S., Too
The criticism over complacency is not limited to Central America or other parts of the developing world. Even in the United States, which has taken a global leadership role in the battle against HIV/AIDS with the Bush administration’s $48 billion President’s Emergency Plan for AIDS Relief (PEPFAR), certain populations claim the government has failed to exert the same efforts at home.
A U.S. organization called the Black AIDS Institute is calling upon the U.S. government to implement a similar PEPFAR plan in the United States, where the prevalence of HIV is growing among black U.S. citizens and men who have sex with men. In the United States, AIDS remains the leading cause of death among black women between 25-34 years old, and black women are 23 times more likely than white women to be diagnosed with AIDS in the United States, according to the Black AIDS Institute.
Blacks in the United States now represent 45 percent of all new HIV/AIDS cases, despite accounting for only 13 percent of the U.S. population.
“The U.S. is a leader in the world, but its not leading by combating the epidemic within its own borders,” says Phill Wilson, CEO of the Black AIDS Institute. “It’s failing, and that’s a direct attack on black America.” Wilson notes that more black U.S. citizens are infected with HIV than the total populations of people living with HIV in nearly half of the 15 countries served by the U.S.
PEPFAR program, the largest international health initiative ever launched by a single nation. Wilson and other black leaders are calling on the U.S. government to launch a similar $1.3 billion “domestic PEPFAR” program in U.S. cities.
Perhaps most shocking to AIDS activists and health-care workers is the culture of complacency that is emerging among the gay community in the United States and other parts of the developed world. Despite being ravaged by the AIDS epidemic in the 1980s and early 1990s, many in the gay community appear to be reverting to some of the same risky behavior of the past, leading to a steady and consistent increase in HIV incidence among men who have sex with men, according to AIDS experts.
“In North America and Europe, HIV is on the rise again among gay men, and complacency is the only answer,” Dr. Mark Wainberg, director of McGill AIDS Centre in Montreal, Canada, told The Nica Times.
“Gay men were dying in the 1990s and they became the main group responsible for becoming proactive, saying we need to stop having unprotected sex or we are going go die. Now, 15 years later, that attitude is gone and they need to bring it back.”
Wainberg says he thinks the problem is due, in part, to the wonderful effectiveness of ARV medications, which has almost reduced HIV to any other manageable chronic illness.
“There are a lot of people who are vulnerable and who adopt the attitude: The drugs work so well, does it really matter if I get infected?” Wainberg says.
The long term effects of the medication are still unknown, however, and people who take the ARV drugs complain of side effects, including nausea and nightmares.
Still, because the pills are working, “there is a tremendous complacency about HIV risk,” says Kevin Fenton, director of the U.S. National Center for HIV/AIDS.
Chris Beyrer, director of the Johns Hopkins Fogarty AIDS International Training and Research Program, blames the increase in infection rates on both complacency and the “club drug” culture that many gay men are involved in, and which dramatically lowers their inhibitions about safe sex practices.
Statistics show that more than 40 percent of gay men in the United States admit to taking non-injection drugs – mostly methamphetamines – in the past 12 months.
The Internet, by enabling gay men to connect more easily, is another factor contributing to an increase in HIV prevalence, Beyrer said.
But it’s not only young gay men who are engaging in unsafe behavior. “When you look at HIV data by age, it’s surprising how much incidence there is among older age groups,” Beyrer says. “You see new infections in men in their 40s and 50s. There are a substantial number of new infections among men over age 35.”
The number of older gay men being infected now indicates that some of the lessons learned in the 1990s about safe sex are already being forgotten, Beyrer says.
“It amazes me. I am a gay man from that generation, I am from New York and I am the survivor of a small number of friends who lived. So I can’t believe it when I see these numbers and that people are back to these behaviors, but clearly they are.”
Still No Cure
Though there is still no cure for HIV/AIDS – all vaccine trials have failed, and many scientists doubt that the future antibody tests will succeed – many in U.S. society seem to have a general faith that science will eventually solve the riddle. Some think this blind trust in medicine could also be contributing to a culture of complacency, and argue that science should never be viewed as a substitute for behavior change.
“On a societal level, people think they don’t have to do the work of behavior change because eventually a magic bullet will be found,” Helene Gayle, president of CARE and former director of the NationalCenter for HIV/AIDS, told The Nica Times. “Even when we find it, we have to continue the hard work of changing behavior. Bio-medical tools are not a substitute for behavior change. There’s been a naïveté, thinking that a magic bullet will keep us from doing the hard work of changing behavior.”
Back in Nicaragua, there’s less science to have faith in, and few initiatives focus on behavior change.
In fact, notes Nicaraguan AIDS activist Rosales, the government has become an obstacle to positive behavior change by forming a pact with the Catholic Church that has tripped up efforts to implement programs on sexual education, gender construction and condom use.
“Even when we are able to convince people to use condoms, many times they aren’t even available.”