Cylone

Summary of meeting held at ODI 29th November 2000.

2009-12-17T08:02:00.001-08:00

Speakers: Alan Whiteside, University of Natal and Tony Barnett, University of East Anglia.
Chair: Simon Maxwell

HIV/AIDS, poverty and development

1) Alan Whiteside started by stating his disappointment with the WDR in terms of HIV/AIDS. Very few of the WB's main strategies, centred around opportunity, empowerment and security, are attainable taking the effects of the epidemic into account. 'Can Africa Claim the 21st Century', another recent World Bank publication, proved equally disappointing in this respect. For Africa AIDS is the number one problem; unfortunately the World Bank has failed to recognise this. Not only are the development targets unattainable due to the AIDS epidemic (especially in parts of Africa), but indeed the very way in which development is practised will have to be rethought.

2) Quoting Tony Barnett, Whiteside described AIDS as a 'long wave disaster…that is a long time in the making and in which the major effects have already begun to occur long before the magnitude of the crisis is recognised and any response is possible' . In fact, the situation is worse than people realise; predictions about AIDS made a decade ago were far too positive.

3) The epidemic curve of HIV/AIDS can be divided into four:
i) the wave of HIV infection
ii) the wave of tuberculosis (most common opportunistic infection in Africa)
iii) the wave of AIDS illness and death
iv) the wave of impact (includes household poverty and orphaning)
Other epidemic curves are usually more predictable; illness leads to death and ultimately the epidemic curve goes down. With AIDS we simply do not know, all we can say for certain is that HIV will ultimately lead to AIDS and death - there is no recovery. What we do not know is what will happen to the epidemic curve in the aftermath of massive AIDS related deaths.

4) A recent survey from South Africa shows that 1 in 5 women attending ante-natal clinics are HIV positive. In Botswana, 37% of women attending ante-natal clinics are infected. We know that the rate of HIV infection will rise significantly in the future, and that most deaths occur in young adults. What will this mean for international development goals?
- In terms of reducing child mortality in Africa we can rather expect a significant increase; up to 30% of children born to HIV positive mothers will be infected and most die before the age of 5.
- In terms of life expectancy the epidemic has equally devastating effects: US estimates show that by 2010 life expectancy in Botswana will be reduced to 29 years.

5) The South African President has claimed that poverty causes AIDS. Does it? The simple answer is no. HIV causes AIDS. But what causes HIV? In Africa and Asia HIV is transmitted mainly through heterosexual intercourse, whereas in Eastern Europe the main source of transmission is needle sharing by intravenous drug users. In terms of sexual intercourse, the chances of transmission in a healthy person is not too great. However, factors such as the type of virus and the stage of infection do matter in terms of facilitating transmission as does the presence of other sexually transmitted diseases. Behavioural factors are of course crucial in this respect. In South Africa for example, people often have several partners at once in contrast to the assumed serial monogamy in the UK. However, sexual behaviour cannot be seen in isolation; migration, the status of women and their (lack of) access to economic resources, general health care etc. are all important factors. Thus, poverty in itself does not cause an AIDS epidemic but certainly contributes to it. However, more than poverty, inequality is a crucial factor (e.g. rich men buying sex from poor women). So yes- attacking poverty is important, but there are multiple factors that need to be addressed.

6) Tony Barnett took up Whiteside's last point, and claimed that the World Bank in fact does recognise a relationship between GNP per capita/income inequality and HIV infection. High HIV infection rates occur along with high income inequality, whereas countries with a high GNP per capita have lower rates of infection. This constitutes at least recognition that there is a relationship between poverty/inequality and HIV/AIDS. This is not a direct or simple relationship but it cannot be excluded from any consideration of poverty programmes or programmes that talk about 'trickle down'. There might not be time to let things 'trickle down'!
Although Africa is usually thought of in conjunction with AIDS, India in fact has the largest HIV positive population in any one country in the world. In China, rising income inequality along with high syphilis and gonorrhoea occurrences raises concerns regarding rapid increases in HIV infection rates. Unofficial estimates indicate that there may be as many as 10 million HIV positive people in China.

7) The youth/adult additional deaths caused by AIDS have huge implications for both health care and the division of labour and production. AIDS has already caused changes in population distribution in some African countries. Original findings from Barnett and Blaikie's research in Uganda in 1989 indicated changed population structure at the local level at that time. The main changes resulted in less good ratios between dependents and producers. A recent US Bureau of the Census model for Botswana in 2020 shows this Ugandan experience being repeated more than a decade later with a dramatically changed dependency ratio (age/gender distribution); this will have serious implications in terms of food availability, medical spending, care of orphans etc. A decline in life expectancy will affect employers and organisations and ultimately have a macro-level impact. On a household/community level, the effect will be seen most clearly in terms of farming systems and food production www.fao.org/sd/wpdirect/wpre0075.htm, and orphaning. Many orphans will lack basic care and grow up without being parented; some might experience orphaning not only once, but 2 or 3 times (i.e. when parents, then carers die). Care of elderly is also a major issue; who will provide crucial care if a large percentage of young adults are ill or die?

8) Barnett concluded by summing up the key areas in terms of the effect of AIDS:
- skills structure
- orphans and elderly (altered dependency ratio)
- inter- and -intra household dynamics and sharing
- trauma
- organisations (carry cost of medications and other employee related liabilities)
- employment
- subsistence agriculture
All of these are potentially impoverishing issues, and will have to be taken into account for any development intervention to be effective. Regrettably, the WDR has not taken these issues seriously.

9) In the discussion that followed it was pointed out that this was indeed welcome analysis: on the occupational side death (and following lack) of teachers have serious implications for education; many children may be forced into child labour; and how will businesses deal with the loss in social capital? A personal perspective on the link between poverty/inequality and risk of HIV infection was provided: In a compound in Botswana, a maid who was paid more than the usual salary still saw it necessary to earn money by 'having boyfriends' in order to send money back to her family. Only when this was discovered and the maid offered far better terms did the men stop coming. This illustrates the very real situation girls may find themselves in; their socio-economic situation may determine whether or not they are putting themselves (and others) at high risk of HIV infection. Tony Barnett commented that the knock-on effects of AIDS on teachers and other occupational groups are indeed incredibly important. In terms of child labour, an aspect often not discussed is military labour. The combination of civil unrest, arms and orphans is a very serious issue.

10)The chair asked whether there was a certain element of 'doom and gloom' in the analysis and the examples used in the presentation. Many countries in Africa do not have high rates of HIV, and some of the countries with previously high rates have seen a significant decline (e.g. Uganda and Thailand). Whiteside replied that the situation described will (if it isn't already) be reality for most of Africa, parts of Asia and Eastern Europe. According to UNAIDS, the lifetime risk of dying of AIDS for a 15 year old boy in Botswana is 85%; this is nothing but disturbing statistics. Many of the countries reporting low infection rates often do not have reliable data. And yes- there have been a few 'success-stories' however these are few and far between and the constant challenge is to stop the curve from rising. It was pointed out from the audience that that very incomplete data exist, especially in countries in unrest. Until now there has been no attempts to deal with HIV/AIDS in refugee camps. There might well be an element of 'doom and gloom' that we don't even acknowledge ourselves.

11) The role of businesses was then commented on: There is a need to encourage businesses to go beyond the business framework - businesses do not exist in a vacuum; they could be involved in both combating poverty and encouraging behavioural change. It was furthermore pointed out that the Caribbean is an area that has been largely neglected in terms of HIV/AIDS - despite an alarmingly high HIV infection rate. The worrying in this situation is that it is not taken onboard at local level nor by agencies such as the World Bank or the World Health Organisation.

12) Concluding, Whiteside and Barnett argued that the main message of AIDS and the effects we are seeing today is that we can not go on doing development in the same way. AIDS has shifted the parameters on which development is based, and this must be incorporated into the way we 'do' and talk about development. Although HIV prevention work is crucial in order to curb the spread of infection, we also need to look beyond infection to address, and deal with, the impact of the epidemic. AIDS poses the major development challenge today.

ASSESSMENT OF THE SOCIO-ECONOMIC CAUSES AND CONSEQUENCES OF HIV/ AIDS

2009-12-17T08:00:00.001-08:00

Objectives, Outputs and Processes

Increasing numbers of countries have undertaken or are proposing to undertake studies of the socioeconomic issues relating to the HIV epidemic. In some cases these studies are planned as part of the preparations relating to Strategic Planning for HIV and AIDS, and in other cases are seen as one of the important outputs of the Plan. The main objectives of such Studies are as follows: -

Advocacy: to increase understanding of the multiple ways in which the HIV epidemic affects human development as an essential input in the mobilisation of government and civil society in the national response to HIV and AIDS.

Economic and Social Analysis of the HIV epidemic: to present data/ information and analysis relevant for the design and implementation of a broad based multisectoral response to the HIV epidemic.

Given these as the two main objectives of such Studies the key outputs that can be expected are: -

· an increased understanding of the threat that the epidemic has for the sustained development of the country, both as a mechanism for raising awareness and as a means of increasing commitment to broad-based action, and,

· a clear specification of the practical activities that are feasible in the country, and which are needed if the socioeconomic aspects of the epidemic are to be addressed in a timely and effective manner.

The precise focus of such Studies needs to reflect the policy and programme needs of the country taking into consideration both the objectives and outputs identified above. Thus if the important issue that requires analysis is the impact of the epidemic on households then this should become the focus of the Study, and resources will not be misused in more general analysis and in less useful ways.

The processes followed in undertaking a Study must ensure that potential users of the data and information are involved throughout so as to ensure that it reflects policy and programme priorities. Furthermore, processes need to ensure national ownership, involve all important stakeholders in the design and implementation of the Study, and strengthen national research and other policy, programme and institutional capacity.

Below, we set out precisely what this entails.

Stage 1. Situation Analysis

Studies must involve an analysis and description of the socioeconomic conditions in the country as an essential step in identifying those factors which affect the susceptibility of the population to the HIV epidemic. Consideration will need to be given to the following: -

· identification of those behavioural and other factors which affect HIV transmission and the capacity to cope with a range of socioeconomic impacts of the epidemic

· the presentation and analysis of socio-economic data and information which increases understanding of the situation in the country at national and other levels, and which have policy and programme relevance both for understanding the conditions in which the epidemic is thriving and as a base for a broader-based policy and programme response.

Thus poverty is often seen as a factor which leads to behaviours which expose socially and economically excluded groups to risk of HIV infection, and which then reduces the capacity of such households to cope with the effects of HIV/AIDS [which are social, economic and psycho-social in their nature]. Exploring these relationships is crucial for ensuring that HIV and AIDS are integrated in poverty programmes.

An important output of will be a better founded understanding of the socioeconomic vulnerability of the population and of the country1s institutions, through a deeper understanding of the structure of the society and the economy. Thus the situation analysis will, for example:

· identify and explore the ways in which conditions of poverty and social exclusion, gender relationships, employment [especially of young persons], labour migration etc. affect the transmission of HIV, and thus have direct relevance for policies for HIV prevention, care and the mitigation of the socioeconomic impact of the epidemic,

in order to:

· strengthen understanding of the socio-economic factors which underlie the epidemic and which determine household, sectoral and national capacity to respond to the epidemic, as a foundation for a broader-based and more effective inter-sectoral national response.

It is also important to undertake an analysis of the existing epidemiological data on HIV and AIDS, so as to establish: -

· from the data/information what are the trends in HIV in the population, its spatial distribution, and its distribution by gender and age,

· the important relationships between epidemiological information and other data relating to education, occupation, rural/urban and other charactersistics of the population should be presented and analysed.

· a discussion of the present sources of data on HIV and on AIDS; the reliability of existing data and its coverage, and identification of any deficiencies with data for establishing more effective policies and programmes within the country.

· analysis of data/information that is set in the context of the HIV situation in the region and sub-region so that the epidemic can be seen within an appropriate context for a regional/sub-regional response ? including identifying relevant socioeconomic factors [such as labour migration and other factors affecting the movement of people].

This review of HIV surveillance and other data should generate a better understanding of trends in the epidemic in the country; a clearer perception of the factors that seem to be important in HIV transmission [including those which are social, cultural and economic in nature]; analysis of those factors which affect coping capacity in affected populations at household and sectoral level; provide a firm base for recommendations in the Study for improvements of the HIV surveillance data and system, and identify behavioural and other socio-economic data important for policy and programme development.

Stage 2. Assessing Socioeconomic Conditions

Identifying Causes and Estimating Impacts

This section of the Study needs to build on the Situation Analysis and other data/information drawn from regional and global sources. It should NOT simply address issues of actual and expected socioeconomic impact but also analyse those conditions which determine vulnerability and susceptability in the different sectors under discussion.

It is also important that each of the following sub-sections lead to practical recommendations of value to those developing the national response to the epidemic.

The Study may focus its analysis and description in respect of each or all of the 3 levels depending on policy and programme priorities as noted above.

A. Households

These are the primary socioeconomic unit in all societies with critical functions of an economic, social and cultural nature. They are important as productive units, especially in respect of farming and food production but also in the formal and informal productive sectors. They have crucial social and reproductive functions in terms of children and their socialisation [economic support, transference of productive skills and social patterning]. At the early stages of the HIV epidemic the effects are usually first felt and are observable at household level ? although many factors may intervene to hide these effects due to the shame, stigma and discrimination often associated with HIV and AIDS.

Issues that need to be addressed include the following: -

· an assessment of the factors affecting the capacity of households to survive in the face of the HIV epidemic,

· this assessment will build on data and information available on conditions relating to the susceptibility of households and their capacity to cope with the epidemic [poverty, proportion of female headed households, employment/unemployment conditions, health /education status of household members, housing conditions, etc.],

· the Study should build on what is known about these matters from elsewhere in the region, and globally, but the focus should be on what is being experienced now by households in the country, including access to public services and support from Government, NGOs and others [such as Churches],

· it should detail what are the needs of households for more extensive socio-economic support, drawing attention particularly to the effects on children and what is being done to address their specific needs,

· this section of the Study should clearly identify the problems being faced currently by affected households, the gaps in current policy and programme response, and what is needed in terms of extended social and economic support,

· where gaps exist in terms of current information and data the Study should recommend how these issues should be addressed, and by whom, so that a firm basis for policy is established,

· it is important that the special needs of children and young adults be identified by the Study and recommendations made for dealing with these ? including issues of access to key services such as health and education, housing and nutrition, and employment,

· constraints as well as needs have to be identified including matters relating to institutional capacity in public and private institutions ? taking into account that existing institutional arrangements for care and support will often be unable to cope with the new and expanded challenges and will need to be extensively reformed.

Undertaking studies of the effects of HIV and AIDS on households is extremely sensitive and all activities need to ensure that the researched community is fully involved at all stages in the design and implementation of the Study and in respect of follow-up activities. All activities need to ensure the confidentiality of respondents, and be undertaken in accordance with generally accepted ethical standards for such research.

B. Sectors

The Study should identify the ways in which the epidemic affects the capacity to maintain efficient forms of production and service provision in key economic and social sectors in the country. It is essential that the Study understand the structural foundations of the economy and the fact that its efficient operation depends on the functioning of its separate parts. In other words that the economy consists on an inter-dependent set of activities and has to be analysed and described in ways that recognise that the epidemic has systemic effects due to the losses of human and institutional capacity. An example is the impact of losses of transport capacity and higher costs in the transport sector for the marketability of rural products both in local and external markets.

· it is not the case that all productive sectors are equally affected by the losses of human and institutional capacity brought about by HIV and AIDS,

· it is essential that the Study identify what is currently happening in key sectors in the country, and building on other information in the region and globally to establish a set of qualitative and quantitative projections as to what may happen, and what may need to be done to reduce the actual or potential socio-economic impact.

Amongst the key sectors that will need to be analysed are the following:-

Transport and Communications
Tourism
Commercial Agriculture
Small-holder Agriculture [and related rural institutions and services]
Key economic sectors, such as Mining and Manufacturing
Finance ? Banking, Insurance, Development Banking
Health services ? public and private
Education
Military and other uniformed services [police and prisons]
Other key public and private services such as general public administration, water and the judicial system

The Study should therefore -

· establish what are the reasons for selecting sectors to be identified in terms of their essentiality for the continued functioning of the economy, and in the light of the predicted effects due to HIV and AIDS,

· make it clear why these sectors are vulnerable to losses of human and institutional capacity due to HIV and AIDS,

· identify what the potential effects may be in terms of higher costs and disruption of output,

· identify policy and programme options for mitigating current and future socio-economic impact,

· clearly identify the possible implications for the economy of the continued provision of key public and private services as noted above, together with recommendations as to what needs to be done to protect these services.

Important in this analysis is the identification of the impact of HIV and AIDS on public budgets and on public polices and programmes [including the establishment of effective HIV in the Workplace Programmes and review of training and other policies for public servants ? including review of the Government1s personnel policy framework so as to make this more relevant].

In all cases the Study should make recommendations as to what actions are needed to reduce future HIV infection amongst workers and managers; what needs to be done to mitigate current and expected socio-economic impact, and where responsibility lies for the development and implementation of appropriate policies and programmes.

C. Macroeconomic

Within the limitations of the HIV surveillance and other data available in the country the Study should attempt to set out the main channels through which the economy in the aggregate may be affected by the HIV epidemic. In addition it:

· should review data from other countries in the region who have attempted to estimate the macro impacts, and review other information on global estimates of the macro-economic impact on developing countries

· should summarise the main findings of such studies and the policy implications if any for the country

· should also indicate what data needs to be collected for rapid estimation of the macro impacts, bearing in mind that estimates of macro-economic effects are more useful as tools for advocacy than for the development of effective and practical responses to the epidemic

· should clearly indicate the limitations of existing macro studies of economic impact, and demonstrate if possible how such studies may be used in moving towards a deeper understanding of the HIV epidemic in the country.

Where data and other resources permit estimates of the macro-economic impact then these estimates can be made. Bearing in mind -

· the fact that projections of HIV are extremely unreliable in most countries, such that estimates more than 2 years into the future may have very high errors,

· that human capital approaches to estimating macro-economic effects contain serious analytical and other estimation problems, and

· that econometric estimates of economic impact require data and information not usually available to researchers in developing countries, and depend on often unjustified simplification of conditions in both product and factor markets.

It is important before setting out to make these predictions to realise their limitations, and to understand their role in the development of practical responses to the epidemic in the country.

Summary of Recommendations and Follow-up Processes

There are 2 basic conditions that need to be established and met by any studies that are undertaken. The study outputs must include the following:-

· the identification of, and policy and programnme recommendations relating to, all important socioeconomic aspects of the epidemic; concentrating on those recommendations that are most relevant for the operationalisation of the National Strategic Plan by the National AIDS Programme and other stakeholders.

· the establishment to the extent feasible of a set of recommendations for follow up by Government and others so as to ensure that the Study does indeed lead to a broader based and multisectoral response to the HIV epidemic. It should indicate what are the next steps in the policy process, and where responsibility lies for implementing the Study's main policy recommendations.

The operationalisation of the recommendations and any consequent decisions at national and other levels will be the litmus test of the value-added by the Study, given that the purpose of such studies is to strengthen the national response to HIV and AIDS within policy and programme frameworks which are multisectoral.

Africa: Next Wave of HIV/AIDS

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This posting contains excerpts from a new report by the U.S. National Intelligence Council, identifying five countries including 40% of the world's population as the focus of the next wave of the HIV/AIDS pandemic. These countries include two African countries, Nigeria and Ethiopia, as well as Russia, India, and China. The full study is available at the NIC's web site at: http://www.odci.gov/nic

Note that the projections in the study are even higher than most others currently presented, and are acknowledged to have wide ranges of uncertainty. Note also that the study repeats the conventional assumption that almost all HIV in Africa results from heterosexual transmission. In contrast, a recent article in the Royal Society of Medicines' International Journal of STDs (Sexually Transmitted Diseases) and AIDS, excerpted in another posting today, contends that the proportion of transmission of the virus through unsafe medical care (injections,transfusions, and other procedures) is being grossly underestimated, and may even exceed the proportion transmitted by sexual intercourse.

The new NIC report was featured at a two-day meeting at the Center for Strategic and International Studies, including a luncheon keynote address by Stephen Lewis, special envoy of the UN Secretary-General on HIV/AIDS. See
http://www.csis.org/press/ma_2002_1003.htm Lewis' speech is available at: http://sustainable.allafrica.com/stories/200210040603.html

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The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India, and China

ICA 2002-04D September 2002

National Intelligence Council

The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India, and China

Prepared under the auspices of David F. Gordon, formerly National Intelligence Officer for Economics and Global Issues.

Summary

The number of people with HIV/ AIDS will grow significantly by the end of the decade. The increase will be driven by the spread of the disease in five populous countries Nigeria, Ethiopia, Russia, India, and China where the number of infected people will grow from around 14 to 23 million currently to an estimated 50 to 75 million by 2010. This estimate eclipses the projected 30 to 35 million cases by the end of the decade in central and southern Africa, the current focal point of the pandemic.

* We project China will have 10 to 15 million HIV/ AIDS cases, and India is likely to have 20 to 25 million by 2010 the highest estimate for any country. By 2010, we project Nigeria will have 10 to 15 million cases, Ethiopia 7 to 10 million, and Russia 5 to 8 million.

HIV/AIDS is spreading at different rates in the five countries, with the epidemic the most advanced in Nigeria and Ethiopia. In all countries, however, risky sexual behaviors are driving infection rates upward at a precipitous rate.

* Adult prevalence rates - the total number of people infected as a percentage of the adult population - are substantially lower in Russia, India, and China, where the disease remains concentrated in high- risk groups, such as intravenous drug users in Russia and people selling blood plasma in China, where some villages have reported 60 percent infection rates.

* Nevertheless, the disease is spreading to wider circles through heterosexual transmission in India, the movement of infected migrant workers in China, and frequent prison amnesty releases of large numbers of infected prison inmates and rising prostitution in Russia.

It will be difficult for any of the five countries to check their epidemics by 2010 without dramatic shifts in priorities. The disease has built up significant momentum, health services are inadequate, and the cost of education and treatment programs will be overwhelming. Government leaders will have trouble maintaining a priority on HIV/ AIDS which has been key to stemming the disease in Uganda, Thailand, and Brazil because of other pressing issues and the lack of AIDS advocacy groups.

* The governments of Nigeria, India, and China are beginning to focus more attention on the HIV/ AIDS threat.

* Even if the five next-wave countries devote more resources to HIV/AIDS programs, implementation is likely to miss significant portions of the population, given weak or limited government institutions and uneven coordination between local and national levels.

* Nigeria and Ethiopia have very limited public services to mobilize. Russia is beset by other major public health problems. China has decentralized most responsibility for health and education issues to local governments that often are corrupt.

* India has taken some steps to improve its healthcare infrastructure to combat HIV/AIDS, but the government has few resources to treat existing infections and must cope with other major health problems such as tuberculosis (TB), which has become linked to the spread of HIV/AIDS.

The rise of HIV/AIDS in the next-wave countries is likely to have significant economic, social, political, and military implications. The impact will vary substantially among the five countries, however, because of differences among them in the development of the disease, likely government responses, available resources, and demographic profiles.

* Nigeria and Ethiopia will be the hardest hit, with the social and economic impact similar to that in the hardest hit countries in southern and central Africa decimating key government and business elites, undermining growth, and discouraging foreign investment. Both countries are key to regional stability, and the rise in HIV/AIDS will strain their governments.

* In Russia, the rise in HIV/AIDS will exacerbate the population decline and severe health problems already plaguing the country, creating even greater difficulty for Russia to rebound economically. These trends may spark tensions over spending priorities and sharpen military manpower shortages.

