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It is very apt that the evolution of the HIV/AIDS epidemic should be considered in the context of global health. One of the critical aspects of global health as a field of study and practice is that it seeks not only the general improvement of health in the world, but more importantly seeks to reduce the inequalities between peoples -- inequalities that in essence represent inequities. There will be no substantial improvement in global health unless there is concomitant international health in the sense of nations and their component actors working together. Success in addressing the problem of HIV is, and indeed will be, a marvellous test case of the ability of nations to work cooperatively, and the characteristics of the infection bring out clearly the inequities that exist within and between countries, which must be eliminated.
But we should pay more attention to the message of the title, which implies that either we win, or lose. A possible interpretation is that it is an "all or none" scenario and the approach used in combating HIV, like so many other diseases, is that of a battle, using military analogy. The implication is that a battle is being fought against the enemy agent and victory will imply the complete vanquishing of the agent. Yet, battles are not chronic: they end in victory for one side and defeat for the other. So far, the history of public health has only one example of a battle won, in the sense of eradicating a disease from the face of the earth: smallpox. The difficulty in eliminating two other viral diseases -- measles and poliomyelitis -- for which there are good tools, must bring some caution to the hope that there can really be an eradication of HIV, although like smallpox there is only a human host. The danger of this approach for many diseases, and particularly for HIV, is that it sets up a scenario in which, unless there is absolute victory, there is the sense of failure. I have been concerned at some of the rhetoric which implies that the efforts to control the HIV epidemic are a failure. They are not.
The best way to evaluate the progress against the spread of HIV/AIDS is through examining various milestones and specific targets, demonstrating that they are being achieved. Preventing mother-to-child transmission is an example of a target that is eminently achievable, as has been shown, for instance, in some countries in the Caribbean. In this region as a whole, prevention rates of transmission from mother to child have moved from 22 per cent in 2003 to 52 per cent in 2008, with countries committing to reducing this form of transmission to less than 5 per cent by 2015. The elimination of HIV transmission through blood and blood products in the Caribbean is another simple but specific example of a target met. Coverage with antiretroviral therapy, which was about 1 per cent in 2003, has increased to 51 per cent in 2008. Perhaps the most critical indicator of progress has been the possibility of prolonging the life of AIDS patients. As Dr. Anthony Fauci, a renowned immunologist from the United States who has made substantial contributions to research in the areas of AIDS, puts it: "In the period since HIV emerged, we went from a twenty-six week lifespan to a forty-year lifespan."
Much of the focus on winning has arisen from the possibility of creating an effective vaccine that would prevent infection. Some of the euphoria about a possible vaccine is no doubt based on the hope that by chemical means, human beings could be relieved from the need for responsible action in sexual relations. Sex would then be "safe". This would be somewhat analogous to the liberation that attended the availability of the birth control pill. An effective vaccine has not materialized yet and the prospects appear to be remote. Given the oft repeated numbers that for every person placed on antiretroviral drugs there are six new infections, and the inescapable fact that the potential treatment pool continues to increase, the possibility of control -- rather than winning immediately -- will depend on the application of effective preventive measures. Winning and losing will have to be established in relation to the degree of application of the preventive measures, even if they are imperfect, and even if the science of prevention is not glamorous nor its funding secure.
But there is tremendous enthusiasm among HIV health workers that feasible prevention targets can be established and achieved in the short and medium term, and that the continuum of prevention, treatment, care, and support is more than a slogan. But if this continuum is going to be effective, then there has to be more concerted international action, and the acceptance that no one aspect of the continuum is intrinsically more important than another.
An international consortium of partners, called aids2031, analyses the possible scenarios that may occur from now until 2031, marking fifty years since the first report of HIV/AIDS. It paints a sombre but realistic picture of what is necessary to face the HIV epidemic. There will be need for more funding, for newer antiretroviral drugs, for the wide application of those preventive measures that are known to be effective, such as condom use and male circumcision. There will be need to advocate more vigorously for the human rights of persons with HIV, and to reduce the stigma and discrimination that attend the infection. It will be critical that we not bow to the tyranny of numbers. These are daunting, but not impossible tasks, for a world which has shown its power for good or evil through cooperative action.
Thus, I would suggest that our "victories" may be small and incremental, but the categorization and management of HIV infection as just another chronic illness will certainly take place soon, and this may be the win we will celebrate in the not too distant future.