Looking Back on World AIDS Day 2008

Monday marked the 20th global observance of World AIDS Day. Each year, this date provides an opportunity to reflect on what has been accomplished and what remains to be done.  Haiti's significant and under recognized progress in its struggle against HIV/AIDS continues.  In fact, Haiti's successes have been replicated in numerous countries throughout Sub-Saharan Africa.  This is something that we can all be proud of.  Below are some thoughts concerning World AIDS Day 2008.  

Starting with the big picture, the estimated number of people living with HIV/AIDS worldwide is now thought to be 33 million.  Over 1.4 million individuals living with HIV/AIDS began treatment last year, more than ever before.  However, 2.7 million individuals became infected with HIV during the same time.   Don’t ge me wrong, treatment is very important.  It sustains individuals, families, and communities.  Without a treatment option, people are very reluctant to pursue voluntary counseling and testing (VCT).  VCT is key in that, whether in the United States or Haiti, the majority of people infected with HIV do not know it.  Treatment reduces viral loads, making it harder to transmit the virus.  Still, we are never going to be able to treat out way out of this pandemic.  

Unfortunately, the evidence base for prevention interventions is not as developed as it should be.  Our undestanding of what works where, why, and how is under-developed.  We have to invest more into impact research that will help us learn what has been working well and what has not.  This would help us make better decisions to shape funding and programs.

HIV continues to feminize, meaning that the majority of people contracting it are women.  We’ve been hoping for female controlled interventions such as microbicides for some time now.  That is several years away.  An HIV vaccine is at least ten years away, and if the development of previous vaccines is an indicator, it will likely much longer.  Clearly, we must develop our collective expertise in prevention.

Peter Piot, the outgoing Director of the UNAIDS program, notes that there is "no single magic bullet for HIV prevention," adding that health officials "can choose wisely from the known prevention options available so that they can reinforce and complement each other."  He advises that programs adopt a "combination prevention" strategy of behavioral, biomedical and structural approaches to HIV/AIDS treatment. Behavioral approaches could include the promotion of condom use and discouragement of multiple sexual partners, and biomedical approaches could include male circumcision or antiretroviral treatment to prevent mother-to-child HIV transmission.  No one intervention by itself will ever be enough.

Some health experts are growing more outspoken in their argument that the international community is over-investing in HIV/AIDS.  I understand the argument.  Strictly in terms of child mortality, investing in acute respiratory infections or diarrhea, while unglamorous, would save many more lives.  However,  I believe the issue is not so much that we have over invested in HIV/AIDS as much as that we have  under-invested in other public health threats.  

A major impediment to expanding access to HIV/AIDS prevention, care, and treatment programs is a lack of health care providers including physicians, physician assistants, nurses, and counselors.  Also needed are program managers who can analyze, evaluate, and improve programming.   Haiti’s facilities for training health care workers are very limited.  Of those trained, many leave.  Based on my experiences working with Haitian health care providers, most would stay in Haiti if they were paid on a regular basis, had the tools they need to do their jobs properly, and received opportunities for training and advancement. Investments in Haiti's ability to train and retain social workers, nurses, physician's assistants, and doctors would pay dividends over the long term in HIV/AIDS and other areas.

Going forward, we need to shift to a longer term approach to advancing prevention, treatment, and care programs.  As mentioned, some of this will be long term such as training new health care providers.  Others will be short term such as training existing health care providers.  Community organizations, faith based groups, government officials, national chapters of red cross/red crescent societies are all in need of the expertise and experiences that will help them to take on a leading role.

It is worth noting that on December 1st, the United Nations appointed Michel Sidibe of Mali as its top official in the global fight against AIDS. Sidibe will succeed Peter Piot, whose deputy he has been since last year. Piot, has led the U.N. response to the AIDS epidemic as executive director of the Joint U.N. Program on HIV/AIDS (UNAIDS) since its inception in 1995.

Credit for bringing down the HIV prevalence rate in Haiti primarily goes to Haitian civil society.  However, a number of organizations have played an important supporting role.  The Presidents Emergency Plan for AIDS Relief (PEPFAR) is the largest initiative devoted to a single disease and has helped expand prevention, treatment and care programs in Haiti.   The Global Fund for HIV/AIDS, Tuberculosis, and Malaria is another initiative to which the United States also contributes.   

Of course, Haitians don’t just live in Haiti.   In the United States, the Center for Haitian Studies has been an important provider of counseling, testing, and prevention awareness programs in Miami.  In Boston, Partners in Health has doen the same. With support from USAID, Clinton HIV/AIDS Initiative, and the Dominican’s Presidential Commission on AIDS (COPRESIDA), Directive for the Control of Sexually-Transmitted Infections and HIV/AIDS (DIGECITTS) and Ministry of Health (SESPAS), the Batey Relief Alliance carries out comprehensive HIV/AIDS prevention and treatment programs delivering free services in laboratory testing, antiretroviral therapy, medical care, nutrition, counseling and education, and economic development to more than 3,000 living in the region of Monte Plata in the Dominican Republic. 

According to the Global Health Council, a ceremony for the opening of an AIDS memorial will take place next year in the Haitian capital of Port-au-Prince.  The event will be the opening ceremony of the International AIDS Candlelight Memorial scheduled for May 2009. The NGO Promoteurs Objectif Zero Sida will help to organize the event, which is intended to bring increased attention to AIDS and the need for enhanced efforts to contain the spread of the potentially deadly disease.

Worldwide, we have a long way to go yet in the struggle against HIV/AIDS.  By turning around the epidemic nationally, Haiti has set an example which was been followed elswhere. I hope that on December 1st next year, I will be able to write that more and more countries have been able to accomplish what Haiti has.

Please feel free to post your thoughts on World AIDS Day 2008 below as well as your ideas for the future.  Thanks! 

Bryan