* HIV/AIDS will drive up social and healthcare costs in India and China, but the broader economic and political impact is likely to be readily absorbed by the huge populations of these countries. We do not believe the disease will pose a fundamental threat through 2010 to their status as major regional players, but it will add to the complex problems faced by their leaders. The more HIV/AIDS spreads among young, educated, urban populations, the greater the economic cost of the disease will be for these countries, given the impact on, and the need for, skilled labor.

The growing AIDS problem in the next- wave countries probably will spark calls for more financial and technical support from donor countries. It may lead to growing tensions over how to disburse international funds, such as the Global Fund for AIDS, TB and Malaria.

The cost of antiretroviral drugs which can prolong the lives of infected people has plunged in recent years but still may be prohibitively high for populous, low- income countries. More importantly, the drug costs are only a portion of HIV/AIDS treatment costs. Drug- resistant strains are likely to spread because of the inconsistent use of antiretroviral therapies and the manufacture overseas of unregulated, substandard drugs. 5

* If an effective vaccine is developed in the coming years, Western governments and pharmaceutical companies will come under intense pressure to make it widely available.

* The next-wave countries are likely to seek greater US technical assistance in tracking and combating the disease.

...

We project that China probably will have 10 to 15 million HIV/AIDS cases by 2010. India is likely to have 20 to 25 million higher than projected for any other country. We estimate Nigeria probably will have 10 to15 million cases, Russia 5 to 8 million, and Ethiopia 7 to 10 million.

Country Profiles

Nigeria.

The HIV/AIDS epidemic in Nigeria is significantly ahead of that in India, China, and Russia - already advancing well beyond high- risk groups and into the general population. The official adult prevalence rate is almost 6 percent, but unofficial estimates range as high as 10 percent which represents 4 to 6 million people infected.

Heterosexual transmission of the HIV virus is the primary mode of spread in Nigeria, and infections appear to be as numerous in rural areas as in the cities. The reported rate of infection apparently varies significantly by region, with the lowest reported rate found generally in the predominantly Muslim northern parts of the country (see 9 figure 3). Infections are most numerous among men ages 20 through 24, but some experts caution that infection rates are rising quickly in young women.

Given the already advanced state of the disease and the government s limited capacity to respond, we expect HIV/AIDS to infect as many as 10 to 15 million people by 2010. This number would constitute roughly 18 to 26 percent of adults close to the current rates in some of the hardest hit countries in southern Africa.

Ethiopia.

Ethiopia's adult prevalence rate estimated at between 10 and 18 percent is the highest among the five countries, indicating that like Nigeria the disease has moved significantly into the general population. Government figures cite 2.7 million Ethiopians currently as HIV positive, although experts believe the actual number may be between 3 and 5 million. Adult prevalence is much higher in cities (13 to 20 percent) than in rural areas (5 percent) (see figure 4). The generally poor health of Ethiopians as a result of drought, 10 malnutrition, limited healthcare, and other infectious diseases has caused HIV to progress rapidly to AIDS. Heterosexual transmission is the primary mode of spread, and people with multiple partners especially those with sexually transmitted diseases (STDs) and prostitutes have significantly higher infection rates, ranging from 30 to 40 percent in STD- positive individuals to 50 to 70 percent in prostitutes.

Unlike conditions in other next- wave countries, war has significantly contributed to the spread of the disease in Ethiopia. Many soldiers contracted HIV/AIDS during the civil war in the 1980s by having contact with multiple sex partners. When the war ended in 1991, thousands of infected soldiers and prostitutes returned home, spreading HIV/AIDS in their villages and towns.

* Another surge of infections may be underway. Ethiopia has demobilized 150,000 soldiers over the last two years as the conflict with Eritrea has wound down. More troops will be sent home as the border dispute is settled.

* As soldiers demobilize, prostitutes who have even higher rates of infection disperse around the country as well.

Looking ahead, we expect 7 to 10 million Ethiopians probably will be infected by 2010 because of the high current rate of adult prevalence, widespread poverty, low educational levels, and the government's limited capacity to respond more actively.

...

HIV: The Science of the Disease

HIV-1 is a fatal infection acquired by contact with the blood or body fluids of an infected person. A transfusion with infected blood almost always results in spread of the virus, and children born to infected mothers have an up to 40 percent chance of contracting the virus prior to birth, during birth, or through breastfeeding. The transmission rate of the disease through sexual contact ranges from 1 to 3 percent. Reusing infected needles results in infections less than one percent of the time.

Sexually transmitted diseases or reproductive tract infections greatly increase the risk of contracting HIV, and uncircumcised men transmit HIV and other STDs to their partners more frequently than circumcised men.

As the disease progresses, a type of infection-fighting white blood cell the CD4 positive-t cell decreases, leading to an irreversible loss of immune function. This period is marked by many illnesses, or unusual opportunistic infections that healthy immune systems protect against.

HIV-positive persons are susceptible to opportunistic and infectious diseases, especially TB. Once they have contracted TB, the disease progresses to the highly infectious, active stage much more quickly and frequently than in HIV-negative persons and is often what kills them. ...

Prospects for Control

We assess that all five next-wave countries will have difficulty controlling their HIV epidemics in the short to medium-term. The disease has built up significant momentum especially in Nigeria and Ethiopia and the governments have been slow to respond. None of the five next-wave countries in this report is on a trajectory to replicate the success of such countries as Uganda, Thailand, and Brazil in stemming the spread of the disease. Several leaders of the nextwave countries are focusing more attention on the AIDS threat, but all face a host of competing demands. In addition, these countries have weak healthcare infrastructures and severe budget constraints, which will create difficulty in financing education and treatment programs for their large populations.

...

Nigeria's leadership has been the most active of the five countries in trying to raise AIDS awareness, for example, by hosting a regional AIDS conference in 2000 and publicly warning about the risk of extinction on the continent. Nonetheless, the Obasanjo administration is beset by such other pressing problems as an approaching election and rising ethnic and religious tensions. Moreover, Nigeria s government institutions have deteriorated so badly over the last decade that Obasanjo has few functioning public sector assets left to mobilize even if he chose to engage fully on the issue.

* Nigeria has taken some steps, however, to build domestic monitoring and diagnostic capabilities especially in Lagos and a major study on the economic effects of HIV/AIDS is underway. * The Nigerian military, concerned about the loss of key personnel from AIDS, now mandates training about the disease for soldiers.

* The Ethiopian Government does not appear focused on AIDS, despite occasional statements on the issue. The government has focused in recent years on the conflict with Eritrea. Healthcare workers privately have criticized efforts in recent years as half hearted, and UN officials have publicly warned Ethiopian leaders to take more measures to stem the epidemic.

...

Weak Healthcare Infrastructure

Although significant differences in capabilities exist among next- wave countries, all five have overburdened and under funded healthcare systems and limited abilities to provide integrated, nationwide programs to test people, track infections, and deliver treatment and education programs. Even within each of the five next- wave countries there are disparities in the ability of cities and regions to deal with the epidemic that are likely to grow in the coming years.

* Nigeria's public healthcare system, which has been deteriorating for years, is hard pressed to provide even the most basic public services. Many facilities lack electricity, water, and soap; even betterequipped hospitals are beset by strikes by medical staff.

* Ethiopia has never had a viable national healthcare system because of overwhelming poverty and years of war. The government is soliciting international assistance to build its capabilities, but progress on this front is likely to take years.

Implications

The rise of HIV/AIDS will have significant economic, social, political, and military implications in Nigeria, Ethiopia, Russia, India, and China, although the percentage of the adult population in each country that is infected is likely to remain below the hardest hit countries in southern and central Africa. The impact of the disease by the end of the decade will vary among the five countries, given differences in disease trajectories government responses, available resources, and demographic profiles.

Nigeria and Ethiopia: Hardest Hit

The social and economic impact of AIDS in Nigeria and Ethiopia probably will be similar to the hardest hit countries in Africa. The disease is likely to negatively impact almost all sectors of society by 2010. AIDS will take a heavy economic toll by robbing the countries of many key government and business elites and by discouraging foreign investment, although the oil sector is unlikely to be hurt significantly. 22

* The professional classes in Nigeria and Ethiopia like other African countries are more vulnerable in comparison to other next- wave countries because adult prevalence rates already are much higher and relatively fewer elites are concentrated in a smaller number of key positions.

* The drag of AIDS on economic growth will further reduce the ability of the government to handle the rising social and healthcare costs.

The further deterioration of already weak government institutions by the escalating HIV/AIDS crisis could leave Nigeria and Ethiopia seriously weakened states and is likely to reduce their ability to continue to play a regional leadership role.

* HIV/AIDS probably will complicate staffing in the military officer corps of the two countries as it has in other African states. Ethiopia is more likely to suffer military manpower shortages through the lower ranks, however, because it has a much larger army and smaller population than Nigeria, which plans to reduce the size of its force.

* Rising social tensions over AIDS and related economic problems could exacerbate regional and ethnic tensions within Nigeria and Ethiopia while leaving both governments less able to manage the problem.

Conclusions and Recommendations

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In the preceding chapters, the impact and consequences of the HIV/AIDS epidemic on small farmers in Eastern Africa, as well as on the estate sector in Zambia and to an extent in Tanzania, have been considered. It was found that some factors appear to be true for all the systems studied, notably that HIV/AIDS furthers the process of impoverishment. Linked to this is the impact which the epidemic has on labour availability. This impact can have grave consequences for farming systems, which are heavily reliant on human labour power, either seasonal or perennial. AIDS-related sickness and death reduce the number of hands available to do both household and farm work having profound effects on the domestic farm labour economy. This results in productivity declines with cash incomes likely to fall.

Obviously the extent to which the farming system is affected depends very much on the particular circumstances which pertain for each situation. Moreover, since farming systems are not static, and at the same time epidemic impact is not constant, with rapid increases in morbidity and mortality being most pronounced in the earlier stages of the epidemic, the consequences vary not only from one context to another, and from also one stage of the epidemic to another.

In Uganda, three different stages of the epidemic as it affects three different farming systems were observed (and supported by population data collected in the course of the study). These were pre-impact, early impact and full impact. Examples of each stage were seen in Rakai, North Mubende and South Iganga respectively. Broadly speaking, it seems that in Uganda, affected households follow a path of regressive decline in terms of the content of their production. This is most marked in the case of Gwanda, where, using comparative material from 1989 (Barnett and Blaikie, 1992), it was observed that there has been a marked shift to more basic and less varied food and other crop production. This change was more pronounced among the poorer households. The focus of these adjustments is in the domestic-farm labour economy, and has serious implications for the lives of women and children. In Uganda, the areas which are more vulnerable to the epidemic are often those which have farming systems which are particularly susceptible to labour loss.

In Zambia, as far as can be ascertained on very limited disease incidence data, the farming systems which are most vulnerable to labour loss are not those which are most vulnerable to the epidemic. epidemic. At the same time, while it may be generally true that the most labour-vulnerable farming systems in Zambia are not immediately susceptible to the epidemic, this should not be taken as grounds for complacency in a country with high levels of seroprevalence and a tradition of large-scale internal and international labour migration. The case studies from Teta and

Chipese indicate that in these communities, the epidemic is already affecting quite large numbers of households. The effects of this differ between patrilineal and matrilineal peoples, the latter, as has been noted above, being much more immediately vulnerable to the effects of labour loss.

In Tanzania where oxen are quite widely used and where there are complex exchanges of labour for use of oxen, one adverse effect of HIV/AIDS may be to increase the depth of socio-economic differentiation between ox-owning and non-ox-owning households. However, a very positive aspect of this is that, in Tanzania, insofar as oxen increase productivity and thus earnings, rural youths appear less likely to leave farming in search of incomes and excitement elsewhere. This is in contrast to the situation in Uganda and is important in relation both to the spread of the epidemic and to labour availability as epidemic-related shortages may be less likely to be exacerbated by labour migration than for example in Uganda.

An important observation, in the light of the differences in the findings, is that it is important to have seroprevalence information from as many sites as possible given that rural data are vital for a deeper understanding of the problem and that currently their availability is very limited.

The recommendations will not exclusively concentrate on the agricultural sector, they also will include nutritional and health aspects, as the impact of HIV/AIDS has multi-sectoral dimensions and has to be tackled multi-sectoral.

6.2 The impact of HIV/AIDS on programmes and projects

Rising mortality and morbidity as a result of AIDS are likely to have an impact on project performance since health is a precondition for development. One of the most serious threats to any project is absenteeism on the part of both beneficiaries and project staff, which can be caused by mortality and morbidity, attendance to funerals and various other exigencies of daily life. Absenteeism from project activities may set back the progress of projects in countries severely affected by the disease. Discrimination at the workplace of HIV-positive staff may further interfere with the work performance of all staff.

The impact of AIDS can manifest itself in various ways. It may result in labour shortages forcing farm households to shift from cash to subsistence crops when food security is being threatened. Cash crops which require a long investment period may not be suitable for families afflicted by AIDS that are in need of quick returns to cover immediate medical, funeral or orphan-related expenses.

Livestock activities might be jeopardized by family members selling off their animals to finance medical care for AIDS patients. In addition, if the person in charge of the livestock dies, family members are often unable to manage the livestock due to the loss of skills and relevant experience.

The viability of agricultural credit schemes may be at risk as a result of HIV/AIDS for three reasons: a) increased mortality may raise the number of defaults; b) AIDS-affected families may be forced to liquidate their assets in order to repay the credit or else have their assets seized, thereby ending up worse off than before they incurred the credit; and c) AlDS-afflicted families may have to spend part or all of the credit to finance medical care for family members suffering from AIDS, rather than use the funds for investment.

Agricultural research priorities might shift in view of AIDS to focus on the special needs of farm household with fewer working adults. Projects supporting agricultural extension services need to ensure that forms of labour-substitution, technical advice and credit services are made available to AIDS-affected farm families. Such projects should review the impact of HIV/AIDS both in terms of increased mortality among agricultural extension staff, but also in terms of the reduction of the work time as a result of the increase in funeral attendance.

In countries or regions where AIDS is claiming the lives of skilled labour and the labour market is limited in this labour segment, consideration of the impact of AIDS may be critical to the success and sustainability of investment projects. Recruitment, personnel replacement, training strategies and employment benefits (medical, pension funds, etc) may have to be revised accordingly.

For any training activity, HIV/AIDS may have to be taken into account both in terms of replacement/re-training provisions and strategies, but also in terms of revising training curricula.

6.3 General recommendations at the planning and policy level

Given that a principal finding of this study is that the impact of HIV/AIDS is uneven between and within countries, it follows that policy responses must be developed in relation to the situation as it is observed in particular regions, districts and communities and thus that local involvement in policy and project development is essential.

Even in countries like Tanzania with high national rates of seroprevalence and cumulative AIDS cases, it is quite difficult to observe the impact of the epidemic in most rural communities. This is because the epidemic manifests quite marked regional and local variations and the impact may vary quite dramatically over small distances. This has implications for the method to be used in any future work on this problem and points once again to the necessity for community involvement in diagnosis and programming if resources are to be used most effectively.

In communities where the impact is just being felt it may be necessary to think in terms of rapid response so as to ensure that

- labour-economising strategies are immediately developed for the specific needs of this type of community through the extension services, research stations and NGOs. This will require considerable inter-agency coordination;
- extension messages contain explicit HIV/AIDS components which should include both general HIV/AIDS advice and education and also sensitization to the known impacts of HIV/AIDS on rural livelihoods and production.

However, in communities such as South Iganga in Uganda the main response should contain medium-term efforts to develop labour economising strategies which are suitable for the local production system plus the inclusion of HIV/AIDS education in the extension service message.

Although these specific points derive from the situation in Uganda, they may be applied to all three countries. Thus, a zoning approach may be adopted using the vulnerability mapping data (see below) from this report or from other sources in other countries. Such an approach would classify areas of each country by a particular type of programme which is relevant.

6.4 Determining epidemic impact on labour availability

The Uganda material, in particular, demonstrates very clearly the difficulty and importance of distinguishing epidemic impact on labour availability from other background effects such as local labour market operation. This observation should be brought to the attention of anybody dealing with responses at the local and district level. At the same time, the most important programme and policy responses will be those which enable people to cope with the results of labour loss.

A major result of HIV/AIDS impact is increased pressure on the household labour economy. The most important programme and policy responses will be those which enable people to cope with the results of labour loss. Recommendations include working with local people, to develop responses which facilitate labour economising responses in:

- production - for example by exploring novel inter-crops or the introduction of new varieties or technologies;
- marketing - for example by assisting women's mobility both spatial and social; and
- caring, for example by the development of and assistance to support groups among members of affected households.

This study reveals that members of communities which have been longer exposed to HIV/AIDS may be more open to innovations than they previously were. People are forced to react to the crisis which is caused by AIDS.

6.5 The use of vulnerability mapping

Earlier work in Uganda used available data to map the relative vulnerability to labour loss of different farming systems. This method has been shown to be as expected a broad but imprecise indicator in the case of Uganda. In the present study, a similar exercise was completed for Zambia, thus providing the basis for broad vulnerability mapping in that country. There were insufficient data to develop the basis for a vulnerability map of Tanzania, although existing reports may provide some guide to this problem and further analysis may be possible.

In general however, it is recommended that an HIV/AIDS farming system/rural livelihood vulnerability mapping system be developed for a country. This would serve three purposes. Firstly, it would enable broad identification of risk by administrative area, agro-ecological zone, farming systems and livelihood strategy. Secondly, it would provide a framework for the development of area-specific policies and thirdly it would facilitate the monitoring of impact and policy outcomes.

The process of vulnerability mapping as a means of understanding how farming and rural livelihood systems are affected by labour loss may also give rise to the development of an early warning system. This would consist of a hierarchy of information - broad classification as has been achieved in Uganda and Zambia, more detailed information from district-level agricultural and other administrative sources, and finally, limited examination of the nature of the impact in specific communities using RRA/PRA methods. The usefulness of such an approach was in part demonstrated in the case work for Tanzania, where, with the exception of Kagera region, the rural impact is so far slight but seroprevalence rates indicate that it will increase in the medium-term. Development of an early warning system should facilitate focused responses when the epidemic impact becomes manifest.

Once a hierarchy has been established three levels of responses could be used.

Level 1: The creation of a broad map of rural vulnerability to the impact of HIV/AIDS. Experience suggests that the information for this first stage of vulnerability mapping description and ranking of farming and rural livelihood systems in terms of their sensitivity to labour loss -may be obtained from country resources in departments of agriculture and from research stations as well as from other sources. This is then combined with seroprevalence and cumulative AIDS case data obtained from National AIDS Control Programme sentinel surveillance surveys.

Level 2: Limited verification of the broad vulnerability mapping through small-scale studies (e.g. RRA/PRA) in order to indicate whether the broad mapping is providing useful guidance, undertaking a detailed description of the situations in specific areas and identifying the types of local coping response and demands for assistance.

Level 3: Development of assistance programmes for areas which exhibit different levels of vulnerability and are at different stages of the epidemic impact.

Moreover, if this approach is to be successful, it will be desirable to develop adequate HIV/AIDS impact training programmes at all levels. These would include:

- general training in HIV/AIDS impact issues for politicians and departmental heads;
- specific training in HIV/AIDS impact issues for middle level administrators in all departments engaged with rural and agricultural development; and
- community-based participatory analysis of the situation and needs in specific communities.

6.6 The targeting of assistance

The main burden of the impact at the household level falls on the labour economy of the household. This has considerable implications for the targeting of assistance on women, children and in some cases widowers who are raising children. It is difficult to see how to target these groups, thus there are few response strategies which can be targeted specifically towards the HIV/AIDS-affected and or afflicted. The issue is poverty and the response has to be to deal with a likely increase in poverty rather than to assume that a high level of targeting is possible. Policy responses should integrate all aspects of poverty relief, the domestic and farm labour, the educational needs of orphans and other young people, food security and income generation.

Using existing coping strategies

Communities and households have developed their own coping mechanism. The reorganisation of cropping schedules, selection of cultivars, rearrangement of domestic/farm labour interfaces are all examples. Some of the accumulated experience of coping should be documented and members of "experienced" communities should be encouraged to share their experience with communities at the beginning of the coping process or which have not yet been affected. This sharing could be achieved both via the extension services, but also through the facilitation of direct contacts between members of different communities.

Cost recovery

Cost recovery of both school and medical costs have become more widespread in recent years as part of liberalisation programmes. These place additional burdens on all households and in particular on affected and afflicted households. Relief in these two areas could make an important contribution to both current and future welfare of rural households.

6.7 Donor funding and the role of NGOs

In Uganda where the long-term effects of an HIV/AIDS epidemic are observable, NGOs have been very active. The difficulty is in knowing how sustainable are their efforts. Accordingly, this is a question which donors should address very clearly when making funding decisions.

Funding decisions should also take into account two other considerations. Firstly, the social and economic impact of HIV/AIDS is, apart from its specifically medical aspects, to increase poverty. This means that specific HIV/AIDS targeting and project design is difficult in a context of general poverty. Policy responses should integrate all aspects of poverty relief, the domestic-farm labour interface, educational needs of orphans and other young people, food security and income generation.

Secondly, whether in some communities (for example Gwanda) efforts to find and fund sustainable projects may be in vain and the need for medium-term relief should be considered. There is a conventional belief that development projects and programmes are preferable to relief projects and programmes. The main rationale for this view is usually that the former are sustainable and longterm, the latter are emergency measures, short-term and unsustainable. While it is certainly the case that in general long-term sustainability should be a policy goal, there is a danger that the provision of long-term development projects and programmes, may be used as a way of avoiding the cost of long-term relief. However, long-term, sustainable development projects require certain macro-economic conditions and a degree of realism if they are to be truly sustainable and appropriate.

6.8 Taking HIV/AIDS into consideration in project design

In countries with pandemic proportions of HIV/AIDS its impact should be taken into account in all steps of a project cycle such as project identification and design, project appraisal, project implementation and monitoring & evaluation.

In the project identification phase, it is important to find out, to what extent HIV/AIDS is prevalent in a project area. Statistical data provide a first indication, but as experience shows, they often differ significantly from the real situation. Therefore the potential impact of AIDS should be included in Participatory Rural Appraisal and Rapid Rural Appraisal exercises. The identification of target groups should be taken serious to ensure that AIDS affected families are not excluded and that their special needs are addressed.

The implications of AIDS need to be considered in cost-benefit analyses on which labour shortages, reduced agricultural yields, absenteeism, etc have their effect. For the project implementation phase the reduced labour availability of both project staff and beneficiaries to participate in project activities should be reflected in the workplan.

The impact of the epidemic on projects needs to be closely monitored in order to make timely adjustments. Due to the special nature of HIV/AIDS the impact is expected to become more serious over the next years. Project strategies and interventions should be revised accordingly.

In view of the above observations, the need for inter-agency and inter-sectoral cooperation in strategy and project formulation is of great importance. This is of some significance for the role which all United Nations agencies will play in the years ahead (and not only in Africa) and may well prove to be a test of the effectiveness of some of those agencies. It also raises the important issue of the relation between United Nations agencies and NGOs, both local and international.

6.9 Specific recommendations at the micro level

6.9.1 Crop production activities
6.9.2 Livestock and small-stock raising
6.9.3 Income-generating activities
6.9.4 Health
6.9.5 Nutrition

In broad terms, for individual farming systems, the following basic types of activities are required:

- improving returns to labour;
- extending the planting period (minimum tillage, early maturing varieties, crops and methods for later planting);
- crop diversification and reducing external input requirements;
- improved livestock management techniques;
- small credit schemes.

6.9.1 Crop production activities

Specific activities or improvements aimed at improving yields, producing more relish crops and helping farmers to adapt to labour shortages might include for crop production, the following:

- advice on possible labour economising methods for cultivating staples in order to delay the effects of labour shortage, for example, how to deal with the weevil problem in bananas;
- advice on how yields of secondary staples, for example cassava and yams, now displacing bananas, may be increased without needing extra labour;
- advice on better storage of secondary staples resulting in an effective increase in production
- access to improved varieties of relish crops, specifically groundnuts, beans, cowpeas and bambara nuts;
- exploring other mixtures and intercrop possibilities;
- use of labour-saving implements e.g. reduced tillage implements for oxen such as rippers and ridgers;
- using minimum tillage and ground cover crops to reduce weeding for hand hoe cultivators;
- consideration of the weed control problem - is there a role for herbicides in some circumstances? Are there alternative mulching methods which do not require large amounts of labour?
- improvements in the marketing of relish crops
- access to small loans for other crops and staples (especially targeting women, see also below);
- promotion of research into indigenous relish crops, processing methods and seed storage;
- improving crop management for intercropping;
- tractor hire; or promotion of draught power; and
- promotion of alternative soil fertility strategies (as opposed to reliance on fertilisers) through the use of organic fertiliser, intercrops and crop rotation.

6.9.2 Livestock and small-stock raising

Specific activities or improvements aimed at livestock production are the following:

- promotion of breeds requiring limited attention;
- advice on feed and health care techniques for cattle, sheep, goats, pigs and poultry;
- in societies where cultural tradition permits, pig keeping may be encouraged as a labour economising replacement for cattle, having advantages both as a source of cash and protein which may be particularly beneficial for female- headed households;
- poultry keeping may be encouraged especially for orphans to raise some cash;
- promotion of non-traditional livestock activities, e.g. bee keeping (apiary);
- finally inheritance customs which may prevent widows from inheriting livestock should be discouraged.

6.9.3 Income-generating activities

Where appropriate, small especially home-based low labour income generating opportunities and petty trading activities may be considered. However, these may well mean that provision needs to be made to ensure access to credit by small farmers, either as individuals or groups. Such activities include sewing, tailoring, bee keeping, pig keeping and the production of handicrafts.

However, it is worth noting that local initiatives and ideas are only feasible in circumstances where there are markets for products. Accordingly, encouragement of any kind of income-generating activity should only be considered on the basis of the right conditions being present. These may include access to the inputs needed for the activity, storage and transport facilities if necessary and reasonable likelihood of the marketability of the product.

6.9.4 Health

The large numbers of AlDS-afflicted and affected families in areas of high seroprevalence means that the care of AIDS patients is an important, time-consuming and expensive part of the daily lives of such households. Many of those interviewed in the course of the field studies whose families had been affected by AIDS said that they preferred to have patients die at home.

In Zambia, for example, home-based care programmes will be essential in most rural areas, especially since several of the local hospitals examined, already had constant occupancy rates of over 100 percent. Thus it will not be possible to care for the bulk of HIV/AIDS patients in hospitals, and neither is it particularly desirable, as they are then separated from their kin.

Women in particular reported that they prefer those who are sick to be at home, as it disrupts their production activities less and removes the cost of transport to the hospital. However, caring for patients at home also involves material costs, notably for food and bedding. With regard to food, it was observed that patients often did not like and would not eat vegetables and thus became very hungry. They wanted meat, fish, and eggs. With respect to bedding, blankets are expensive and if they become soiled and torn are costly to replace.

Measures should therefore be taken regarding the home care of HIV/AIDS patients so as to:

- provide for the training of family members in the basic skills of handling and taking care of patients to avoid the risk of infection; and
- provide resources so that households can afford both food and medication, treatment and bedding for the sick.
In all farming systems, regardless of the stage of epidemic impact, AIDS prevention measures, most notably through health education' urgently need to be introduced (or strengthened as the case may be). Such measures include:
- promotion of social activities since many, particularly marginalized rural areas, offer virtually nothing in terms of activities apart from beer drinking and sex;
- door-to-door awareness-raising campaigns are preferable to rallies as a means of disseminating information;
- health education/AIDS teaching should be integrated into work with agricultural extension groups;
- schools should be supported to provide health and AIDS education. This is particularly relevant in areas where the HIV/AIDS epidemic is regarded as a kind of witchcraft or is generally considered to be a taboo subject. In a number of villages in Zambia, for example, people were more reluctant to discuss at any length symptoms of the living, however, knowing that to say someone has AIDS is to condemn that person. There was no occasion when someone said categorically that a living person had AIDS, but there were occasions when it was stated that someone had died of AIDS. One difficulty in dealing with AIDS in Zambia, in urban as well as rural areas, is that often it will be associated with witchcraft. This lack of understanding of what AIDS is simply hinders campaigns to arrest and mitigate its impact;
- support should be given to awareness-raising concerning the use of condoms. The wider distribution of condoms is also required e.g. from stores, depots, grocery stores etc.;
- pregnancies amongst HIV couples should be discouraged; and
- cultural tradition like sexual cleansing in Zambia, should be discouraged or at least men should be encouraged to use condoms.

6.9.5 Nutrition

Findings from the research in most of the farming systems studied cited the declining nutritional status among households affected and or afflicted by HIV/AIDS. Thus efforts should be made to improve the diets of households burdened by having to care for patients or having a high dependency ratio, because of children (and mothers) who have been relocated through divorce and death.

Greater encouragement should be given to:

- the production and use of groundnuts, soyabeans (soya flour) and mashed cowpeas;
- creating awareness of the need for a balanced diet (and therefore for diversified production);
- mothers continuing breastfeeding even when pregnant again;
- improving food preparation (many foods are frequently over cooked);
- involving men in nutrition programmes; and
- promoting child spacing programmes (i.e. to allow sufficient time for a baby to be adequately weaned and to grow before the next child is born).

6.10 Recommendations for specific target groups

Orphans

As noted in previous chapters, a direct effect of the HIV/AIDS epidemic has been to increase the number of orphaned children.
Accordingly, support to orphans and institutions or organizations concerned with the welfare of such children should be assisted or where necessary established. This includes assistance in the payment of school fees, skills training, etc..

Pastoralists

In Tanzania efforts to complete a study of pastoralists were unsuccessful. Little is known about the effect of the epidemic on such livelihood systems (see Chapter 3), these groups are often marginalised, and such a study should be given priority in future work on HIV/AIDS impact.

Women

In many instances women form the backbone of the farming systems. At the same time, their responsibility for the collection as well as the production of food, and their household duties render them particularly vulnerable to the effects of HIV/AIDS morbidity and mortality. Measures which might assist women and especially those who are or become (e.g. by reason of sickness or divorce) heads of households include the following:

- regarding both land and inheritance laws, such legislation should be reviewed so as to clearly stipulate land ownership rights for women. And although laws may not discriminate against women with regard to land rights, traditional or customary laws often do. In this regard, state laws should prevail over customary or religious laws;
- assistance and advice is generally required in the transport, storage (e.g. through the provision of milling facilities for grains in order to produce flour) and in the marketing of products;
- access by women to draught power, farm implements and other inputs;
- provision of adequate extension services especially to women in remote areas;
- encouragement of group formation among widows who currently and in the future will carry much of the burden of coping;
- encouragement of the use of bicycles by women to ease the burden and time required in undertaking a number of farm and household tasks especially for the collection of firewood, water and in the transport and marketing of produce.

6.11 Recommendations relevant to the Estate Sector

6.11.1 HIV/AIDS education and prevention
6.11.2 Improvement of the socio-economic environment
6.11.3 Recruitment policies
6.11.4 Training and staff development
6.11.5 Employment benefits

So far, the impact of HIV/AIDS on the estate examined in this study, the Nakambala Sugar Estate (NSE) has been noticeable and worrying, but not devastating. In general, there are two main responses for HIV/AIDS: HIV prevention and mitigation. In an environment with limited financial resources, these have to be cost-effective.

In the NSE example, medical staff had strongly expressed the need for HIV testing facilities in order to make better diagnosis and hence provide more appropriate treatment. The testing should obviously not be compulsory but be available for individuals wishing to know their status. In addition, the development of HIV infection could be monitored. However, it is absolutely necessary that results be kept confidential.

HIV testing should also be accompanied by counselling and a home-based care system. In the study of NSE, respondents frequently said that they could not endure an HIV positive result. Therefore, psychological support is essential. The opinion of women in the NSE townships, for example, was split between AIDS patients being cared for at home or in the hospitals. Some women expressed the fear that they do not know how to care for patient and therefore think that the care in hospitals is better. Others believe that the conditions in the hospitals are not favourable and prefer to look after patients themselves? especially if they are taught how to treat the patients. The establishment of a home based care system would be one way to mitigate the effect of HIV/AIDS on companies.

6.11.1 HIV/AIDS education and prevention

Companies should become more active in HIV prevention and education to limit the spread of HIV among the workforce. The present HIV education activities are not sufficient to reach all employees. The expense of such a programme is minimal compared with the cost of replacing someone who dies of the illness. In an awareness campaign, other STDs should also be included. High risk groups, such as cane cutters in the NSE example, should receive special attention. As alcohol abuse is often associated with unreasonable risky sexual behaviour, an HIV prevention programme could be combined with an anti-alcohol campaign.

6.11.2 Improvement of the socio-economic environment

Companies should contribute towards creating a socio-economic environment, which makes the spread of HIV more difficult. One way is to empower women by improving their economic status. In companies such as NSE, there are often plenty of positions, which could be occupied by women, ranging from the unskilled to the professional level.

6.11.3 Recruitment policies

Pre-employment testing is not recommended and would be discriminatory. In countries, such as Zambia, where there is a narrow skill base for professionals and high rates of infection, exclusion of HIV positive persons would be a self-defeating policy. An HIV positive person can be productive and beneficial for the company for a considerable number of years. Even if an employee is HIV negative at the time of starting work, there is no guarantee that the employee will not be infected afterwards. The situation is different with applicants who are already sick and stretch the company's budget on medical costs and other benefits right from the beginning of their assignment. Therefore a mandatory chest examination as part of routine medical evaluation for permanent employment is recommended as is the practice in other parts of the world.

6.11.4 Training and staff development

It is debatable whether employees should be screened prior to training, as training is an investment in persons, which will only be paid back over time. If the employee falls sick soon after completing the training, the investment will have been lost. This investment is also lost if the employees leave the company for other reasons. But such cases tend to be in the minority. Where there is a proven positive result, owing to the nature of the HIV/AIDS, it is not known whether the employee is able to work for the next 6 months or the next 10 years. Therefore a company could still realize a return on its investment because afflicted individuals may still have a fairly long work life. The longer the training takes, the less return could be expected. A cost-benefit analysis could compare the costs of the training with the likely return form the individual; such an analysis would also have to take into account the probability of death and disability occurring from other diseases or circumstances (Pangs, l 992).

6.11.5 Employment benefits

Most of the costs which arise due to HIV/AIDS may be attributed to employment benefits. These costs are inevitable and the company has to live with them. But as it is expected that these costs will rise in the near future consideration should be given to whether any financial limit might be set. If this is the case? these limits should be negotiated with trade unions.

Projections of the economic impact for the near future

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The projection in Table 9 is based on an assumed increase of AIDS deaths and sickness of 70 percent. The expenses due to the epidemic will not proportionally rise in all affected departments.

Table 9: Cost increase due to HIV/AIDS from 1992-93 to 1995-96
Description Costs 92-93 Increase Costs 95-96
(US $) (%) (US $)
Lost workforce 148920 70 253164
Extension of expatriates 60000 100 120000
Medical Department 70124 70 119210
Funerals 24314 70 41333
Pensions for death +early retirement 75184 0 75184
Repatriation 59448 70 101061
Training 35208 100 70416
Total 473198 780368

Source: Haslwimmer. 1994

The projected costs caused by HIV/AIDS could rise until 1995-96 to 3.1 percent of the total costs. But two variables could influence these costs more dramatically than is indicated in Table 9. These development of the Zambian and Southern African labour market and production losses.

At the lower end of the skills spectrum in Zambia, labour is abundant. HIV/AIDS will not reduce this labour force to such an extent that labourers at this level become scarce. On the skilled and professional level, the market is much thinner and is influenced by various factors. It is only since 1991 that the Zambian Sugar Company has offered competitive salaries compared with other employers in Zambia. In the past the company had found it difficult to attract highly qualified people, in particular engineers, who preferred to work in the Copperbelt. The Estate's rural setting also appears to be a disincentive in terms of attracting qualified people and attractive housing facilities are also lacking at NSE. Moreover, because Zambia's neighbours, particularly South Africa offer better salaries, many highly qualified Zambians prefer to work abroad. AIDS will contribute to the tightness of the labour market, especially as the disease has claimed a number of people among the ranks of professionals.

It is also possible that professional salaries will increase. This also means that, for example, an extra 20 percent increase for the salaries of professionals could to be included in the cost estimates for 199596.

5.9 The impact of HIV/AIDS on the Kaleya Smallholder Company in Zambia

Kaleya Smallholders Company Limited is a smallholder settlement scheme established to develop 1 885 ha of sugar cane in the district of Mazabuka in Zambia. Two-thirds of the area is settled by 300 smallholders and one-third remains a nucleus estate. The target annual cane production is 200 000 tonnes - 15 % of the national output.

Currently 1 782 ha have been planted and 140 smallholders settled. The company supplies the smallholders with training and extension services, agricultural inputs and mechanical services, arranges cane harvesting and haulage and distributes irrigation water. The smallholders are responsible for 4 ha of sugar cane, with family members caring for the infield irrigation, weed control, fertilizer application and removal of diseased cane stalks. The cost of all direct service is charged to the smallholders. Kaleya pays the growers for standing cane, with the price related to Nakambala's production costs.

The cane is sold by Kaleya to the Zambia Sugar Company which processes the sugar cane. The terms of the sale are determined by a cane purchase agreement negotiated between Zambia Sugar Company and three outgrowers (Kaleya, and two private farms). Currently the Kaleya is controlled by the founder shareholders - the Commonwealth Development Corporation, Zambia Sugar Company, the Development Bank of Zambia and Barclays Bank of Zambia. Ultimately it is intended that all of the ordinary share capital of Kaleya will be purchased by the smallholders who will become the owners.

It appears that the smallholders are equally or worse affected by HIV/AIDS than the population of Mazabuka. The smallholders come from different parts of Zambia, many having previously lived on the Copperbelt, which is characterised by very high rates of seroprevalence. Being a smallholder in Kaleya is an attractive occupation which provides a relatively high income (in comparison to most of the rural population). Polygamy is widespread among the cane growers and marriages are reputedly very unstable. At the time of this study, 14 out of the 140 smallholders and their families were suspected of having died of AIDS.

Box 12: Case study 6

Eleanor is a 24-yeas old widow. She has three young children of her own and one son of her late husband. She and her husband came to Kaleya some years ago.

Her husband died in July 1993 aged 36, most probably from AIDS. While her husband was ill with AIDS Eleanor nursed him. As a result she did not have time to produce enough maize for her family's consumption. Added to this the yield of sugar cane was low last season, which Eleanor believes is due to the age of the cane and not because of a labour constraint. Next season her yield is likely to be even lower. Eleanor employed part-time workers to undertake irrigation works on her plot but because she does not know enough about irrigation in sugar cane, she could not control the work properly. Although she had asked the local extension service for advice, at the time of the interview nobody had been to visit her.

Eleanor believes, that she and her late husband's sixteen year-old son could manage the farm in the future. However, although she and the son are the official holders of the settlement, her in-laws have been pressing to gain control of the farm. Now she is afraid that she is bewitched.

The smallholders rely mostly on family members for their production activities, but they also hire labour. Labour, which is provided by family members, who fall sick and finally die of AIDS, cannot be as easily replaced as on an estate. As observed frequently in many of the small farming systems described earlier, care for patients at home, attendance at funerals and the loss of management skills, all contribute to the labour constraints of an AIDS-affected household. But all households are not equally vulnerable.

For example, one farmer who was interviewed, and is probably suffering from AIDS, has several grown-up children, who now do all the work in the fields. The death of the father would not necessarily have an effect on sugar cane production, because there is still enough labour force and the father's knowledge has already been passed on to his children. However, the death of the most experienced person in a household, especially in the production of sugar cane, can have serious consequences, especially where the remaining family members do not have the necessary farm management skills, as in the example below of case study 7.

Box 13: Case study 7

Justin is 22 years old and has three brothers aged 24, 20 and 16, and two younger sisters are at school in the Copperbelt. In 1986 his parents came from the Copperbelt as smallholders to Kaleya.

In 1989 Justin's father died of AIDS. Two brothers were forced to leave school to work on the family farm. With their help and the employment of part-time labourers sugar cane production could be maintained under the management of the mother. In 1990 Justin's mother also fell sick and returned to the Copperbelt with her youngest child. In 1991 both his mother and the child died and all the children left Kaleya for one month to attend the funeral in the copperbelt. During that time the neighbours assisted in caring for the farm, but they were unable to carry out the farm work as effectively as Justin's family. As a consequence, yields declined by 40 percent in 1991 and the household's income suffered accordingly.

Since then production has begun to increase once more but has not yet reached its previous level. It appears that once sugar cane yields drop significantly, it is very difficult to reach previous levels. In 1993 the household was are also able to produce enough bags of maize for themselves to eat.

The most vulnerable households are those with a high dependency ratio, since widows will frequently loose many of their possession when, by traditional custom, the husband's relatives arrive soon after the death to claim all the household possessions.

5.10 The impact of HIV/AIDS on the Tukuyu Tea Estates in Tanzania

The Tukuyu Tea Estates are located near the Ushirika minor settlement in Tanzania. Covering an area of 1 530 ha they consist of seven estates with two factories among them. The estates have a permanent staff of 1 200 and employ an additional 2 000 labourers during the peak tea picking season. Most of these casual labourers come from neighbouring villages.

Although there have only been two confirmed cases of AIDS to date, the general situation of the Tukuyu Estates renders them potentially vulnerable. HIV/AIDS can affect this estate as in the cases of those described above in Zambia since they depend on the availability of trained manpower. It takes a long time and significant resources to train an expert. Thus experienced workers are difficult to replace.

Since the Tukuyu Estates are located on the highway to Malawi and close to two settlements and the town of Tukuyu, there is a lot of contact with urban and more densely populated areas, one of which, Ushirika is considered to be a high-risk area. Whether by chance, or partially as a result of the preventive measures taken by Tukuyu Tea Estates to date, AIDS has had a minimal impact on the company.

The preventive measures that may be in part responsible include the supply of condoms to male workers (although such supplies are irregular) and the establishment of an AIDS education programme using television and videos. At the same time the company offers its employees free lunches, medical care and clinic facilities. Child nutritional status is reported to be good.

The estate sector

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In order to consider the ways in which HIV/AIDS affects not only the small farm sector but also the commercial sector, studies were carried out on several estates in Zambia and in Tanzania. In particular, a detailed analysis was made of the Nakambala Sugar Estate (NSE) in Zambia. This forms the basis of the present chapter.

The aims of the study of NSE were to determine the present position on the estate vis a vis HIV and to make projections for the future; to assess the knowledge and attitude towards HIV/AIDS among NSE employees as well as the social implications of the disease; and to consider the present economic impact in terms of costs caused by HIV/AIDS in affected departments and make projections for the near future.

5.1 About the Nakambala Sugar Estate

The Zambia Sugar Company is the sole producer of sugar in the country. The head office is in Lusaka while all the sugar cane is grown at NSE. The Estate is situated near Mazabuka, in Southern

Province where good soil and climatic conditions exist for growing sugar-cane under irrigated conditions. Rains falling between mid November and March result in an effective cultivation season between April and October. The Estate has experienced several periods of expansion and now has a nominal capacity of 140 000 tonnes of sugar per year with some 10 000 hectares under cane cultivation. In addition, 1785 hectares of sugar cane is provided by the Kaleya Smallholders Scheme, where 140 smallholders manage 560 ha and the remainder is run as an estate. Two neighbouring farmers own 450 ha of sugar cane which they deliver to Nakambala for processing.

Employment structure on the Nakambala Estate
Some 22 000 people live at Nakambala Estate (Census 1993). It is estimated that a further 10 000 people, who live outside Nakambala, derive their livelihoods from the sugar estate.

The Nakambala Sugar Estate provides permanent employment to 3 250 people. Seasonal employees bring the total to 8 100 during certain periods of peak operation. Fourteen expatriates also work at NSE mainly in senior management positions.

The labour force is strongly male-dominated; women are overrepresented among the seasonal workers and underrepresented among the unionised employees. Altogether women make up about 12 percent of the workforce, and are mostly in low paid positions.

At present the company is not able to provide housing for all employees. but the aim is eventually to house all permanent employees. There are five townships on the estate and a senior staff housing area. Nakambala provides utilities and community services such as water, refuse collection, electricity and community halls. There are fifteen churches dotted around the estate. The estate employs two doctors and operates one main clinic and several subsidiary ones in the townships. The clinics are inevitably one of the most heavily used facilities provided on the Estate, frequently seeing 300 patients per day.

HIV/AIDS care and education at Nakambala Estate

Medical staff at the estate currently carry out HIV/AIDS education at the clinics and also conduct seminars on AIDS for a limited number of more senior employees. Condoms are distributed free of charge at the clinic on demand. Two officers with clinical experience in the running of the Chest and Skin/STD clinics had also lately recruited. Pre-employment testing is not practiced by Zambia Sugar Company. HIV/AIDS is treated as any other life threatening illness. Employees continue to work as long as they are able to do so. After retirement on medical grounds or death they or their families receive the same benefits as any other employee.

5.2 Socio-economic conditions

Women are in an especially vulnerable position to contract the AIDS virus. At Nakambala as in the rest of Zambia, women have an inferior economic and social status to men. The majority are economically dependent on men. Some women at NSE have the possibility to cultivate vegetable gardens and thus earn a small cash income, but others in other townships have limited possibilities to generate income. Economic dependence may also determine with whom a woman has sex. The women at NSE reported that the first reason to have sex with a "boyfriend" is money. Single women are especially at risk, but married women often have to use sexual relations to supplement their incomes because men at NSE do not always share their earnings with their families. This limits the ability which women have to control their sexuality and to protect themselves. In interviews women said that they cannot determine the terms under which they have sex, including whether a condom is used and whether their partner is sexually faithful. While infidelity is by no means exclusive to men, it is more acceptable for a man to have more than one regular partner. Therefore it happens that women who are infected are monogamous and have contracted HIV from their nonmonogamous partners

Migration is a factor which may often be associated with the spread of HIV. Although Nakambala Sugar Estate is a rural area, a lot of migration and movement takes place. People looking for work, such as cane cutters, are recruited seasonally from other parts of Zambia and many truck drivers pass Nakambala daily on their way along major communications routes. In any case, the tradition of labour migration which has become a pronounced feature of Zambian life in the last seventy years, with long separations and frequent breakdown in family patterns, contributed to a rise in prostitution and the incidence of STDs long before HIV appeared. Migrants who contract HIV may infect their spouses when returning home.

5.3 The incidence of HIV/AIDS on NSE

The Zambia Sugar Company has not yet developed a policy towards HIV/AIDS, but the management is very concerned about the development of the disease. However in view of the fact that the epidemic has spread rapidly in Zambia in the last decade, what was originally a more urban disease has now reached rural areas.

According to the medical records for 1991 and 1992, 75 percent of deaths in 1991 were attributed to HIV/AIDS as well as 70 percent of the medical retirements. In the medical report 1992/93 the causes of death are classified as tuberculosis/AIDS, gastroenteritis, pneumonia, malaria, malnutrition and others. In this classification only 45 % of deaths are attributed officially to TB/AIDS, but in reality it is suspected that many AIDS cases are hidden in other categories, such as "gastroenteritis" and "others". Therefore it is assumed that also in 1992193 probably as many as seventy-five percent of deaths were HIV/AIDS related.

As elsewhere, so also the Estate Sector, and as noted in Chapter 3, HIV/AIDS incidence has been age selective. Sixty-two percent of the deaths among company employees were in the age group 21 40 years in 1992-93. No employees died above the age of 50. This lends weight to the hypothesis that AIDS takes its toll from the younger age groups. The overall mortality rate among all company employees was 9 per I 000.

It was also observed that there was a marked decrease in AIDS-xrelated deaths between 1991 and 1992-93. While this may simply be attributable to the fact that the small numbers in total could be within the range of reporting and sample variation, another explanation is also possible. In Zambia the epidemic was initially more prevalent among the educated, well-off and mobile in urban areas. Most of these people are now relatively knowledgeable about the disease, thus they may well have adapted their behaviour accordingly. The basic knowledge about HIV/AIDS has only recently and or partially trickled down to the less educated or illiterate in remote areas. Most of those who die today were infected before 1987. It is possible that this particular group has already reached a peak of AIDS cases. In future, the death rate among staff may stagnate or decrease while the rate may increase among unionised and seasonal employees. But this is only a hypothesis which has not yet been confirmed by any research in Zambia. What is known is, that the gap between company professionals and the poor with regard to seroprevalence is narrowing fast.

In 1992-93 the mortality rate among staff and unionised company employees was 14.9 per 1 000 much higher than the rate among seasonal workers which stood at 3.9 per 1 000. The usual yearly rate of adult mortality in sub-Saharan Africa is about 5 per 1000. This does not necessarily mean that seasonal workers are less affected by HIV. One of the reasons for the difference between the groups could be that the seasonal workers are characterized by a high turnover rate and that they are hired every year anew. It is less likely that a very sick person will apply given that most of the seasonal jobs are physically very demanding. The company does not monitor the deaths of seasonal workers who have stopped working for the company, therefore many cases of AIDS in this occupational group will go undetected.

From January 1993 until September 1993, 16 employees were given early retirement on medical grounds due to HIV-related symptoms. Projections for the future indicate that the number of AIDS deaths and medical releases due to HIV/AIDS could increase by 70 percent from 1992-93 to 1995-96'. Even after 1996, the number of people with AIDS will certainly increase, but the longer these data are projected into the future, the more imprecise any forecasts become. The annual adult mortality rate due to the epidemic could rise to 28.2 per 1 000 for permanent staff members.

5.4 HIV/AIDS-related morbidity and absenteeism at NSE

Morbidity due to AIDS has a strong impact on a company like the Zambia Sugar Company. Once an individual develops AIDS, the average survival time appears to be between six months and two years. In cases of prolonged illness, the salaries of the permanent employees are paid for the obligatory three months, after which a further three months are paid at a reduced level. As shown in Table 5, the person-hours lost due to tuberculosis/AIDS account for 50 percent of cases. If gastroenteritis is added to this total, because it is often associated with HIV, the figure rises to 60 percent. Experience at NSE indicates that AIDS patients are variously in and out of their work places for one year. When they return to work they often cannot perform their duties as well as before. On average a person with tuberculosis is absent from work for 60 days a year.

Table 5: Person-hours lost due to major illnesses in 1990, 1991 and 1992 at NSE
Disease Year
1990 1991 1992
Malaria 36,024 25,268 20,060
Accidents & Injuries 28,232 17,224 12,346
Gastroenteritis 12,576 10,792 12,176
TB/AIDS 102,591 71,507 61,713
TOTAL 179,423 124,691 107,295
Total all diseases 266,752 162,584 122,567

Source: Medical Department, Zambia Sugar Company

Since 1990 there has been a continuing decline in the incidence of major illnesses affecting the employees on the estate. There could be different reasons for this decline. One, the health status of the employees may have improved due to better medical care and an improved sanitary infrastructure. Two, it is also possible that the criteria used for including employees on the sick-list have become stricter. Any absence from work is recorded officially under the following categories: paid leave, unpaid leave, sickness and absenteeism. Healthy employees are absent from their workplace for various reasons, which could be HIV-related such as caring for sick relatives. Furthermore, employees can leave the workplace for some hours at the discretion of their supervisor for special occasions such as funerals, medical reasons and other urgent matters. Thus, different types of absence can be influenced by HIV/AIDS but the quantity is difficult to estimate.

The overall rate of work due to illness was about two percent. This is a very low figure and even lower than in industrialized countries. By contrast, among nurses in a University Teaching Hospital in Lusaka, the rate of sickness is usually assumed at 8 percent, while the absenteeism rate is 16 percent. In England, the sickness-absence rate was 4.7 percent in 1989-90 (Foster, 1993). As stated above, 50 to 60 percent of recorded sickness cases can be attributed to HIV/AIDS.

In studying the records for NSE, it appears that as recorded by the company, funerals have become a major reason for employee absences from work. There is a strong social obligation to attend the funerals of near and distant relatives, friends and neighbours. Compassionate leave has been abolished for unionised employees in order to harmonize the working conditions with staff and unionised labourers. Thus employees must use their annual leave if they have to attend a funeral, which takes place some distance away. There its anecdotal evidence that some employees spend all their annual leave attending funerals and even have to take additional unpaid leave to meet their social obligations in this respect. In the case of the death of a company employee, at least 80 colleagues attend the burial and some are occupied with the preparations for several days.

The increasing incidence of Tuberculosis

Tuberculosis is increasing at NSE and Pulmonary Tuberculosis is part of the clinical case definition of AIDS. Tuberculosis is especially serious for the company because patients are absent from work for a minimum of 60 days. In 1991, for example, 73 cases of tuberculosis were registered as compared with 106 cases in 1992 and 141 in 1993. It should be noted, however, that this rise can also be partly attributed to better diagnostic facilities. By far the largest number of cases were reported in the age group 25-34, some 52 percent of cases, and compared to 27.8 percent and 11.3 percent for the age groups 35-44 and 45-54, respectively. The clinical staff do not know who among these patients is HIV-positive, because they do not have any HIV testing facilities. Patients presenting HIV-associated chest problems end up receiving treatment for suspected tuberculosis when they fail to respond to the usual antibiotics. This means that half of the patients are not treated appropriately due to the lack of testing facilities. However, currently available national data suggest that between 70 and 80 percent of tuberculosis patients are HIV positive. Although drugs against tuberculosis are distributed without cost at the NSE clinic, treatment for one patient costs US$ 175. Therefore the medical staff strongly expressed the need for HIV test kits.

Malnutrition

Malnutrition continued to be a problem; from July 1992 to March 1993, 19 children died of malnutrition at NSE. After pneumonia, it was the second highest cause of death among children. Malnutrition is considered more of a social than a medical problem. Social workers support women with malnourished children with High-Energy-Protein (HEPS) food. Presently they care for 68 severe and 194 non- severe malnourished children.

The social workers observe that a lot of malnourished children do not respond to HEPS, even after 4 weeks. Considering the high incidence of HIV at NSE it can be assumed that a number of these children are children of HIV positive mothers and themselves positive. Despite the efforts to combat malnutrition, these cases are likely to increase in the near future due to the epidemic.

5.5 The spread of HIV/AIDS infection at NSE

Polygamy is quite widespread in Zambia and is practiced by people living and working on Nakambala Estate. In addition, in a number of interviews, respondents reported high frequencies of change of sexual partners and multiple sexual partners. According to the Medical Department, the level of sexually transmitted diseases (STD) is high among the population of NSE. STDs are associated with the same behaviour that exposes individuals to potential HIV infection and greatly facilitates both the acquisition and transmission of the AIDS virus.

Some culturally enjoined sexual practices, in particular the tradition of "sexual cleansing" associated with the levirate may further contribute to the spread of HIV at NSE. But these traditions are starting to change. Group discussions with women in the townships showed that a lot of women would not agree any more to be sexually cleansed after the death of their husbands because of the existence of AIDS. Accordingly, other methods of cleansing, which do not involve sexual intercourse, are becoming more common.

5.6 Knowledge of HIV/AIDS at NSE

The level of knowledge among the population at NSE varies considerably. Everybody, who was interviewed at Nakambala had heard about HIV/AIDS, although people are differently informed. Generally men know more than women, because they have better access to information. One woman from a township asked: "Everybody speaks about AIDS, but what is it?". Women have heard about condoms, but some have never seen one. A survey which was conducted by the Medical Department at NSE on the subject of health issues showed the incomplete knowledge which respondents have about HIV/AIDS. Two hundred and sixty employees of different departments filled out questionnaires. Nearly all knew about HIV and that it is sexually transmitted. But 42 percent did not know that HIV also can be contracted through blood transfusion. The higher the level of education the greater was the understanding of the disease and the way it is transmitted.

Another finding of the survey was that willingness to use condoms is low. It should be a matter of concern that only 32 percent of the employees stated that they have ever used condoms, especially given that a lot of men are reputed to have extramarital affairs.

Witchcraft is still very strong in Zambia and is often given as the cause for sickness and death instead of AIDS. People indicated in interviews that they have a contradictory attitude towards witchcraft and AIDS. Some reported that they can identify a person with AIDS, but if a member of their own family or they themselves are concerned, they say it is witchcraft. AIDS cases which are attributed to witchcraft have already caused problems at NSE. The AIDS afflicted, or the relatives of people who have died of AIDS have reputedly accused colleagues of bewitching them for various reasons. This is a harmful phenomenon in any work environment, but it is even more so in one where places of work and residence are the same.

5.7 The social impact of HIV/AIDS at NSE

Although the company has to deal with the serious impact of the epidemic, HIV/AIDS-affected households carry the major burden.

These households have to care for the sick and face increasing medical expenses. They lose the income and entitlement to housing after six months after the employee's death. Seasonal labourers are in an even more vulnerable position than permanent employees, because they do not receive the full range of benefits. Although the estate is not concerned, because HIV-affected families leave the estate, the number of orphans in the villages around Nakambala is growing, with all the additional pressures that this places on relatives and the community at large.

5.8 The economic impact of HIV/AIDS.

5.8.1 Production loss
5.8.2 Costs caused by HIV/AIDS
5.8.3 Summary of the costs
5.8.4 Projections of the economic impact for the near future

The economic impact of HIV/AIDS is basically felt as a result of two factors; in the loss of production and by increasing costs.

5.8.1 Production loss

The production of sugar cane and sugar has increased continuously since the creation of NSE. In 1992/93, the sale of sugar reached its peak since the founding of NSE. It can be concluded that AIDS has not so far had a serious impact on production. The question arises however, how high can the number of AIDS cases rise without affecting production? What is the threshold?

In order to answer these questions, it is necessary to identify the most important and therefore vulnerable phase of the labour process of cane cultivating, harvesting, processing and selling, plus the support services to ensure smooth integration of these processes. According to senior management, the post of a farm officer is quite crucial for the development of the cane. Each farm officer is in charge of 200 ha of cane. Production levels depend very much on timely farming operations. Although some of the farm officers had developed AIDS in recent years, their absence was compensated for, and thus no serious impact on the cane yield occurred.

Table 6: Cost statement for the Nakambala Estate 1992-93
Description Labour Materials Total
(US $) % total (US $) % total
Agricultural costs 3143465 33.5 6229841 66.5 9373306
Cane purchase 0 0 6350007 100.0 6350007
Factory cost 932378 20.4 3636946 79.6 4569324
Business Dept. 151985 38.7 238262 61.3 390346
Purchase &Supplies 137556 50.4 134554 49.6 272110
Personnel Dept. 2111724 77.6 608481 22.4 2720206
Medical & Public Health 138091 49.5 140970 50.5 279061
Estate Services 321334 46.6 365642 53.4 686876
Total Dept. Costs 6936532 28.1 17704603 71.9 24641136
Depreciation 0 0 1252787 100.0 1252787
Insurance 0 0 364981 100.0 364981
Forward Crop
Adjustment 0 0 (3736835) 100.0 (3736835)
Total Op. Costs 6936532 30.8 15585537 69.2 22522069
Refinery Cost 40370 40.8 57649 59.2 98018
Packing Cost 469107 20.3 1.840682 79.7 2309789
Total Nakambala
Cost 7446008 29.8 17483867 70.2 24929875

Source: Business Department, Zambia Sugar Company

Overtime working is common at NSE to compensate for absences from the workplace. In some sections of the factory, overtime is not exceptional. Indeed employee complaints suggested that it appears to be all too common. According to interviews with management, the quality of work suffers under these circumstances. Unfortunately, it is not possible to quantify this possibly important factor.

5.8.2 Costs caused by HIV/AIDS

Material costs make up the major part of the costs while those caused by HIV/AIDS are mostly labour-related.

- Absenteeism and sickness

About 50 percent of the absenteeism at the company is due to sickness of which 2 percent can be attributed to HIV/AIDS. It is also assumed that one percent of the labour force is lost by leaving the workplace for some hours a day to attend burials, to go to the clinic and to attend to various other exigencies of daily life.

- Additional employment of expatriates

Zambia Sugar Company trains and promotes highly qualified Zambians to gradually replace expatriates. However, this process is now in danger due to the epidemic. In 1992-93, for example, one senior Zambian manager was supposed to substitute an expatriate. This person died of AIDS and the contract of the expatriate engineer had to be extended because there was no other Zambian who could have filled this position quickly. This is costing the company about US$ 60,000 per year.

- Medical care

It is difficult to assess how much of the medical budget goes towards caring for HIV/AlDS patients. According to the causes of sickness, 50 percent were HIV and AIDS related. Therefore it is assumed that 50 percent of the drugs are used for AIDS patients. Staff costs consume the major part of the medical budget. It is worth noting that the drugs for the treatment of tuberculosis, which are very costly, are presently free of charge. Otherwise, the cost of drugs for a single tuberculosis patient (September 1993) would have been US$ 175. In 1993, 141 tuberculosis patients were treated; it can be assumed that 80 percent of these were HIV positive. This means that a further US$19 740 in drug costs may be assumed, but the company does not have to pay for this. The company provides staff and, if necessary, the transport of the patients to the clinic.

The drug costs (without TB) for a single AIDS patient at NSE's clinic ranged between US$ 44 and US$ 83, which is comparatively low. Most of the opportunistic infections associated with HIV can be treated with cheap drugs during the early stages of the disease. Furthermore, it is estimated that 30 percent of the remaining medical budget is attributed to HIV/AIDS. Out of that, staff costs account for the major part. It is debateable whether without the epidemic the budget for the medical department would be lower. Instead it is likely that the medical service would have been improved. On the other hand, as noted above two clinical officers have recently been recruited both in relation to HIV/AIDS. Without the epidemic the recruitment of these officers would not have been so urgent.

- Funerals

When a death occurs on the estate, the company's employees and their dependents are entitled to a coffin, firewood, foodstuffs and transport to the burial site. In 1992/93, there were 232 deaths among company employees and their dependents. The number of deaths has risen to such an extent, that the vehicle, which was assigned to transport the coffin, is no longer sufficient and the department has recently applied recently for a second vehicle.

As noted above, 75 percent of deaths at NSE can be attributed to HIV/AIDS. It is not known how many dependent adults and children have died of AIDS. But, according to medical statistics AIDS cases among dependents were lower. It can be estimated that at least 60 percent of the budget for funerals may be counted as costs generated as a result of AIDS.

- Medical retirement

In cases of medical retirement, an employee is entitled to a grant which is dependent on his or her salary and according to the amount of time the person has worked in the company. In cases of death the family are the beneficiaries. In 1992-93, it appears that four staff members died due to HIV/AIDS and two retired under the early retirement package. Among unionised employees, 36 died and 22 retired on medical grounds due to HIV/AIDS. It can be argued that these are not additional costs because employees go on retirement anyway and this entitlement depends on the time served. But in 199293, these costs have been generated by HIV/AIDS, which would not have otherwise occurred and furthermore their effective working life and the availability of their experience to their employer was truncated by the disease.

- Repatriation

In cases of medical retirement, the staff members and unionised workers are entitled to be repatriated. In case of death, the family of the deceased is taken back to their home areas. Transport costs take by far the major part of the repatriation allocation. There is a common budget for repatriation and recruitment. In general, recruitment is cheaper than repatriation. It is estimated that about 30 percent of the budget for staff and unionised employees can be costs attributed to repatriation due to AIDS-related death or retirement.

- Training

Nakambala is the only sugar estate in Zambia and ZSC has to invest substantially in training given the specialized nature of the work. This applies especially to cane growing activities, but also to areas in the factory. Once a highly skilled person is lost, he or she cannot be simply replaced from the Zambian labour market, because an already trained successor cannot be found. Added to this, ZSC competes on the Zambian, and increasingly on the Southern African, labour market with the mining industry for a limited number of engineers. The training process can take as much as two years during which the trainees are often sent abroad on special, and costly courses.

5.8.3 Summary of the costs

Table 7 shows that the largest portion of costs are associated with sickness. Nearly 50 percent of these expenses arise from the benefits which the company offers its employees. Companies in Uganda noted that morbidity has a higher impact than mortality (Pangs, 1992). At Nakambala, the costs of sickness (lost working days plus medical expenses) are about as high as the costs in the case of death.

In 1992-93, costs attributable to HIV/AIDS represented 1.9 percent of the total costs of Nakambala Estate. This appears to be quite low. Sales for 1992-93 for ZSC as a whole were about US$ 50.0 million. Even if US$ 2.2 million in head office costs are added to the Nakambala costs, the profit margin remains wide enough to cover the additional expenses arising from HIV/AIDS. The costs caused by HIV/AIDS make up about 2 percent of the profit.

Table 7: Costs generated by HIV/AIDS at Nakambala in 1992/93
Description Costs (US$) Costs (%)
Lost workforce 148, 920 31.8
Extension of expatriate
contracts 60,000 12.7
Medical Department 70,124 14.7
Funerals 24,314 5.1
Pension for deaths +medical retirements 75,184 15.9
Repatriation 59,448 12.5
Training 35,208 7.3
Total 473,198 100.0

Source: Haslwimmer, 1994

The following table provides an estimate of how the costs could be allocated between labour and materials.

Out of the total labour costs, 4.7 percent are due to HIV/AIDS, while only 0.7 percent of the total material costs can be attributed to the disease. This lends weight to the hypothesis that AIDS is predominantly a burden for the labour budget.

Table 8: Costs resulting from HIV/AIDS divided between labour and materials
Description Labour Materials
(%) (US $) (%) (US $)
Lost workforce 100 148920 0 0
Extension of
expatriates 100 60000 0 0
Medical
Department 50 35062 50 35062
Funerals 10 2431 90 21883
Pension for death+ medical
retirement 100 75184 0 0
Repatriation 20 11890 80 47558
Training 40 14083 60 21124
Total 73.5 347570 26.5 125627

Source. Haslwimmer, 1994

The estate sector

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The consequences of HIV/AIDS impact on small farmers

2009-12-17T07:45:00.003-08:00

As discussed in the previous chapter, the impact of HIV/AIDS is being felt, be it directly or indirectly, on almost all aspects of the farming systems studied. In some cases there is a tangible though not necessarily quantifiable effect on farming systems, especially in Uganda, where the epidemic is seen at an advanced stage of its development, and thus its impact is more directly evident.

In both Tanzania and Zambia, the impact is less evident but the vulnerability of the farming systems and the trends in agricultural development generally, may be used to preview, and hopefully prevent, as serious a deterioration of the status quo because of the HIV/AIDS epidemic as might otherwise be the case.

In Chapter 3 consideration was given to the impact of the HIV/AIDS epidemic on different aspects of small farming systems in Eastern Africa, this chapter considers the consequences of the changes that are occurring in the rural communities studied.

The main consequences include: the threat to household (see box below) and community food security; decline in the nutritional and health status of smallholders and their families; decline in educational status as children are forced to leave school; and changes in the social system as households adapt to the impact of HIV/AIDS. These latter may involve the break-up of families, a growing incidence of female-headed households, and changes in attitudes to indiscriminate sex. The impact of HIV/AIDS is also likely to be most severe among already vulnerable groups such as the malnourished and the food insecure.

More positively, individuals and groups have begun to develop survival strategies in the light of the changes which are occurring as a result of the impact of HIV/AIDS on their lives. Despite what are, in some cases overwhelming mental and physical hardships, with spouses losing not only their partners but also one or more children and experiencing increasing difficulties maintaining and making a daily living, households have continued to function.

Box 10: The Zambian farmer who only just copes

In the village of Mpongwe, amongst the more productive farmers, those whose production is now being affected by illness, or is likely to be in: the near future one: of the farmers identified three ways in which HIV/AIDS had and was affecting his life. These were through; (i) the impact on his cattle, with draught oxen having died for lack of care; (ii) his six children from his first marriage had gone to live with their maternal grandmother on the death of their mother his wife; (iii) the shortage of labour meant that his maize crop which be said had declined sharply, was affecting his own staple food security.

In some of the case studies described in Chapter 3, farmers have expressed interest in supplementing their incomes through small income-earning activities either on or off-farm. Such activities are extremely diversified and include bee keeping, beer brewing, tailoring, pig keeping, etc. Smallholders have also shown a growing interest in receiving extension advice, skills training or education in areas such as basic literacy, numeracy and health.

4.1 HIV/AIDS: a threat to food security?

4.1.1 The situation in Zambia
4.1.2 The situation in Tanzania
4.1.3 The situation in Uganda

In considering the consequences of the general decline in the standard of living and in household productivity as a result of HIV/ AIDS, the question arises as to whether food security is at risk.

Food security is defined by FAO (1994) as "enough nutritious and safe food being available and accessible for a healthy and active life by all people at all times". At the household level it is defined as "the capacity of a household to procure a stable and sustainable basket of adequate food" (IFAD 1993). This food must be adequate in terms of quantity and quality to compose a diet which meets both the nutritional needs of the household members as well as being culturally acceptable. Stable access is assured through various mechanisms that enable the household to procure food supplies across seasonal and transitory shortages. Sustainable access requires that the means of food procurement in the long run are consistent with:

- sustainable resource use and management;
- maintenance of productive assets;
- self reliance and human dignity; and,
- overall livelihood needs (IFAD 1992).

The nature of food access depends on the particular conditions prevalent in a given farming system. Food may be derived from home production, through purchase, through gathering (e.g. fishing), or through barter arrangements, gifts or some other means of transfer.

4.1.1 The situation in Zambia

In early 1993, up to 2.6 million people (33 percent of Zambia's total population) were reported as being vulnerable to food insecurity. Of these, over one million were in the marginal rural areas (IFAD, 1993).

In the rural areas, food insecurity is due to low smallholder productivity associated with maize monocropping, as well as limited access to agricultural services such as input supplies and other resources, as well as past market distortions (and consequent crop mix distortions) associated with Government price subsidization policies for maize. In towns and cities, food insecurity and malnutrition are related to the deterioration of purchasing power as a result of the long term stagnation of the economy, the scarcity of income-earning activities, inflation and the effects of a severe structural adjustment package. Urban earnings are linked to rural food insecurity through remittances (see Chapter 3), which are particularly important in certain farming systems. Such systems are likely to be adversely affected by the HIV/AIDS epidemic in the urban areas as well.

In Zambia, the highest levels of malnutrition are in the agriculturally-marginal rural areas, the pert-urban localities and the shanty towns of major urban centres. In general, malnutrition appears to be more serious and widespread in the northern, north western, Luapula, western and eastern provinces. Zambia also has one of the highest levels (54%) of childhood growth stunting in Africa (International Fund for Agricultural Development (IFAD) /World Food Programme (WFP) 1993). Stunting is an indicator of long-term deprivation.

Analysis of labour and labour management in the Chipese area of Mpongwe, showed that the more food secure clusters had men and women (a husband and wife) involved in production, and the most efficient were those in which men organised timely ploughing arrangements, either through tractor or oxen hire, or through labour-pooling arrangements. This situation arises through the need to plant as large an area of maize as possible to ensure a surplus, and the fact that maize tends to be a crop controlled by men - they have greater access to credit and usually control the marketing arrangements.

In the area of Teta, however, the situation is different. The area planted to maize and other crops grown in ploughed fields is much smaller than in Mpongwe. It is therefore easier for women themselves to manage this operation, and to hire oxen to cultivate this smaller area.

Diversity in the production system gives women more independence. The cultivation of local maize and beans are largely women's activities; it is only with the advent of Irish potatoes, an expanding cash crop, that women have become involved with the techniques of wetland production. The construction of mounds and planting of sweet potatoes, beans, cassava and millet also tend to be activities controlled by women. As a result, a larger proportion of the production output, including some cash income, and the marketing of such output is controlled by women. Maize production itself is often split between men and women, with both husbands and wives tending their own fields. During a series of meetings with villagers, of the 25 women in the women's meeting, only three were not tending their own fields. Accordingly, it would appear that women are going some way towards ensuring their own staple food security.

The net result is that amongst the vulnerable group (see Chapter 2) from which farmers were interviewed in Teta, four of the nine were headed by women. These women were often involved in hiring oxen or piecework labour. With a range of crops to sell, and access to millet for beer brewing, it is possible for them to raise enough income to purchase such resources. Because of the quantity of millet that is grown, beer brewing amongst these more food secure farmers is a regular not an occasional income-earning activity.

It would also appear that livelihood security is better guaranteed because of the greater range of options in the system. The different production types and crops mean that generalised crop and income failure is unlikely - risk being spread more widely.

The resource poor producers (cluster type 4) in Teta were also mostly women. Several of them were divorced or widowed, or if married, receive less assistance from their husbands. Thus less labour was available. The households of these women producers are probably more food secure than their Mpongwe counterparts because of the diversity of staples, relish crops, and income sources available. During the drought, the women resorted to beer brewing and the selling of crops such as vegetables, beans, sweet and Irish potatoes, rather than undertaking piecework, as was the case with the women in Mpongwe. This meant that less labour was diverted from their own fields.

In this community, the poorest producers tend to be reliant primarily on citemene production (see Chapter 3) of millet for their staple food security; they grow little maize and do not use fertiliser. Consequently, although beer brewing is a survival strategy, there will be more conflict over the use of millet for food or beer. These households run out of staple food earlier than other households. They also tend to have fewer relish crops.

In Chipese district, it was estimated that by the time the HIV/AIDS epidemic reaches the stage of increased mortality, probably within two to three years, the impact on agricultural production and livelihood security would have increased substantially. It was also clear that as sickness and death due to HIV/AIDS rises, the effect will be to exacerbate the already significant vulnerability and food insecurity of large numbers of women and children. This is due to the fact that it is common amongst the matrilineal peoples (prevalent in many parts of rural Zambia) for the death of a parent, as with the already common event of divorce, to lead to the break up of the nuclear family itself. Death like divorce causes social dislocation. Women, with their children, move back to the villages of their own mothers, or other matrilineal kin, leading in these villages to an increasing number of single parent producers and a growing dependency ratio.

4.1.2 The situation in Tanzania

An estimated 90 percent of the population of Tanzania are reputedly dependent upon their own subsistence (FAO; 1992). Research in two areas - Mtwara and Morogoro - indicates that 74 percent and 60 percent, respectively of the households surveyed had insufficient food. In such circumstances, the impact of illness or death on the household labour economy and thus on nutrition may be very dramatic indeed. For example, Semali and Ainsworth (1993) report that in Kagera the restriction of normal activities due to illness or injury (not necessarily related to HIV/AIDS) was resulting in a very considerable loss of working time in agriculture in 1992.

However, in an examination of indicators of food and energy adequacy for Tanzania, it was found that those regions which are most exposed to the HIV/AIDS epidemic in the medium-term are not, with certain exceptions', the regions which also have a current energy deficit. This is illustrated in Table 3 below which compares exposure to the HIV/AIDS epidemic and food insecurity as measured by dependence on emergency food aid.

The point however is that even in relatively robust systems such as those of the Kagera and Mbeya regions in Tanzania (and similar systems in Uganda), ten years of HIV/AIDS exposure do, nevertheless, result in dramatic declines in the standard of living, particularly among poorer households, and in a marked decline in the energy balance as indicated by the decline in the production of matooke and the rise in the production of sweet potatoes, cassava and yams.

Table 3: Emergency food aid and epidemic exposure
Region Population N. in Target Group Target Group as % of population Target Group Rank Epidemic Impact Ranking
Arusha 1390000 81833 5.89 9 11
Coast 656000 83289 12.70 3 5
Dodoma 1272000 82508 6.49 6 12
Iringa 1243000 50000 4.02 11 2
Kagera 1363000 73600 5.40 10 1
Kilimanjaro 1140000 96903 8.50 4 9
Lindi 665000 131949 19.84 2 18
Mara 998000 378891 37.97 1 7
Mtwara 914000 76518 8.37 5 6
Morogoro 1257000 79785 6.35 7 4
Mwanza 1931000 30000 1.55 14 3
Singida 824000 20000 2.43 12 10
Tabora 1065000 64890 6.09 8 9
Tanga 1320000 31564 2.39 13 3

4.1.3 The situation in Uganda

A small-scale but detailed study of nutrition in rural Masaka carried out in 1993 (Seeley) showed very low levels of current nutrition and food security in households. According to the field work undertaken for the present study much the same situation appears to be true at present in Gwanda and in other similar communities in Uganda. Moreover, a community wealth evaluation estimated that about 45 percent of people in Gwanda are poor (according to the community' own standards). But only ten years ago Gwanda was considered to be a wealthy community, by local rural standards.

With the advent of the HIV/AIDS epidemic, the community has seen a measurable decrease in its own standard of living. In the Table 4 below which summarizes the coping responses of 14 households in Gwanda of which case study analyses were made, some 36 percent (of the 14 families surveyed) reported food shortages. A similar study carried out in the community of Nakyerira found that 40 percent of the ten households interviewed suffered food shortages. These figures may be compared with those for the third area studied in Uganda, the Ndaiga communities on which HIV/AIDS had had, (at the time of the study), little if any impact. In Ndaiga of the 16 households surveyed, only two (or 12 percent) had reported food shortages.

In Gwanda as noted in other communities the severity of epidemic impact is unequally experienced as between differently-resourced households. The richer the household, the longer it can maintain adequate food supplies; the poorer the initial endowment of a household, the more difficult this will be. Given that the community itself considered that at present 45 percent of households were poor in terms of its own standards of evaluation, then it must be concluded that for 45 percent of the people in the community, any further stresses, whether related to the epidemic or for some other reason, can only have dire results.

Table 4: Summary of coping responses in Gwanda
Household Experience Number Percentage
HIV/AIDS affected 8 57
Decline of cultivated area in the past ten years 7 50
Decreased range of crops 10 71
Labour shortage 12 86
Change in cultural practice 8 57
Food shortage 5 36
Land shortage 2 14
Decline in off-farm activity 4 28
Increase in off-farm activity 2 14

Note: these data were collected from a village transect and are not the result of a random sample. They are illustrative only. Total number of cases 14, percentages rounded up or down to nearest whole number.

4.2 The declining status of nutrition and health standards in epidemic-affected communities

In Chapter 3 it was observed that a recurring pattern in the communities studied is the change in the volume and kinds of crops produced in the farming systems. Partly as a result of this, and other factors, e.g. the process of impoverishment induced or exacerbated by HIV/AIDS affliction, it would appear that levels of nutrition are falling. The reliance on starchy staples like cassava and sweet potatoes, compared with other more nutritious traditional crops like matooke, and or protein from animal products, is partly to blame. In addition there is the problem of the lack of understanding of the nutritional value of other produce, fruits and vegetables which though they may be produced are not favoured in the diet (see Chapter 3).

Lower levels of nutrition result in the increased vulnerability of the individual to disease and thus to a decline in health. Increasing morbidity in turn has a negative affect on household and individual productivity, resulting in long hours and hard labour for the already weak, and creating additional burdens on able-bodied family members.

One of the exercises that was carried out during the visit of the survey team to the Chipese area of Zambia was a health time line. Some of the older men participated especially, in identifying the type and severity of diseases that had been experienced in different decades since the 1920s. What the exercise showed was that by the l940s, several of the early twentieth century diseases such as smallpox and leprosy had disappeared, whilst others such as venereal disease and pneumonia had become much less prevalent. The 1940s through to the 1970s were relatively free of major diseases or epidemics. In the 1980s, however, health trends took a significant turn for the worse again. Many diseases became more virulent and widespread than they had been for decades - sexually transmitted diseases, scabies, pneumonia and tuberculosis. Malaria became much worse and is now the most commonly registered illness for admission to both the Mpongwe and Ibenga hospitals. Cholera also reared its head again in the late 1980s. And then there is AIDS.

During case study interviews, information was sought on major illnesses experienced within the community and deaths that had occurred within the last three years. Within most villages, illnesses such as malaria (fever), coughing and diarrhoea are common, the latter especially among children. Pneumonia is relatively common too, and with children malnutrition is an increasing problem. Older women and men suffer from backache, aggravated in some cases by the need to produce more food because of an accumulation of mouths to feed. Children who are ill during the weaning age of about 8 to 18 months can have a serious effect on women's agricultural production. In Kapenda village, a young woman reported having spent three weeks in hospital in January 1993 with a baby that had fever and diarrhoea. January is the peak weeding month. Consequently her 0.6 hectares of maize produced enough to eat as green maize only.

By contrast, another young woman also spent two-and-a-half months in hospital at the end of 1991 with a child suffering from diarrhoea and malnutrition. In 1993 the couple were still able to produce 40 bags of maize from 2 hectares. Her husband had assumed responsibility for staple food security and did the work when she was ill.

It appears clear from the general health status of this population that it is already profoundly vulnerable - especially the women and children. If the impact of the HIV/AIDS epidemic is considered in addition, the situation may have critical consequences.

4.3 HIV/AIDS: education and declining school attendance

One of the consequences of impoverishment and contracting household incomes in communities like Gwanda and Nakyerira in Uganda, is that with limited cash incomes, families can barely afford to send their children to school. On the one hand, extra hands may be required in the household to undertake farm or domestic chores. On the other hand, and judging from the case histories where several or all the children in a family were attending school, rather than helping with the farm work' education also appears to be a priority. In some families resources were provided by NGOs (see Chapter 3) to help with children's education. Certainly, if they are not provided with external assistance, families that are already at or close to subsistence level will have to forego educating their children simply to meet basic survival needs.

In Ndaiga and Nakyerimira it was estimated that 60 percent of all children of primary school-age children (6-14 years) were not attending schools. The reasons advanced for this phenomenon were lack of money to pay for their education.

It was also noted that female children were less likely to be in schools than were their male counterparts. Of all the children in school only about 10% were females. Some of the reasons given were the early marriage of girls and their leaving school because of pregnancy. This in turn has discouraged parents from paying for their female children.

4.4 The problem of orphans

The situation is still more serious with respect to orphans. With increasing numbers of children left orphaned by the HIV/AIDS-related deaths of their parents, the education of such children is a special problem. If orphans are taken over by other relatives, the cost of educating such children may well strain the resources of the receiving households. The children themselves may not have the time, let alone access to money, or even the intellectual wherewithal to consider education as a priority. Again, in areas with a high incidence of HIV/AIDS and large numbers of orphaned children, NGOs have so far been making efforts to fill the gap.

In the Mbeya region of Tanzania, the local hospital at Igogwe, which runs a home for orphans, reported that although attempts were made by relatives to care for orphans, they find it impossible to shoulder the burden of their own children and the orphans together. Most orphans are adversely affected in terms of their access to essential services, particularly education. They cannot pay school fees or buy uniforms and other school necessities such as exercise books and text books.

4.5 HIV/AIDS and changes in the social system

It is difficult to state absolutely that HIV/AIDS has been directly responsible for marked changes in the social organization of rural families. It is certain, though, that the epidemic impact has often exaggerated pre-existing problems. In Zambia, for example, where divorce was reported by focus group respondents to be a serious and growing phenomenon, it seems likely that the current economic circumstances have exacerbated the divorce rate, although there is no direct evidence for this. Previously marriages used to be arranged and a bride price was paid. These days almost no bride price is paid. Moreover, marriages frequently occur due to the pregnancy of the girl. Her parents may force the pair to marry but such a marriage may not last long.

In matrilineal social groups in Zambia, another practice which exacerbates the break up of marriages and has a negative impact on agricultural production is that of sons-in-law going to live in the village of their spouse's parents. The son-in-law has an inferior status and is rarely motivated to work particularly hard.

Rapid Rural Appraisal studies in the Central and Copperbelt provinces of Zambia have found that the most vulnerable and resource-poor farmers are always from indigenous matrilineal social groups. In this system, the increasing incidence of divorce results in social dislocation for both women and children. When a wife is forced to leave the house she goes back to her parents with her children. Fathers thereafter are likely to take only limited responsibility, if any, for their children.

In cases of divorce, which seems to be a growing phenomenon in the Zambian communities studied, a woman moves back to the village of her own mother, usually with most or all of her children. In the event of her death, it is possible the children will be subsequently split up (see Chapter 3). This is very common in the case of urban deaths. But in an area such as the Chipese community the net result will be an accumulation of children in the households where there are middle-aged or older women.

4.6 A change in attitudes to social customs?

During a focus group meeting at the village of Mpatisha in Zambia the women were asked about the responsibility of a husband for his children if his wife should die. Their first response was that if the wife of their son dies the children should go to relatives of the wife. 'Those children [of our sons] are not our relatives'. But asked a question which challenged the morality of this response and it provoked a very different reaction (see Box inset overleaf):

This exchange gives an insight into many of the now extremely negative 'customs' that are associated with matrilineal culture. The normative basis of the custom or tradition has disappeared, and now practice is driven only by expectation. The women showed through their general agreement with the remark that change was up to them and that if they do so others may follow their example -thus much of "tradition' is just example. Practices are followed because others do so, even if when challenged most will agree that the practice has no sound moral basis and has negative consequences.

The social problem is how to change undesirable 'customs', which have long evolved away from any ethical basis, and now merely undermine social solidarity and exacerbate the vulnerability and trauma experienced by women and children.

4.7 The growing reliance on income-generating activities

About 40 percent of farm households in Gwanda reported that they supplemented their incomes from off-farm activities. These range from petty trade, fishing, and beer brewing to small-scale handicraft production. For the majority of Gwanda households, off-farm income-earning activities do not feature in their livelihood strategy because they: do not have the small amounts of capital necessary to start this kind of work, they choose to limit their consumption, and they are able to sustain an adequate standard of living from their farms.

The case material for Gwanda suggests that there are two clear categories of household with major off-farm components to their livelihood strategy. The first category is composed of wealthier households which, even if they have been affected or afflicted by the epidemic, are able to maintain a high standard of living because they were well-off before they were affected by the epidemic and this has acted as a buffer to its impact. For these households, who are in the minority, farming was only one among a fairly large number of income-generating activities in which the household enterprise was involved.

By contrast, there is another category of households which have taken-up off-farm work as part of their coping response to the depredations of the epidemic. In such cases, which often seem to be female-headed households, these activities will be on a very small scale indeed, perhaps a little beer brewing, mat making or bark cloth production.

Whether or not the decision to enter into off-farm activity is taken may also have to do with the cultural expectations of a particular household. It may be no coincidence that the widow of a high salary earner for whom the epidemic has meant a dramatic drop in level and expectations of life should choose an off-farm activity as an effort to retain a lost standard of living. However, for those in the community who form the vast majority, the middle and the poor, there is perhaps no cultural expectation of anything much more than the difficulties that they currently face. Additionally, they may not have the social support networks which would provide access to the small amounts of capital required to start up an off-farm enterprise.

Box 11: Focus group meeting (Mpatisha, Zambia)

Question:"lf you have both a son and a daughter and they both marry and have children, who are the grandchildren, those from the daughter or from the son?"

Answer:"They are both our grandchildren. But it is a tradition we follow that only the children of our daughters are our grandchildren, but it is not a good tradition."

Question: "Can a chief change a tradition?"

Answer, first respondent: "We can't follow the chief unless we ourselves believe it. An individual we can copy, but not the chief."

Answer, second respondent:"lt is up to me to change. Now we have been discussing we can see that it is good that we keep the grandchildren of sons as well as daughters. We can change and others who are not here will stay the same. But they can see what we do."

In Nakyerira, as in Gwanda, farm production cannot provide for all the nutritional, social and economic needs of the majority of households. Even for those able to produce a surplus for sale, marketing remains a major bottleneck, and this is particularly the case in households where a person who has died as a result of HIV/AIDS or from another cause was instrumental in marketing farm produce.

Many of the young men and women, form part of the migrant, often semi-skilled, population seeking employment in Kampala, Mityana or elsewhere, sending remittances home. Most single women heads of households engage in making and selling local beer. In contrast to Gwanda, fewer women are involved in weaving mats and baskets or making other traditional handicrafts for sale. Apparently there is little local demand for these products. However, those who do undertake such activities were more likely to be in the middle income households.

Young unmarried adults often combine several occupations into a livelihood strategy because, as they say, "agriculture does not pay enough to sustain a person". Although the predominant occupation of young men seems to be cultivation of crops and raising of small stock, approximately 85 percent are also engaged in casual labour.

The main off-farm activity for the few adult male householders is trading in agricultural produce.

Except for the middle-aged single women heads of households who are often engaged in the brewing and sale of beer, women are not involved in many off-farm activities. However, some of the young single mothers seek employment from better-off families and perform such tasks as land preparation and weeding.

In contrast to the opportunities which appear to exist for supplementing incomes from activities other than those traditionally or normally relied upon, the situation in Ndaiga is also relevant. Here, although there is little HIV/AIDS impact on the communities, given the livelihood strategies characteristic of the area, there seem to be many reasons for the epidemic to spread in the next few years. In that case it is possible to speculate that the dominance of maize monocropping for the market, the presence of a relatively large landless population and the absence of off-farm income-earning opportunities and market isolation, would indicate that this farming system and its connected livelihood strategies would be less resilient than for example those in Gwanda.

The effects of HIV/AIDS on farming systems in eastern Africa...

2009-12-17T07:44:00.003-08:00

Like any other disease, HIV/AIDS results in direct costs, mostly medical and funeral expenses, and indirect costs, which are labour related. Potential income is lost because of the illness and death of individuals and the diversion of labour to the task of caring for the sick. If no safety net is present or is incomplete as in Uganda, Tanzania and Zambia, households and rural communities have to bear these costs alone.

Before considering the impact of HIV/AIDS on small-scale farmers, a few words should be said about the organization of the farm-household system. A farm-household system generally consists of three closely interlinked sub-systems:

- the household as a decision-making unit; establishing goals and controlling the system, providing labour, and ensuring food and cash in fulfilment of set objectives;
- the farm and its crop and livestock activities; providing employment, food and cash for the household; and
- the off-farm component, competing with farm activities for labour, providing employment and income-generating activities, becoming increasingly more important to supplement the well-being of farm families (FAO, 1990).

HIV/AIDS intervenes and affects these different sub-systems and their interlinkages as demonstrated in Figure 5. Cash and labour flows are partly diverted to AIDS leaving less labour for farm and off-farm activities as well as reducing cash for the household. Cash which is exchanged by the farm and off-farm system for the purpose of, for example, purchasing fertilizer or financing investments in off-farm activities, may also be used for AIDS related expenses.

It should be noted that this generalized definition of the farm household does not take into consideration the fact that households may be internally differentiated by, for example, age and gender. Thus it is important to recognize that distributional consumption and other entitlement inequalities may be of considerable importance in determining the precise impact of HIV/AIDS on any particular household. This point is of great importance when we consider the relative impact of any traumatic event - such as HIV/AIDS- on the internal operation of a household and thus the relative robustness of different households in the same society and similarly constituted households in different societies. Some of these issues are dealt with below.

Figure 5: Resource diversion due to AIDS in a farm-household system

3.1 The direct costs of HIV/AIDS and the process of impoverishment

In general terms HIV/AIDS has the effect of increasing poverty by escalating costs at every level, to the individual, to the community, to government and to the private sector.

At the family level, medical costs associated with caring for the sick and bedridden have to be borne along with the funeral expenses of family members who die of the disease. Besides the costs of drugs, conventional and traditional medical treatment, households caring for AIDS patients are often faced with meeting expenses for additional special foods to comfort the sick or for items such as extra blankets.

Funeral costs appear to be even higher than expenditures for medical care. A household study carried out by the World Bank in Kagera, Tanzania, revealed that on average US$ 60, of which 60 percent was spent on funeral expenses - the remaining 40 percent having gone towards medical care - was spent on the funeral expenses of a household member. This is an amount which is probably close to the annual per capita income in Kagera. Due to the nature of AIDS, as a predominantly sexually-transmitted disease, there is frequently more than one death in a household. As a result, numerous cases can be observed where a family's entire savings, often meagre before the onset of AIDS, are completely consumed.

Box 1: Case study 1 (Gwanda community, Uganda)

The cost of AIDS

Sarah is a 44-year old widow who lost her husband in 1990 due to AIDS. Apart from caring for her children, farming her 3.5 acre plot, and breeding pigs for sale, she also makes mats, baskets and table cloths which she sells to earn extra income although finding a market for her wares is often difficult.

From the time at which her husband first became ill she has had to use most of her money to pay for his treatment and for that of her mother who was also sick. This took up much of her time and thus she now has fewer hours to manage the farm. Apart from the time she spent canny for the sick, followed by a month mourning the death of her husband, the deaths of other people in the village also interrupt her farm work because she has to attend funerals and prepare food for the relatives of the dead. Since most of the people in her village are closely related and there have been many deaths, in most cases she spends one to four days in mourning with the result that much of her plot is now under weeds and she derives little income from what she is able to produce in the remainder of the time.

The high cost of treating AIDS and the expenses incurred through the death of a person with AIDS, mean that households either require assistance or cash incomes to cope with these additional expenses. Case material from Mpongwe village, Zambia, indicates that one possible source of assistance is from remittances sent by working-age relatives employed elsewhere. There are few households, however, which appear to be actually receiving such external support. This is certainly connected to the straitened circumstances of most urban households whose budgets have been affected by structural adjustment. Inflation has resulted in food and other commodity prices rising considerably in excess of any gains in wages. Within the Mpongwe case studies there were only two households out of 34 being helped by remittances sent from outside the area. Both of these were elderly retired couples; one had 10 successful children, with one son living in London. These children sent money which was used to hire a tractor. Local sources of employment are, however, important for others. Such income sources can pay for resources such as tractor or ox hire, as well as supplementary food and household items.

In the Mgeta area of Tanzania, households headed by women are not uncommon and do not necessarily represent one of the poorest groups of the community, as they frequently benefit from the remittances sent by their husbands. The money received is often used for employing labour and thus their agriculture does not suffer from the lack of labour. Female-headed households, following the death of a husband, are in a much more difficult situation as there is no cash to replace the shortfall of workers.

An increase in the number of female-headed households might occur if women do not become infected or are infected after their partners, and without the benefit of remittances to support their production, only the wealthiest may continue to hire labour and thus for most their output will suffer. The position of women after the death of a spouse is, however, much more favourable amongst women in patrilineal systems, like the Luguru in Tanzania. Although the husband's land will be returned to the clan, the widow will still have access to the land she has inherited from her own clan. In other areas widows may become landless and forced to seek off-farm employment, but in Mgeta they are likely to be able to maintain their agricultural incomes.

The general lack of remittances, however, and the fact that many of those being affected by AIDS are employed locally, means that most of the cost of AIDS will have to be borne internally. Men will experience this cost, because they and their wives will receive the children from brothers and sisters. The brunt of the burden, however, will fall on women, because of the fact that death, like divorce, leads to the social relocation of children to matrilineal kin, which often means in practice to the care of the grandmother. Thus it happens that a number of children end up in households headed by middle-aged or older women.

Inheritance practices may have a negative effect on production and increase the vulnerability of women and children. Especially in Zambia, (but also in Uganda) property grabbing after the death of the husband is a wide-spread practice. According to customary law, in patrilineal systems, all property acquired during marriage belongs to the husband, and after his death, to the husband's family. Relatives arrive soon after the death to claim all the household's possessions which may even include cooking utensils. Despite enactment of the Inheritance And Succession Act of 1989, which was designed to prevent precisely this situation, but seldom respected, this remains a serious problem in Zambia (Foster, 1993). In Uganda, women do not have any official ownership of the land. Once widowed. they may even lose the right to use the land.

At the national level, costs resulting from HIV/AIDS include additional provision for health care directly associated with HIV/AIDS, diversion of resources from other areas of health care, and money for health-education programmes. These expenses involve not only treatment programmes but awareness-building and information campaigns. While much of this work is being undertaken by non-governmental organizations (NGOs), the effective dissemination of information requires the support of governments. Additional costs to governments may also arise from the loss of skilled labour in certain areas, to be replaced by replaced international employees, or from the import of foodstuffs or other items which may be needed to supplement the loss of production etc.

Despite wide-spread impoverishment as a result of HIV/AIDS there may also be some who benefit from the epidemic. While a large number of farmers are forced to sell farm assets like animals and implements to raise money, there are some others who have actually benefitted with the result that they can afford to acquire assets. Box 2 is an example of one such case.

Box 2: Case study 2 (Gwanda community, Uganda)

Benefitting from AIDS?

Peter, 47 is married to a strong looking wife aged 30 and has eight children between the ages of one and, 11 years. His family has so far neither been AIDS affected nor afflicted. Peter can be described as a so-called progressive farmer; he is convinced of the utility of mulching and composting practices end is open to new practices such as growing tomatoes as a cash crop.

Five years ago, this household relied totally on family labour, and owned no cattle. Today, the same household is able occasionally to hire labour, owns 20 head of cattle, a boat with a motor and a television. Peter said that this rise in wealth was possible due to hard work on his farm and to his beer brewing, which he described as a profitable business. But it also seems that his family benefitted by buying cattle from AIDS-afflicted households!, which were short of cash to pay medical bills. His boat was bought from a family who could no longer afford to keep this asset because the husband, a fisherman, had died of AIDS and, the remaining family members did not know how to manage the fishing business.

3.2 The impact on population

In the three countries studied where the HIV/AIDS epidemic has struck, or where its effects are beginning to be perceived, the disease has been both age and gender selective. In Uganda, for example, young adults above 12 and below 40 years of age have been shown to be most at risk, accounting for 91.8 percent of all HIV/AIDS cases. Of the remaining eight percent, children below the age of five account for three-quarters of the total. Men and women are also exposed to different degrees of risk at different ages. Of the 2 089 reported cases of youths aged between 13 and 19 years (June 1993), 1 736 were young women. Recent population-based studies in Uganda have shown women to have a much higher rate of HIV infection than men, sex ratios ranging from 1:1.12 to 1:1.18.

These findings are significant in the context of the present study given that the majority of Uganda's agricultural producers fall within the age group that has been shown to be most at risk of HIV/AIDS infection. This is particularly significant when considered in the light of the labour intensive nature of agriculture. Similarly, it has important implications in terms of the interconnection between domestic and farm production in rural households and the important role of women in agriculture.

In Uganda's Gwanda community, it is suspected that HIV/AIDS had a marked impact on the age pyramid shown in Figure 6. The 20 to 49 year age group is particularly under-represented as well as the very young, children between the ages of 0 and 4, in comparison to the national age pyramid.

Figure 6: Age pyramid of Gwanda

In Tanzania, of the total of 20 694 cases recorded between 1983 and 1993, the cumulative rate per 100 000 is 89.9 for men and 82.4 for women. The highest case rates per 1 000 are seen in the 30 to 39year age group for men and in the 25 to 29-year age group for women.

The situation is less clear in Zambia, since the recorded incidence of HIV/AIDS has so far been largely an urban phenomenon, with 45 percent of recorded cases within the urban areas of the country's Copperbelt. However, the pathways of the spread of infection from the main urban centres are the major transport routes. The carriers are those that use the routes regularly, traders, truck drivers, and business people. Where they interact with people from rural areas, HIV/AIDS infection will spread into the rural areas.

3.3 The impact on labour

As noted above, the effect of HIV/AIDS on the population has been to hit not only women as primary agricultural producers but also the most productive age groups generally. In terms of availability of labour this has significant implications. Population growth was long perceived as the problem in Africa. HIV/AIDS is now resulting in labour shortages for both farm and domestic work in some areas. This phenomenon is likely to become more widespread in the coming decades.

In Uganda, one of the findings has been that the negative impact of HIV/AIDS on agricultural labour is more a result of death than it is of sickness. This is due to the fact that the period between illness and death in this environment is short, reducing the amount of time required in nursing AIDS patients. Even so, in farming systems that are essentially labour dependent, the complete loss (if a person falls sick or dies) or partial loss (if time has to be diverted from farming to the care of the sick) of any household member who is involved in agricultural work, can have a severe effect on that household's agricultural production and finally on its level of consumption and general well-being.

Different factors determine the sensitivity of agriculture to labour loss resulting from AIDS (Gillespie, 1988) these are:

- Seasonality of labour demand

Seasonal labour constraints are not new, due in part to the fact that: farm incomes are low and adults often spend part of the year away from the farm in search of cash incomes; in some regions distribution means that labour has to be mobilised intensively for brief periods only; and daily life requires substantial amounts of labour for non-farm work associated with maintaining the household. Water and fuel collection may occupy as much as eight hours a day - tasks usually carried out by girls and women.

Figure 7: Activity Calendar (Women) Zambia study rainfall

Agricultural labour requirements seem to be more equally distributed over the year in the Ugandan study areas than in the communities examined in Zambia. This can be attributed to the fact that large parts of Uganda are characterized by a bimodal rainfall pattern and a wide range of crops are cultivated, while there is only one rainy season in Zambia and the predominant farming system is maize-based. Figure 7 shows labour distribution for women in Zambia with two marked labour peaks in the year.

- Degree of specialization by gender and age

While farming may be done by women or men or jointly, it is generally recognized that in large parts of Africa women carry the bulk of the farm workload in addition to the domestic activities. A study in the banana-coffee farming system in the Kagera Region, Tanzania, revealed that the asymmetric division of labour between the sexes lead to allocative inefficiency such that farms produce at less than full capacity, and this is without the existence of AIDS (Tibajuka, 1994). In cases of the death of a spouse, the impact is likely to be greater the more differentiated the gender roles are in any particular society. Traditions and a lack of agricultural knowledge generally hinder spouses from easily taking-over their partner's share of the work. Thus it is not only the person who dies, but the knowledge and skills of that individual which die with them. This situation is aggravated where women are concerned. With the death of their husbands, they are likely to lose access to the extension service, to credit, marketing facilities, etc.

In Uganda, some women, having lost their partners, who previously handled marketing, have completely abandoned commercial farming. The widows now only plant enough for their subsistence and have grown very poor as a result. In these and other households, time accorded to nursing the sick, frequent funerals and the mandatory one-week mourning period, second burial ceremonies, deaths of progressive farmers and general demoralization, have all contributed negatively to agricultural production.

- Economic return to labour

In Gwanda community in Uganda, many households appear to be experiencing labour shortages. On the one hand, the high incidence of AIDS-related sickness and death, has caused a labour deficit. On the other hand, there are also some features of the local labour market which contribute to this shortage. In a remote village like Gwanda, agriculture itself has been extremely limited due to the lack of marketing facilities. Rural youths in particular have not found such work attractive, in addition to their perhaps natural wish to explore a wider world away from the constraints and obligations of the village. Even though it is the case that most agricultural work is done by women, it is also true that there are important tasks carried out by men, in particular the clearing and initial cultivation of land. Both men and women farmers complained about, the lack of marketing facilities, low prices for agricultural products and the deteriorating terms of trade for their produce in comparison to products like soap, salt and paraffin.

Moreover, while the farming system changes in response to labour constraints induced by HIV/AIDS, other sectors of the local economy which require workers are nevertheless able to command some of whatever labour is available. In a fishing village near to Gwanda, in spite of numerous deaths due to HIV/AIDS, there are still plenty of fishermen. Those who die from the disease it seems are quickly replaced by others. Many youth from Gwanda and other inland villages apparently find it very hard to acquire employment in the fishing village because although, only a few kilometres away from Gwanda, there is a surplus of labour.

Thus the attraction of the fishing villages, and probably other regional towns and even the capital, Kampala, all act as competitors in the labour market for young male workers, and thus may take labour away from agriculture in the area. These constraints are then further exacerbated by the high level of deaths in an already labour-depleted farming village.

Economic returns to labour are closely linked with the level of intensification in terms of improved seeds, input of fertilizer and pesticides and the level of mechanisation. In all three countries studied, cultivation is mostly done using a hand-hoe, although in Tanzania and Zambia animal traction, and to a lesser extent tractors, are used by wealthier farmers.

- Cultural factors

One of the most significant traditions, which has an impact on labour in times of high mortality is attendance at funerals and the mourning time. Box 3 describes the tradition of mourning in Rukwa region, Tanzania.

Box 3: The tradition of mourning in a Tanzanian village

Following a death in the community of Rukwa in Tanzania, the following customs are observed:

Relatives and neighbours gather to prepare for the burial bringing with them food and livestock to assist the bereaved in feeding those who gather for the burial ceremony. Gifts of money are also made.

On the day of burial, all farm activities are suspended by the entire community. (This may involve more than one village. For example, when the research team was travelling to Lula village, it encountered many people travelling in the opposite direction to Kaengesa village where a person: had died, All of them were carrying something; one for example had a goat).

If an adult dies, mourning takes three days; if it is a child, the rite lasts for two days.

During this period, all relatives do not work while neighbours collect at the house in the evenings to comfort the bereaved family amidst eating and drinking. If the person who died had been wealthy or prominent, neighbours may remain longer still. Cattle, goats and chicken are slaughtered and the local homemade brew is drunk.

When those who were unable to attend the burial ceremony eventually come to console the bereaved family, (even if a month later), the ceremony takes on a new impetus with renewed crying, wailing and more eating and drinking.

When a man dies, his wife is inherited by one of his relatives, usually one of his brothers. The inheritor takes charge of all affairs of the deceased relation e.g. property and children.

When the loss of labour hours as a result of mourning activities is added up and multiplied by the number of burials, the economic impact can be considerable. In other areas of Tanzania traditional mourning rites are even longer. For example, in Mbeya, the period of mourning can last as long as one month. Because of the impact of this custom on the rural economy and in order to prevent the spread of HIV/AIDS during these occasions, the Kyela District Council in Mbeya region has attempted to restrict the mourning period to four days. Similar efforts to restrict funeral rites have also been observed in Uganda and are likely to be an important component of local coping mechanisms more generally.

Before the impact of HIV/AIDS on particular aspects of farming activity is described, the following example will serve to show how the farming system in a particular community changed over time without the presence of HIV/AIDS. This brief examination of developments in Nakyerira village, Uganda, illustrates not only how the labour market has changed but how this factor has impacted on the overall farming system.

For the past ten years, there have been marked changes in the types and volume of crops cultivated. Previously, the range of crops commonly included sweet potatoes, bananas, cassava, yams, peas, beans, egg plants, groundnuts, maize, sorghum and a wide variety of green leafy vegetables and fruit. All these crops, especially the vegetables, were grown for home consumption. At times however bananas, beans, groundnuts and maize were sold.

The people of Nakyerira used to employ a large number of migrant labourers from south-western Uganda, Rwanda and other parts of the country. Nakyerira farmers who could not afford to enter into exclusive contracts with migrants depended on casual labour employed elsewhere, particularly on the "Indian" tea plantations about six miles away. These casual labourers were often paid in food.

The introduction of cash crops in the other areas of Uganda and the later decline in tea production, after the 1972 expulsion of Ugandans of Asian origin, led to a drastic decline in labour supply for Nakyerira and the surrounding communities. At the same time the decline of coffee in the mid-1970s meant that many farmers could no longer afford to employ workers. Thus the youth started to migrate from the area to Kampala and Mityana town in search of employment. An agricultural system that had been a net importer of labour thus became a net exporter.

The effects on the farming system were quickly evident. Control of banana pests and diseases became difficult without the farm labourers to do the work. Farmers began to develop labour economising strategies in response to these conditions. Banana and coffee, each for different reasons, is labour demanding and became progressively less cultivated as a result. Coffee trees were cut down and replaced with drought resistant cassava that did not require either labour for mulching or hand weeding. Hardy beer bananas that neither required much labour for weeding, nor labour for cutting grass for mulching or pruning, together with sorghum, replaced banana and coffee as the new cash crops. The available labour was shifted to groundnut and bean growing as well as the production of maize and Irish potatoes. While some of these were labour demanding, the return was apparently superior and offered more food security than retaining weevil-infested banana groves. Where these crops could not be grown, farmers started acquiring and rearing cattle.

As a result, the inadequate labour supply largely accounted for a decline in crop range and volume. Along with loss of soil fertility, high incidence of pests and diseases (see below), prolonged droughts, the main contributory factors were high labour costs resulting from demand exceeding the locally-available supply, and the frequent deaths of farmers and their children. In addition, local people made reference to other recent changes in the labour market. Two main trends were identified. Firstly, former migrant labourers no longer come to the area but instead remained in their home areas producing cash crops in those areas - for example coffee in Ankole and tobacco in Kigezi. Secondly, former migrant labourers who had settled in Mubende and having acquired land and property, have become wealthier and compete in the local labour market as employers. The end result of this labour shortage has been a reduction in the quality and quantity of crops produced.

These events in Nakyerira's recent history indicate that over the last thirty years the population has been adapting its farming system to labour deficits. It could thus be argued that they may be in a good position to cope with the future effects of the epidemic. However, it may also be the case that with poor soils and less dependable rainfall, the community could now be confronted by a dramatic decline in labour availability with results that prove even more destructive of food security on the rural standard of living than are being witnessed in Gwanda, for example.

3.4 The impact on crop production

3.4.1 Reasons for decreasing land use
3.4.2 Decline in crop yields
3.4.3 Changes in cropping patterns: a strategy for survival
3.4.4 The advantages of crop diversification

The direct impact of HIV/AIDS on crop production was observed in terms of a reduction in land area cultivated, a decline in crop yields, and a decline in the range of crops grown. However, the extent of the impact and the relevance of contributing factors differed from country to country and from one farming system to another.

3.4.1 Reasons for decreasing land use

In the first instance, the reduction in land use is attributable to a number of factors which have occurred as a direct result of the HIV/AIDS epidemic or indirectly with the effect of exacerbating existing constraints. These include: sickness and death in households leading to fewer family members being available to work in the fields and thus in the amount of land that it is possible to cultivate; the limitations of land inheritance and land tenure systems, especially as they may affect widowed and orphaned households; poverty, resulting in malnutrition, which in turn affects the health of family members and their ability to perform agricultural work, and which leads to reduced cash incomes needed to purchase inputs such as seed and fertilizer; the selling of land to meet the cost of medical and funeral expenses; and the loss of soil fertility on farms with limited land areas.

A land utilization survey carried out in Masaka and Rakai Districts in Uganda in 1991 found that 23 percent of all farms reported a reduction in land use in the preceding four years (Hunter, 1993). Death and sickness as well as old age and poverty were the leading causes for this decline in land use apart from land given to older children.

The effect of HIV/AIDS in reducing the number of household members available to cultivate crops and large areas of land, has led to substantial reductions in land use in many of the communities studied, especially in Gwanda which has been extremely hard-hit by the epidemic.

In one case, a Ugandan family in Nakyerira community, in which three sons have already died of AIDS, reported that the proportion of land now under cultivation or for livestock grazing had declined from 95 percent in 1991 to 60 percent of the total by July 1993. Furthermore, the expansion of the land which the family had started to realize through the purchase of neighbouring plots, had to be stopped in 1991 due to the sickness of two family members. Some of the land that they had hoped to buy in the neighbourhood of their existing plots had instead been bought by other people. The area which had been planted with coffee, cassava and bananas was abandoned and allowed to revert to bush early in 1992. Even the banana plantation, healthy by local standards (due to the use of cow dung as manure) was overgrown with weeds and contained weevils. Where once the family had planted beans, maize and cassava on 1.5 hectares of land, because of the time needed by family members to nurse the AIDS sick, and due to a lack of money to hire farm workers for ploughing, substantial areas previously devoted to these crops now lay derelict.

A common farming system among the communities studied, particularly in Uganda and Tanzania, is the coffee-banana system. In the zone which forms an arc around the western shore of Lake Victoria and stretches into the north-western part of Tanzania around Kagera, for example, the majority of households cultivate Robusta coffee and savoury bananas matooke as their main crops in combination with a wide range of other annual and perennial crops.

This farming system predominates in Gwanda. Where formerly, larger land areas were planted to banana and coffee, such farms are being abandoned (many having reverted to bush) due to the lack of household labour or money to pay for temporary help to weed, mulch and control against weevil infestations. At the same time, it was observed that many households now consist of orphaned children and their grandparents or other senior relatives, with few young adult family members who would otherwise have done much of the cultivation of crops.

Farming systems which are particularly vulnerable to the impact of HIV/AIDS are likely to be those which are labour intensive in nature.

An example is the village of Mgeta in Tanzania. At the time of the study no AIDS cases had been recorded, but it is easy to see how, given the labour-intensive nature of the farming system, an overall reduction in the area of land prepared for cultivation might be expected, as a consequence of labour shortage due to sickness and death. Some households are already unable to cultivate all of their fields because land preparation is such a time-consuming activity. These are usually the poorest families who need cash incomes and so work on neighbouring fields at the expense of their own, rather than because they have insufficient labour or a large area of land.

A further expectation would be of a simultaneous increase in the land area given over to fallow crops, which require neither weeding nor irrigation. These crops include cassava, pigeon pea and sweet potato. However, households go to great lengths to ensure a rainy season crop of maize and beans so the planting of fallow crops would be likely to increase only during the dry season at the expense of the more labour-intensive cash crop production.

The nature of land tenure and inheritance

In some communities, where land tenure and inheritance traditions favour male inheritance, for example, the effect of the HIV/AIDS epidemic may be especially severe. As increasing numbers of women are left widowed, becoming de facto heads of households, with their rights to land already constrained by the traditional inheritance customs, their access to land is automatically constrained.

In Gwanda and other parts of southern Uganda, land tenure is based on the colonial reform implemented early this century. This is known as the mailo system. The reform, which was important in the colonial political settlement, ensured that the nobility were given superior land rights and the majority of the population became their tenants, whereas previously they might have been described as "serfs" within a "feudal" structure. This system has subsequently become confused in a number of ways, and today there is considerable uncertainty about land tenure.

In practice, both cultivation rights (in the case of the tenants) and land title (in the case of title-holders) are inherited through the male line and women do not inherit these rights except in certain circumstances where they hold rights of trusteeship for a limited period, for example until a male heir attains his majority. In cases where a woman holds such a trusteeship, her husband's patrilineage is likely to bring considerable pressure upon her to relinquish it. This has special implications in the case of HIV/AIDS-affected households where the woman is the survivor.

In cases where people enter into sharecropping arrangements, they may be given land which is heavily infested with perennial weeds requiring considerable manual work before planting is possible. In order that such seasonal cultivation rights do not become transformed into longer-term claims, these loans are for limited periods of around two years. The study noted that land surplus households are reluctant to lend their land because they fear losing their "ownership" rights.

The uncertainties concerning land tenure have given rise to a paradoxical situation where for some, usually poorer, households, there is an effective land shortage which may require that they enter into sharecropping arrangements with households having a surplus, while elsewhere in the community large areas of land remain uncultivated.

In Nakyerira, while local people report that they experience land shortage, in the majority of households there is insufficient labour to ensure optimum utilization. The result is that in most cases farmers have abandoned about one-third of their land to bush due to the lack of farm workers to manage the fields.

The practice of dividing land between children of both sexes (it is not uncommon for fathers to give land to daughters) when they come of age and start their own households or, at the death of the father, is prevalent. In polygamous households, different wives are given usage rights to their own individual plots. These plots will eventually pass on to the male children. As in Gwanda, this practice has the effect of reducing holding size to uneconomic proportions.

A major development observed in most small farms covered in the field work has been that of a decline in the crop yield per area, especially in the last five years. The factors identified as responsible for this decline include:

- a decline in soil fertility;
- an increase in pests and plant diseases;
- changes and delays in cropping practices; and
- a decline in external production inputs.

These factors are in part attributable to the effects of HIV/AIDS morbidity and mortality on the availability of labour which has meant that certain necessary tasks like weeding, mulching, pruning, particularly, as noted above, and the clearing of land, generally, have either been inadequately carried out, or completely neglected.

Declines in yields result in a relative reduction in spending power by households which might otherwise have used cash from the sale of produce to buy basic items like soap and paraffin and to hire occasional labour, or to purchase inputs such as seed and fertilizer as well as agricultural implements.

Decline in soil fertility
There are initial signs that an indirect effect of the HIV/AIDS epidemic is to reduce soil fertility. This appears to be due, in part, to a reluctance by farmers to carry out long-term soil conservation measures. This may well be because such measures do not yield an immediate result and are also labour demanding.

Box 4: Case study 3 (Gwanda community, Uganda)

The story of Martin

The story of Martin is the history of a household which has witnessed a dramatic change of circumstances, in a large part attributable to the devastating impact of HIV/AIDS on the family. Martin was an able farmer and a former fisherman. On one acre of land he used to grow bananas, coffee, groundnuts, beans, sweet potatoes, cassava, mangoes, a variety of other vegetables, and a little maize. Most of the time he produced enough food to feed his family of ten and to earn a small amount of cash. The entire half hectare of land was cultivated, with all the family members taking part in the planting and weeding. Thus Martin was able to prepare his land early enough - planting in good time to take advantage of the rains and thereby achieving high yields. He also raised chickens, giving his family ample protein throughout the year.

Some time ago, Martin's wife left the house, but, according to him despite his unhappiness at her departure, at least his farm work did not suffer. However, since then, three of his nine children have died of AIDS and one of his sons was murdered. The shock of these deaths has left him almost mute. Three of his remaining children are also living away from home and it seems they rarely visit their now 70-year old father. These days two-thirds of Martin's land is under bush. The coffee trees, which used to yield about three sacks of coffee each year, have disappeared. Martin doesn't have anyone to tend the groundnuts because they require a lot of work and now there are no garden vegetables either. The banana plantation occupies less than 0.6 hectare and is weedy and dying, being heavily infested with weevils. Last season Martin said they could not plant maize because he could not afford the seed. Although he still produces some cassava and sweet potatoes, there is often not enough of these basic foods to feed his family. Now, if they are lucky, they may be able to eat meat at Christmas, and once a month Martin's eighteen-year old grandson buys a little fish.

In Rakai district in Uganda, for example, the banana plantations used to be either mulched by residues of the plantation where the nutrients of the same plot are recycled, or with grass cut and carried from the open fields, the latter practice requiring considerable labour which was previously hired. This alternative practice is reportedly decreasing due to the expense of hiring farm workers. The farmers themselves frequently do not have the time and energy to carry out these tasks. They may also lack access to the financial resources to purchase fertilizer.

Conversely, soil regeneration may be aided by the fact that a large number of plots are no longer cultivated due to the numerous deaths and sickness within families in the district of Rakai, and the land is thus left fallow by necessity.

In Nakyerira, one farmer, who was considered to have been progressive and successful, reported that he was now poor partly due to a decline in soil fertility. He said that he used to have a good banana plantation, well mulched, weeded and pruned. He had used both organic and non-organic fertilizers. However, with the loss of two daughters as a result of AIDS, and the departure of other children from the home, he could not now afford to hire farm workers. At the same time, his land had suffered the effects of drought and fire. He now complains of poor crop yields due to infertile soils, the presence of banana weevils and the lack of help to do the weeding and mulching. Now, he says he grows mainly cassava, maize and sweet potatoes purely for household consumption.

Box 5: Case study 4 (Gwanda community, Uganda)

How AIDS sickness and death have resulted in a reduction in the land area and a change in the cropping practices of one family

Robert is a 38-year old primary school teacher. He has inherited two hectares of land from his father on which he owns a small mud and wattle house. Four years ago his wife died as a result of a mysterious disease leaving Robert with four young children, two of whom now live in a village 30 miles away with their grandmother. He has remarried and it is the new wife who now does both the housework and the farm work. Only one of the two hectares is cultivated with bananas, groundnuts, cassava, sweet potatoes, beans, cabbage and many other crops.

At present Robert's wife can only grow sufficient produce to feed her family since they do not have enough cash income to buy food. Since the land was only acquired in 1992, the entire area has been overrun with couch grass, Robert's wife has not had the time to do the arduous task of clearing the remaining 1.5 hectares of land, Because of the burden of having so many household and farming tasks, including caring for her father and two sisters who are dying of AIDS, Robert's wife has only been able to plant maize very late in the season. The delay in planting, she believes is the reason that her maize plants are stunted and affected by a virus. It seems that the maize crop will yield almost nothing, and in the meantime she has not had time to prepare the land in order to plant groundnuts.

In order to ensure that she has enough basic food crops for her family, Robert's wife decided to plant early-maturing varieties of cassava, sweet potatoes and bananas which were also supposed to produce good yields. Initially she had problems with banana weevils until the NGO, World Vision, advised her and her husband to control the weevils using cultural methods; this method controls the pest to levels where it does not cause much economic loss, although the weevils have not been eradicated completely.

Increase in pests and plant diseases

A common feature of the farming systems studied, particularly those where there has been a high incidence of AIDS cases, has been an increase in pests and plant diseases. A common pest, which was present or reported in a large number of farms is the banana weevil. Banana weevils used to be controlled either by traditional means, which are labour-intensive, or with the use of chemicals. A shortage of labourers hinders farmers from controlling weevils using traditional methods nor do they necessarily have the financial resources to purchase chemicals.

In the village of Gwanda in Uganda, a cause of decreased production in the coffee shambas has been an increase in insect infestations, particularly of large black stinging ants which are believed to be symptomatic of poor cultural practices. These insects now discourage farmers from working on the starchy crops which they have been trying to cultivate on their run-down coffee shambas. This situation is now described as critical, the plots in many cases, having reverted so far that it is no longer economic for all but the wealthiest or most labour-endowed households, either to recover their old coffee trees or open new areas for coffee production.

At the same time, it was also reported that coffee has generally become a less attractive crop for farmers in the last twenty years. Until the early 1970s, Gwanda was a major coffee growing area. Much of this coffee was grown on land which has now reverted to forest. A decline in world coffee prices, corrupt marketing practices and civil strife, have lessened interest in producing the commodity.

In Gwanda, weevil infestations have contributed to declining banana yields. Although it has been observed that this might have happened anyway, the absence of effective and cheap chemical control methods together with a lack of labour have meant that this problem has now become critical.

In the same village, there also appears to be an increase in the plant diseases, fusarium wilt and sikatoga. The greater incidence of these diseases may also be associated with changes in cultural practices due to a lack of farm labour. Apart from pests and diseases, couch grass, a notorious weed, poses an increasing hindrance to farmers. It is extremely demanding to dig out couch grass manually, because the roots grow very deep. Herbicides, which would be another way of fighting the plant, are too expensive.

Decline in the variety of crops

In a comparison between a study conducted in 1989 and the present fieldwork in Gwanda, marked changes were observed in cropping patterns. There was a general shift away from crops that are labour demanding, like bananas and coffee, to those that are the least labour intensive most frequently cassava and sweet potatoes.

In Nakyerira, farmers claimed that since 1980 there had been many changes in the type and volume of crops grown. Irish potatoes had recently been introduced and cassava and sweet potatoes were now being grown on a larger scale than in the past. The increased cultivation of sweet potatoes and cassava was attributed to the fact that they are easy to plant and maintain, they require less attention than other crops and are also drought resistant. Generally farmers remarked that at present, a narrower range of crops is grown, the emphasis being on sweet potatoes' cassava, beans and maize. Other crops such as sesame and vegetables are either produced in smaller quantities or have been completely abandoned.

An example of a similar trend in Zambia can be taken from the village of Teta, a community which is only just beginning to feel the effects of HIV/AIDS. In the case of one family, where both the husband and wife were ill, the couple reported that they were, as a result of their declining health, reliant both on owning or hiring oxen for planting anything but the smallest area, and that they needed to hire occasional help to weed their lands. Such labour, they noted, was expensive and they could not always afford the cost. Consequently, while the couple had recently been able to hire oxen in order to harvest their maize crop, they were not able could not afford - to grow a significant area of any other produce except for some sweet potatoes cultivated using hired workers. As a result of illness and the family's reliance on hiring oxen and part-time labourers which they could little afford, overall farm production has suffered dramatically leaving the couple with little cash and lower yields of fewer crops.

3.4.3 Changes in cropping patterns: a strategy for survival

In order to adapt to changing, social, economic and environmental factors like disease, drought, and erosion, farmers have responded, in many cases, by changing their cropping patterns. This may be interpreted as a coping mechanism. A recurring pattern in a number of the villages visited during the study was a reduction in the cultivation of cash crops like Irish potatoes and coffee in order to concentrate all available labour on the production of the main subsistence crops like sweet potatoes and cassava. With respect to specific crops the following observations have been made.

In Gwanda, the response to declining banana cultivation has been an increased emphasis on producing the two secondary starch sources, cassava and sweet potatoes, and to a lesser degree on yams and sorghum (the latter being used for beer brewing and thus providing a source of cash income for some households). These crops, apart from being less labour demanding, are more easily stored than bananas; neither is particularly prone to disease infestation at present. However, there are indications of an increasing incidence of cassava mosaic when new cultivars have been introduced by farmers in an effort to arrive at a suitable combination of storage potential, early and late varieties, and palatability of this new staple. What appears to be occurring in Gwanda is a transition from a banana-based farming system to a cassava-based system. This may be considered a period of experimentation and forms part of the epidemic-impact coping process.

Bananas. In both Nakyerira and Gwanda, bananas have been grown for a long time. Traditionally, their production benefitted from better climatic conditions and more available manpower to tend the banana trees. Under careful management, these savoury green bananas, matooke were the staple food of the communities. However, in Nakyerira, adverse climatic conditions (especially the droughts in 1988 and 1991), poor soils, requiring intensive labour for tillage, mulching and pruning, the addition of manure or fertilizers and for the control of weevils, reduced the supply of household labour (due to migration and death), of casual labourers and the increased incidence of crop pests, especially banana weevils, have all contributed to declining banana yields.

Box 6: Case study 5 (Gwanda community, Uganda)

This story illustrates how the break up of a household due to AIDS related sickness and death changed the structure of the household's crop and livestock production

Formerly a family with ten children, the husband and wife owned half a hectare of land on which a new house had been built. The husband, the first to die of AIDS in 1991, had been a successful small trader at a nearby fishing village. Originally the family owned five cows, a banana plantation and had borrowed some additional land. The wife, before contracting AIDS herself in 1992, had made and sold handicrafts to pay her children's school fees and had even gone so far as to operate a craft shop out of her living room.

With the deaths of first the husband and then his wife, the banana plantation went progressively to weed. On the borrowed land some cassava, sweet potatoes and groundnuts were planted. However, during the wife's sickness both the banana plantation which had been briefly intercropped with beans, and the borrowed land went to bush. All five of the family's cows died from a cattle disease because the children did not have the money to pay for veterinary drugs.

Late in 1992 the brother began to reclaim the overgrown plantation. He also started to raise pigs and chickens on the plot. While some of the original land is still being used productively, the family is completely dislocated and all the children depend on the goodwill of relatives some of whom are elderly and themselves suffering from illnesses. Now only two of the ten children live in their original home, the others have gone to stay with relatives.

In the 1960s, two hardy species of beer banana were introduced and widely adopted. These varieties require minimal labour for weeding and pruning. The bananas are very leafy and the fact that they are not pruned lessens the need for mulching. Beer bananas have consequently taken over from matooke and coffee, as the major cash crop.

Other forms of coping mechanisms adopted by farmers after the failure of bananas have included:

- Increasing the cultivation of cassava, maize and sweet potatoes to replace matooke as staple foods because they are better suited to the area especially if planted in time and properly managed; and
- The substitution of banana cultivation with livestock production.

In Gwanda, it was reported that historically, matooke was cultivated by all households together with a fall-back crop of cassava and/or sweet potatoes. Today, both the area cultivated and quality of the matooke produced have declined. The proper cultivation of the savoury banana requires adequate mulching. The mulch consists of surplus banana leaves and, in some cases, additional green matter gathered from swamps. Lower levels of care have meant that there is less leaf matter available from the bananas themselves. In addition, declining household incomes, resulting in part in reduced income opportunities and thus out-migration by the migrant labour population, have meant that this swamp mulch is no longer used.

The ficus tree was also a source of crop mulch as well as improving soil fertility. Ficus trees were planted in the banana groves for this purpose as well as being a source of bark for the traditional craft of bark-cloth making. As the tree takes four years to mature, people consider it a long-term investment which they could not expect to realise in view of their perceived lower life expectancy. Adequate de-suckering and pruning of the bananas is said to be less widely practiced for the same reason and also because these are labour demanding tasks.

Coffee. Prior to 1970 Nakyerira was an important coffee growing area. From 1960 to 1980 many people were able to improve their standard of living markedly through profits made from growing coffee. Some farmers believed it worthwhile to mulch carefully and to use fertilizers. At the same time, many such farmers earned enough and thought it worthwhile to employ labour to tend their coffee plantations. In some cases they also purchased land to increase the volume of production. Today, coffee has almost disappeared from the area, many farmers having given it up completely. The reasons for this are:

- frequent droughts;
- the poor marketing system and late payment;
- HIV/AIDS-related deaths; and
- competition for land between cash and food crops among farmers who have holdings of two acres or less.

In Gwanda increased intercropping of cassava, sweet potatoes and yams, along with some beans, in coffee plantations reflects a combination of the effects of land shortage on some households as well as labour shortages, low prices and poor marketing arrangements.

Maize. White maize is one of the staple crops which has replaced matooke in Nakyerira. Today, each household ensures it has a plot of maize, often inter-cropped with cassava and beans or groundnuts. Households which produce a surplus or are short of money also sell some of the maize they produce. A review of the case histories in the area indicates a decline in maize production over the last decade. Several factors account for this decline:

- inadequate labour supply resulting in poor and often delayed land preparation, late planting and weeding. In the more severely affected households, secondary tillage operations and weeding are simply abandoned;
- crop pests and diseases, especially the maize stalk borer and maize streak virus;
- the lack of extension service advice;
- the lack of capital inputs; and
- unreliable climatic conditions.

Cassava and sweet potatoes. These two crops are important in the agricultural production system. Together with maize, they are now two of the main food crops which have compensated for the decline in matooke. Almost all families in Nakyerira have their largest cultivated area under cassava (usually inter-cropped with maize and groundnuts or beans) followed by sweet potatoes. Under conditions of labour depletion associated with HIV/AIDS, even cassava and sweet potato production may now be abandoned by some households.

Relish crops. A popular relish for people in both Gwanda and Nakyerira is a sauce made of either beans or groundnuts. But there is now insufficient labour available for many households to be able to cultivate plots devoted to these crops. In Gwanda, beans are now more usually inter-cropped among bananas, and are eaten fresh rather than dried - another indication of a decline in food security in this community - average household production having declined to a level where there is insufficient surplus to store and certainly not enough to sell, both of which had been common practices in the past. There has been a similar decline in the cultivation of groundnuts. In the case of both crops, deaths of women together with epidemic-related pressures on women's time have contributed to the declining importance of what were traditionally women's crops.

Many farmers produce between two and ten sacks of unshelled groundnuts and about one sack of beans annually. These require considerable time and labour to shell and this is not readily available. Consequently such producers now receive lower prices for their produce from middlemen who can reap the value-added through their ability to employ processing labour.

Both crops are also vulnerable to disease - groundnuts to rosette and beans to occasional attack by blight. They are also sensitive to the timeliness of planting. Thus HIV/AIDS-associated morbidity and mortality affects production with fewer labourers available to carry out seed-bed preparation, timely planting, weeding and harvesting.

Irish potatoes. Although traditionally grown as a secondary crop and often inter-cropped within the banana plantations, Irish potatoes are now a major cash and food crop. As a quick maturing food crop, the potatoes often protect households against food shortages. Timely planting, proper seed-bed preparation and the selection of varieties that are drought and disease resistant are key considerations towards ensuring a good harvest. In some cases the crop has already suffered from the loss of labour due to HIV/AIDS with whole seasons being foregone due to the lack of labour.

Other produce. Many types of fruit trees and other minor crops were once more popular than they are at present in Nakyerira. On most farms such tree crops as mangoes, pineapples, avocadoes, passion fruit, pears and jackfruit may still be grown but they receive little care from householders since they are not considered part of the normal diet. In recent years these have either been abandoned or largely overlooked and are no longer regarded as everyday crops for cultivation.

Horticultural and root crops, especially vegetables like tomatoes, pumpkin, cabbage and egg plant used to be more widely planted than they are today. Few farmers continue to grow these vegetables owing to pests and plant diseases, especially fungal diseases, which attack tomatoes and cabbages. Fungicides are generally too expensive for poor farmers to afford.

Another reason for the low priority given to these crops may be that there is a lack of understanding by farmers about the importance of fruit and vegetables both as food and cash crops. At the same time, it may be perceived that the growing of these, ostensibly less important crops, entails competition for labour with other subsistence crops like maize, sweet potato and cassava.

3.4.4 The advantages of crop diversification

The example of Teta community in Zambia is also relevant since the diversity of this labour intensive system carries both benefits and trade-offs. In Teta there are four types of production system with most households employing at least three of the four cultivation types. These are:

- upland flat production of maize, millet, possibly sorghum and groundnuts;
- upland mount (or ridge) production of sweet potatoes, beans and cassava;
- citemene production of finger millet and pumpkins; and
- dambo cultivation of maize/beans, cucurbits and Irish potatoes.

The benefits of the Teta farming system derive from the use of residual moisture in dambos to plant food crops in September and the use of composting mounts to plant beans and cassava in March. This system means that the planting season lasts for seven months. This is in marked contrast to the situation in Mpongwe, where the planting period is only two-and-a-half months before the onset of rains (usually November to January).

The advantage of the lengthy planting season lies in the diversity of food crops it is possible to grow and the alternative sources of income so derived which make it possible to supplement income from maize alone. However, one trade-off is that less maize is grown. Maize, which is a main staple may also attract less labour during the weeding months of January and February, since people tend to be busy constructing mounds and planting sweet potatoes. As a result, in 1992-93 yields were slightly lower in Teta than amongst farmers in Mpongwe. Production outputs and sales were significantly lower amongst all types of farmer. But in compensation for the reduced maize and cash outputs, other food and cash crops were able to be substituted as alternative sources of income available to the farmers.

In terms of overall livelihood and food security, the gains of diversification have to be measured against the loss of opportunities to gain a single income from one major activity.

3.5 The impact on livestock production

3.5.1 Changes in livestock raising practices: coping mechanisms
3.5.2 The impact on pastoralists

In some of the communities which were studied, changes in livestock raising practices have occurred in recent years. The direct impact of the HIV/AIDS epidemic has been felt in several ways. Firstly, cattle are frequently sold to pay medical bills and funeral expenses. Secondly, both AIDS-related death and sickness result in decreases in labour availability, as already noted, further resulting in lower levels of livestock husbandry. In Uganda, partially as a result of the latter, there appears to be a parallel trend towards the keeping of smaller stock, most notably pigs and poultry, which are less labour demanding.

At the same time, there is evidence that some households in Nakyerira, which in the past concentrated on crop production, have begun to turn to livestock production as soils become infertile and previously widespread crop management practices have become difficult to follow or are completely abandoned.

In the same village, for example, more than 50 percent of households keep some cattle and about 30 percent breed pigs. About 80 percent of households were reported to be raising poultry. Goats and sheep are also kept by some farmers. In all cases only a very few animals are held, due to the shortage of land and the incidence of animal diseases. Farmers also recognise that in an area of poor soils, animal manure is an important input for crop production and yet they are restricted in the number of animals they can keep.

Cattle. In Nakyerira, cattle used to be predominantly in the hands of settlers who had migrated to work in the coffee and tea plantations. They started by keeping small herds (8 -15 cows per household) in the 1960s. Today, however, the herds are very small, perhaps 2 - 3 cows for each household. This change is attributed by the people to:

- land shortages and a reduction in farm size per farmer (from about 7.5 hectares in 1960 to an average of approximately 1.5 hectares today);
- an increase in the price of cattle arising out of the sudden realization that cow dung is important in restoring soil fertility to the banana plantations, as well as for other cattle products such as milk and ghee;
- expanded markets for meat in the rural and growing urban centres of Mityana and Kampala which have encouraged many farmers to sell off their large herds;
- diseases such as worms, East Coast Fever, Anaplasmosis, water-borne diseases and Nagana due to tse-tse flies;
- it was also observed that grazing was poorly managed. There was no rotational grazing using paddocks which might have improved the pasture and discouraged the build-up of disease and pests. Water supply, especially during periods of prolonged drought is another major problem requiring arduous labour for water carrying, work which is mainly performed by women.

Goats. Goat raising used to be an important activity in Nakyerira with a significant number of farmers keeping as many as 10 goats up to the early 1980s. Today, the herd size among those who still keep these animals has declined to 6-7 goats. Lack of grazing land and insufficient people look after the animals are given as the reasons for the decline.

Pigs. Pig husbandry became popular in the late 1960s. It expanded in the 1970s and 1980s when women began taking up the activity in response to the increased local market associated with local beer selling establishments and at which roasted pork and beer are sold together.

Poultry. In Nakyerira it was estimated that over 80 percent of households kept poultry. As with livestock, the numbers per household have declined in recent years due to diseases such as coccidiosis and chicken worm.

3.5.1 Changes in livestock raising practices: coping mechanisms

In Gwanda, it was observed that poultry numbers have increased in AlDS-afflicted households and especially in households with orphans. Previously, the free-range system of rearing chickens did not allow farmers to keep many birds at a time, because the banana plantations used to be properly mulched and the chicken would scratch the mulch and damage the beans grown in the plantation. This generated serious conflicts where a neighbour's banana plot was involved. Therefore most households owned only 3 - 5 chicken. Nowadays however, the banana plantations are no longer mulched due to labour constraints, and more chickens are able to forage in the plantations. It was noted that orphans, in particular, tended to keep chickens as a relatively easily available income source. The hens and eggs are usually not for home consumption; they are sold to raise some income, since the orphans' guardians are often too poor to buy the clothes and pay the school fees. Sometimes even the eggs are not sold, but reserved for hatching to produce more chicken.

However, the impact of AIDS has also had a negative side effect on poultry raising. Wild cats are the main predators for poultry. Their numbers are rising because a considerable number of banana plantations and fields have reverted to bush due to the high AIDS mortality in the community.

Pig rearing is another activity which has only been adopted recently in this community. It seemed to be especially attractive as an income-generating activity for widows. Pigs are not very labour demanding and the market price seems to be attractive. Since farmers tend gradually to substitute the production of matooke with cassava and sweet potatoes they soon have enough feed for I - 3 pigs. However, most farmers still lack marketing experience with pigs, pork or piglets.

Farmers, especially young men, also show a keen interest in taking up bee-keeping as a new income-generating activity. Honey, a nontraditional export product of Uganda, presently offers a good price.

One positive impact of the HIV/AIDS epidemic on livestock raising generally, according to the District Veterinary Officer in Rakai District in Uganda, is that farmers are becoming more open to innovations and have expressed an interest in dairy farming and cattle rearing using the "zero-grazing" method.

3.5.2 The impact on pastoralists

In Rakai, the Bahima, who are predominantly pastoralists, have close relationships with the settled farmers and have some traditions, such as the levirate, which are known to increase exposure to HIV/AIDS infection. Even before the HIV/AIDS epidemic, a high rate of tuberculosis was found in this community due to the consumption of unboilt, unboiled milk. This risk is increased insofar as the local Ankole cattle have been reported as very susceptible to bovine tuberculosis.

Among these pastoralists, there has been a tendency for herd sizes to become smaller. One of the reasons given was due to an outbreak of the disease, Contagious Bovine Pleuropneumonia. Another reason is due to HIV/AIDS. As with sedentary cattle keepers, people who fall sick sell their animals to pay for drugs and hospitalization. One example was cited in Rakai, of a farming household which had owned 15 cattle. When the parents fell sick and eventually died, five animals were sold. After the deaths of both parents, the children were forced to sell the remaining cattle, one by one in order to survive.

In Tanzania, due to the fact that the HIV/AIDS epidemic is only gradually being felt, while no specific data were available, it is believed that the situation among pastoralists of the Usangu plains in Mbeya rural district, is highly conducive to the spread of the disease. In the past, the nomadic Maasai were considered to be a closed society. However today, the Maasai mix freely with other ethnic groups as they roam through much of the country in search of pastures indeed, in the course of the research project some were seen in northern Zambia. Because of their relative wealth, as they own large herds of livestock and have been introduced to, and accepted the cash economy, the men frequently visit bars and patronise prostitutes.

The mixed population of the plains provides opportunities for the sharing of ideas and customs. For example, in the Usangu plains, there are five irrigation projects belonging to parastatal organisations. These projects employ a large number of workers, hence enhancing further contacts between the pastoralists and the settled population. The rice projects are close to major truck stops on the Dar Es Salaam - Zambia highway. According to local AIDS coordinators, Chimala is one of these settlements, Chimala has a high incidence of HIV/AIDS.

3.6 The impact on the agricultural extension services

In Rakai District in Uganda, HIV/AIDS is reported to have a marked impact on the local extension service. The District Agricultural Officer for Rakai noted that with regard to staff of the Extension Service, between 20 and 50 percent of all working time is lost due to the disease. Staff members were frequently absent from work attending funerals and caring for sick relatives. At the same time, a number of staff members at all levels had fallen sick and some had died. The problem was compounded by the fact that it is difficult to find trained people to replace former staff, both because the area is remote and also because it has the reputation of being a highly HIV/AIDS-affected area.

The epidemic had also made it more difficult for extension staff to meet the farmers. If a meeting coincides with a funeral, the meeting normally has to be rescheduled. In a community such as Gwanda where there were as many as 10 - 15 deaths a month such meetings with extensionists were thus difficult to organize.

It is also becoming apparent that, in some cases extension messages will have to be revised to take into account the impact of the disease on agricultural systems. For example, the European Union's Farming Systems Support Programme has been considering reviving coffee production and consequently promotes a high yielding, pest resistant and early maturing coffee variety. Despite the early maturity of the new variety (18 months) many young farmers do not appear interested in the crop, seeing it as a long term investment and fearing that they may fall sick or die before they reap any benefit from their investment.

3.7 The impact on the fisheries sector

In several communities where fishing constitutes an important primary or secondary activity, it appears that the sector provides a vital source of off-farm employment, in particular for rural youth. In Ndaiga village in Uganda's southern Iganga District, it was noted that for youth from fishing families, fishing is the main source of livelihood. Some of the fish is consumed or traded locally, through a cash or barter system with farmers, while the major portion is sold to local traders or exported further afield.

In both Gwanda and Ndaiga it was noted that young men preferred to work as fishermen than as farmers. In some cases this meant that young adults working away from their families remitted money back to their homes. In other cases, however, it appears that they actually deprived households of vital farm labour. This may have implications for particularly marginalized communities where incentives may be needed to encourage young adults to take on more term work. possibly through the provision of incentives.

One non-governmental organization (NGO), ActionAid in Mityana district in Uganda is reported to have had some success in persuading the youth in some sub-counties to become farmers. This was achieved partly by introducing them to the advantages of cultivating high-value crops.

3.8 HIV/AIDS and the loss of agricultural knowledge and management skills

3.8.1 The loss of other traditional skills
3.8.2 Loss of skills and the division of labour

Although more difficult to quantify, multiple references were made by respondents in the case studies to the loss of traditional knowledge and cultural practices. This was attributed in part to HIV/AIDS-related morbidity and mortality. When one or both parents die or are seriously ill, their skills may not be able to be transferred to their children or other relatives. This may have far-reaching implications in terms of the continuity of agricultural and livestock production as well as for other areas of life (such as craft production) which depend on the continuity of skills and knowledge.

In Eastern Africa, where growing coffee and bananas has been a traditional feature of the farming system, cultural practices associated with coffee and banana tree cultivation may be essential to ensure the system's survival.

As observed earlier in this chapter, the correct mulching, weeding and pruning of plantations is a fair guarantee of reasonable yields. However, in areas where there is a high incidence of HIV/AIDS, plots have become neglected or abandoned, with yields proving correspondingly poor as a result of some or all of the following: insufficient labour to carry out the work; inadequate understanding of the correct agricultural practices; and lack of knowledge about marketing aspects. In several Ugandan villages studied, many successful farmers with a variety of skills had died of AIDS and this had often led to the neglect of crops and livestock, as their surviving relatives have lacked sufficient knowledge of the correct farming practices.

In several Ugandan villages surveyed, many successful farmers, with a variety of skills had died of AIDS and this has often led to the neglect of crops and livestock, as their surviving relatives have lacked sufficient knowledge of the correct farming practices.

In one case study, a group of older men reported that a number of nutritious crops that used to be grown in the past, including certain exotic bean varieties have now been abandoned, mainly because they would require surplus labour which is not available. Groundnut production which used to be the pride and source of income of many households is also declining as middle-aged women, combining strength and knowledge for the preparation of fields; timing of ploughing, planting, weeding, and pest control, are dying, and not being replaced by younger women (among whom the number of deaths is even higher). Added to this, the changing emphasis on the production of foodstuffs, which were formerly regarded as produce of last resort, notably cassava and sweet potatoes, at the expense of other crops is leading to the loss of skills in such areas as banana weevil control, mulching, pruning and the control of stinging insects in coffee shambas.

Evidence that knowledge of cultivation techniques and cultivars is in danger of being lost, particularly among children of families in which one or both parents had died of AIDS, is available from a consideration of new coping strategies. For example, in some cases the local community was reputedly responding to orphaning by neighbours and family members specifically undertaking the agricultural training of orphaned children. Local groups were also beginning to undertake this work, especially women's groups. These might well provide a basis for future development of agricultural training among the young and in particular among those who have been orphaned. This would have a dual effect, notably it would allow for the preservation of local knowledge, while providing activities for rural youths who might otherwise be unemployed.

One example of loss of knowledge is the decline of cattle husbandry in Gwanda. Even if the cattle are not sold during the sickness or after the death of a household member, the remaining family often does not have the management skills and knowledge to care for livestock. This was observed in cases where the head of household, usually the man, died. The wife and the children did not have the time, the knowledge or the financial resources to care adequately for the cattle. The wife often did not have the same access to extension services and other ways of acquiring knowledge as her late husband. Therefore numerous cases were found in the studied communities where cattle had died soon after the death of the head of household.

3.8.1 The loss of other traditional skills

In communities like that of Gwanda where there has been a high incidence of HIV/AIDS, there is also evidence of the loss of knowledge of traditional crafts and skills. While some 5 - 10 percent of the houses in the community were built out of stone, mud and cement, the technique of stone laying has all but disappeared for a number of reasons. These included: the fact that the artisans who knew this skill have died and have not been replaced by younger men; the wealthier farmers and traders who used to provide a market for such building skills have either died of AIDS or are unwilling to invest in such costly ventures knowing that sooner, rather than later, they may be faced with dependent grand-children and other relatives to look after. And finally, apart from skills, such work requires a lot of cheap human labour, and the available labour is, of course, now insufficient for the activity (considering that many have died of AIDS and others are engaged in activities such as trading or fishing).

The demise of the indigenous art of bark cloth making in the community, represents yet another example of how AIDS is leading to the loss of a basic local skill. In a focus group discussion with elderly men in Gwanda, and at a community self appraisal exercise, it was pointed out that now - as opposed to in the past - bark cloth making was strictly the domain of older men, and despite increasing prices for this product.

Two explanations were offered for this phenomenon. First, young men are unwilling to plant the ficus trees, the source of the bark, fearing that they might die before the trees mature. Second, such youths now prefer fishing and trading to bark cloth making. While it is the case that even in the past the men who took-up the profession were mainly middle-aged, since a significant proportion of these have died due to AIDS, it is not surprising that there are few younger people taking up this occupation even though it is perhaps more rewarding than in the past. Thus it appears that some local crafts, like bark cloth making, may be disappearing in the absence of a link between the older and younger generations.

An important finding from all three countries is the significance that the loss of male household members has for the management of the household economy, and for the marketing of agricultural produce. With respect to this last, the deaths of men who were conversant with marketing, has meant that many households have had to rely on selling their produce to unscrupulous middlemen. These middlemen exploit the farmers. In so doing, farmers frequently become demoralized, sometimes to the extent that they have abandoned farming as unprofitable.

In Gwanda, there has traditionally been a marked gender division of labour, between crops, agricultural tasks and above all between domestic and other work. This has significant implications for the way in which the epidemic affects the lives of women. Most women are overburdened with housework, taking care of babies and now, in many cases, orphaned children, collecting firewood and fetching water. School children contribute little in terms of labour since most are away at school all day.

The women complained that they have to walk long distances to collect water and firewood and that it took about two hours just to fetch water, while the collection of firewood took even longer. These tasks greatly reduce the time women have to participate in agricultural activities. When a household is then confronted with the additional burden of caring for the sick, for members of related families, in mourning ceremonies, women are faced with major problems of managing their own labour and that of others in the household. It is important to note that it is not only the additional tasks which take up their time (and energy), it is also the increased management demands of the household and farm which require additional thought, worry and effort.

In addition to this problem, it is also knowledge of domestic and farm management skills, as well as the skills themselves which are threatened by the loss of mature women from the community. In Uganda, it was found that more women aged between 13 and 44 died in a two-year study period than men. Since it is the women in this age group who are primarily engaged in full-time agricultural production throughout most of the country, the rapid progression to death of this group allows little time for adjustment and coping in the household's farming practices. This inevitably has serious consequences for the affected households.

In Gwanda, the study has already noted that the rural farming system was in a stage of transition from a banana-based system to one composed primarily of what were once considered secondary crops such as cassava. Cassava, like sweet potato and to a lesser degree yam and sorghum, used to be produced by women rather than by men. Some men who have lost their wives, and who are unfamiliar with the crop varieties and cultivation methods, have found it hard to take over the cultivation of these crops. However, it was also observed in all three countries, that widowers usually remarry fairly quickly and therefore solve the problem in that way.

In Teta community, in Zambia, there are significant differences in the role and position of women within the diversified farming system, as compared, for example, with the maize-based system in Mpongwe District. In an analysis of labour and labour management in one area of Mpongwe, it was shown that the more food secure households are those in which both husband and wife are involved in agricultural production, and among these, the most efficient were those households where men were organising timely ploughing arrangements, either through tractor or oxen hire, or through labour-zpooling arrangements. This situation is due to the necessity of planting as large an area of maize as possible to ensure a surplus, and the fact that maize tends to be a crop controlled by men - since they have greater access to credit and usually control the marketing arrangements.

In Teta the situation is different. The area planted to maize and other crops grown in ploughed fields is much smaller than in Mpongwe. It is therefore easier for women themselves to manage this operation, and even to hire oxen to cultivate this smaller area. The diversity in the production system thus also gives women more independence. Dambo cultivation of local maize and beans are largely women's activities; it is only with the advent of Irish potatoes, that women have become involved with the techniques of wetland production.

3.9 Coping mechanisms: the role of NGOs and self-help groups

Given the fact that deaths from AIDS and other diseases are affecting the transfer of skills and knowledge in East African farming systems, certain coping strategies are emerging which may help to counteract the negative effects of these impacts.

At the level of the farming system, coping responses have already been touched upon. What needs to be emphasised is that these responses are not uniform and that there is a clear gradient in ability to cope in relation to the wealth of a particular household.

At the level of the community as a whole, the most important response has been the formation of self-help groups, some spontaneous and some under the aegis of an NGO. This is in itself an important development in some societies, particularly in southern Uganda, where inter-household cooperation has not been the norm. It suggests that here the traditional response may provide a firm base for future efforts to cope not only with the impact of the epidemic, but also with the wider problems of low incomes and poverty which form the background to that impact.

However, it should also be noted that in some cases the impact of the epidemic has been so severe that the limits of traditional cooperative resilience and response have now been reached and exceeded. In such circumstances, the supporting role of NGOs may be crucial in working to provide advice to farmers and extension staff in animal and crop husbandry practices. Agencies currently working in this way include, ActionAid, InterAid and World Vision International, whose activities are described below. Already, and often with the assistance of NGOs, special interest and other self-help groups have come into being with members pooling their knowledge and giving each other confidence in undertaking on-farm as well as income-generating activities.

In Gwanda, for example, World Vision International has encouraged the formation of small self-help groups primarily engaged in agriculture and handicraft making. The NGO has been instrumental in providing vocational training for groups in the field of carpentry, tailoring and construction. These are aside from the NGO's other activities like providing complete packages of school assistance to orphaned children and giving counselling and care to AIDS patients.

Box 7: Self-help group 1. Kayunga United

Gwanda Community

Kayunga United started operating in March 1992 and was aimed at improving the morale of unemployed youths by encouraging them to grow cassava cooperatively. The 1 2-member group has since offered considerable assistance to orphans, widows and the needy including house construction and repair as well as offering food.:

Recently, World Vision International gave them a donation of hoes, herbicides, pesticides and vegetable seeds. Training has been given to the group in bee-keeping and they are also expecting to receive/modern bee hives from the NGO.

In addition, the group has benefitted from the technical training sponsored and offered by World Vision International.

Action Aid is also highly active in Uganda mainly in the district of Mubende. Under its General Community Support Programme the NGO has built schools, assisted farmers in agricultural production through the provision of inputs, and through assistance to the health sector, by means of an immunization and treatment programme. Other activities have included: awareness and sensitization programmes; assistance with farm-management; and assistance in improving animal husbandry practices. In the past, farmers would only be interested in owning large herds of cattle, irrespective of how they were looked after. Recently, many farmers are adopting the practice of improved animal husbandry incorporating tick control, farm fencing and supplementary feeding of cattle. The result has been improved milk production and increased farm incomes which are reflected in a higher standard of living of farmers to the extent that households have graduated from grass thatched houses to houses roofed with iron sheets; finally, the area under various crops has increased, for example some young people are forming cooperative farming groups and are now able to cultivate large areas.

However, AIDS is likely to affect the progress of the NGO's work in the community. Some youths have already died and many are infected. Those that are sick are unable to work effectively. Once they die, their activities are not usually taken up by survivors who are often their elderly parents or younger siblings. In some of the more affected areas, ActionAid is launching an anti-AIDS campaign through such measures as video shows, condom supply and demonstration, as well as the care of AIDS patients.

As a result of increased deaths due to AIDS, the number of orphans has risen in the area. ActionAid is now supporting local group efforts to care for these orphans.

Box 8: Self-help Group 2. Agaliawamu (Unity is strength)

Gwanda community

Agaliawamu is regarded as one of the most successful groups. It was started in 1992 for school girls to provide them with basic training in tailoring and farming. By 1993, 10 members had graduated in skills development. The group is currently also helping to look after the sick.

Agaliawamu was given a donation of US $17.00 to buy handicraft materials, and assistance in purchasing the materials. The group has also received pesticides, fungicides, vegetable seeds, implements and technical training in nursery-bed preparation from World Vision International. It is, nevertheless, experiencing similar problems as Abagalanyi, see above, i.e. a shortage of agricultural inputs especially tools and equipment and proper marketing awareness for their products.

3.10 The personal and community trauma of HIV/AIDS

In a heavily affected community such as Gwanda, the social impact of HIV-AIDS on the population has been enormous. Gwanda was one of the first communities in that country to experience the HIV-AIDS pandemic. Since little was known about the disease when it struck, few if any precautions were taken with the result that the community lost many able-bodied people, young men, women and young children. Almost every household in Gwanda is HIV-affected, afflicted or both. A walk round the community provides adequate evidence of the impact. The presence in almost every homestead of graves of people who have died of AIDS, and the incidence of AIDS-related sickness in many households bear witness to the widespread trauma. As a result, many aspects of social life and behaviour have been affected and most of the women's and youth groups are concerned with providing assistance to widows and orphans.

Given the above, it is even more surprising that many of the youth in the most afflicted communities continue to have indiscriminate sex; even having sex with widows and widowers of people who are widely known to have died of AIDS, according to discussions held with groups of local villagers. This behaviour is attributed to the fatalistic attitude most youths have towards the epidemic generally. Many of them believe that they are already infected and consequently see no reason why they should not have normal sexual lives and maximise their pleasures before they die. This may also have something to do with the nature of life in many rural areas. For example, in the Mpongwe area of Zambia where local people reported that pre-marital sex was very common, it was simultaneously pointed out that in rural areas such as these, there is no entertainment, as such, apart from beer and sexual relations.

By contrast, discussions with several groups of teenage girls in Gwanda revealed that the girls are truly frightened of contracting AIDS. Many of them believe that one can only be safe through sexual abstinence. The girls lamented that it is material poverty which compels them into early marriages or to have premarital sex. They claimed that if they had financial support, mainly in the form of access to income-earning activities, they would abstain from premarital sex and early marriages to much older men, both of which increase their exposure to infection. Widows in the same community likewise believed that if they were given financial support, they would abstain from sex or avoid remarrying and therefore stop the spread of the disease.

Nonetheless, village group discussions and individual interviews also made it clear that many adults in Gwanda have, in fact, significantly changed their social and sexual behaviour. Most were said to have stopped indulging in indiscriminate sexual intercourse preferring to remain with their spouses. At the same time, the groups also reported that many families are additionally burdened with the responsibilities of fostering orphans of their deceased relatives and the only way of fulfilling this responsibility was to stay alive (i.e. by avoiding HIV-infection).

In general, the extended family system is still said to be strong. As in all societies in Uganda, however, this system is being undermined by social change. Associated increased individualism has had implications for the fostering of orphans in the AIDS-afflicted communities. In several AIDS-affected and afflicted households in Gwanda, the extended family system has been further over-burdened with the problem of large numbers of orphans and many surviving households have found it increasingly difficult to cope. This situation is being alleviated by some NGOs like World Vision and InterAid which are paying school fees for the orphans in addition to providing them with clothing, blankets and a few other basic commodities like agricultural implements, and water containers.

In Zambia, the social impact of the disease is also observable. On the one hand, in the case of divorce which seems to be a growing phenomenon in a number of the villages studied, a mother moves back to the village of her own mother, usually with most or all of her children. In the event of death of the mother, it is possible that the children will be subsequently split up and sent to different relatives.

Box 9: Self-help group 3. Abagalanyi (Those who love each other)

Gwanda community

This women's group was formed early in 1993 with an initial membership of 75 persons, although currently it has only 11 active members. The group's aim is to improve the standard of living of women in the community and to take care of orphaned children as well as the sick by giving them emotional support and providing them with the basic necessities.

The group undertakes communal farming and meets at least twice a week. Having secured a piece of land, members are growing tomatoes and potatoes which they hope to sell and thereby: generate sufficient income to enable them to expand their operations. The women also meet to discuss e problems encountered and to mane plans :for the week ahead

The group has plans for extending the farm and starting up handicraft production with the aim of making and selling mats and baskets. The group has also benefitted from training in bee keeping with World Vision International providing the members with beehives. In addition, the NGO has also provided the group with vegetables seeds as well as pesticides and fungicides. At present the group: faces a number of problems, the most crucial being a lack of agricultural tools. Another problem is in the marketing of produce. The women are worried about middlemen who usually travel to rural areas and exploit farmers by offering them abnormally low prices. Considering the perishability of the vegetables they produce, the women are certainly vulnerable to exploitation. This is particularly unfortunate given that :these women already require as much assistance as possible in order to be able to assist orphans and the sick.

In one village in Zambia, a woman farmer complained that her production had deteriorated because she had been nursing one of her daughters who eventually died from HIV/AIDS. Apart from the time spent in caring for her sick daughter, the emotional cost of seeing her children decline, having to care for them but being helpless to arrest the progress of the disease, must also be taken into account. Since 1990, of this particular woman's three daughters, two had died from HIV/AIDS, as did a daughter-in-law. Another farmer, a former council worker, from Teta in Zambia is another example of the emotional cost of the disease having been high. The farmer's daughter died in 1991 after he and his wife had nursed her for some time, and in 1993. just before the interview another daughter had committed suicide, inexplicably.

HIV and AIDS in South Africa

2009-12-17T07:38:00.001-08:00

The statistics discussed here come from two prevalence studies that estimate how many people are living with HIV in South Africa, and two reports on AIDS deaths. Viewed together these sources give an idea of the scale of South Africa's HIV epidemic. If you are looking for statistics from elsewhere, try our statistics section.

The first section is based on the report of the Department of Health "National HIV and Syphilis Sero-prevalence Survey in South Africa 2007", published in 2008. This annual study looks at data from antenatal clinics and uses it to estimate HIV prevalence amongst pregnant women.

The second section is based on the report of the "South African National HIV Prevalence, HIV Incidence, Behaviour and Communication Survey, 2008". In this survey, a sample of people were chosen to represent the general population. Of those who were eligible, 64% agreed to give a blood sample to be anonymously tested for HIV. The report contains estimates of HIV prevalence in various groups of people, derived from this general population sample.

Seen together, the two prevalence studies provide a clearer picture of the South African epidemic than either of them viewed alone.

The third section looks at AIDS-related deaths using data from death certificates. Reports published by Statistics South Africa contain the raw data, while the article "Identifying deaths from AIDS in South Africa" analyses a large sample of death certificates and attempts to estimate how many deaths caused by HIV have been misclassified.

The page goes on to compare the two types of prevalence study and to draw conclusions.
The South African Department of Health Study, 2007

Based on its sample of 33,488 women attending 1,415 antenatal clinics across all nine provinces, the South African Department of Health Study estimates that 28% of pregnant women were living with HIV in 2007. The provinces that recorded the highest HIV rates were KwaZulu-Natal, Mpumalanga and Free State. The Northern Cape and Western Cape recorded the lowest prevalence.

Until 1998 South Africa had one of the fastest expanding epidemics in the world, but HIV prevalence now appears to have stabilized, and may even be declining slightly. Among teenage girls, the rate fell from 16.1% in 2004 to 12.9% in 2007, possibly indicating a drop in the rate of new infections. The health department believes this is due to a change in safer sexual practices among younger women. The inability to moderate cultural circumstances is believed to be a factor in the high and rising HIV prevalence among relatively older women.

More historical prevalence figures can be found in our AIDS in South Africa page.
Estimated HIV prevalence among antenatal clinic attendees, by province
Province 2001 prevalence % 2002 prevalence % 2003 prevalence % 2004 prevalence % 2005 prevalence % 2006 prevalence % 2007 prevalence %
KwaZulu-Natal 33.5 36.5 37.5 40.7 39.1 39.1 37.4
Mpumalanga 29.2 28.6 32.6 30.8 34.8 32.1 32.0
Free State 30.1 28.8 30.1 29.5 30.3 31.1 33.5
Gauteng 29.8 31.6 29.6 33.1 32.4 30.8 30.3
North West 25.2 26.2 29.9 26.7 31.8 29.0 29.0
Eastern Cape 21.7 23.6 27.1 28.0 29.5 28.6 26.0
Limpopo 14.5 15.6 17.5 19.3 21.5 20.6 18.5
Northern Cape 15.9 15.1 16.7 17.6 18.5 15.6 16.1
Western Cape 8.6 12.4 13.1 15.4 15.7 15.1 12.6
National 24.8 26.5 27.9 29.5 30.2 29.1 28.0
Estimated HIV prevalence among antenatal clinic attendees, by age
Age group (years) 2001 prevalence % 2002 prevalence % 2003 prevalence % 2004 prevalence % 2005 prevalence % 2006 prevalence % 2007 prevalence %
<20 15.4 14.8 15.8 16.1 15.9 13.7 12.9
20-24 28.4 29.1 30.3 30.8 30.6 28.0 28.1
25-29 31.4 34.5 35.4 38.5 39.5 38.7 37.9
30-34 25.6 29.5 30.9 34.4 36.4 37.0 40.2
35-39 19.3 19.8 23.4 24.5 28.0 29.6 33.2
40+ 9.8 17.2 15.8 17.5 19.8 21.3 21.5

Because infection rates vary between different groups of people, the findings from antenatal clinics cannot be applied directly to men, newborn babies and children. This is why South Africa has sought also to survey the general population.
The South African National HIV Survey, 2008

The National HIV Survey is a "household" survey. This involves sampling a proportional cross-section of society, including a large number of people from each geographical, racial and other social group. The researchers take great pains to try to make the sample as representative as possible, and the findings are later adjusted to correct for likely over- or under-representation of individual groups (according to census data).

The survey's fieldworkers visited 15,000 households across South Africa, of which 13,440 (90%) took part in the survey. Of the 23,369 people within these households who were eligible to take part, 20,826 (89%) completed an interview and 15,851 (64%) agreed to take an HIV test.

Based on this survey, the researchers estimate that 10.9% of all South Africans over 2 years old were living with HIV in 2008. In 2002 and 2005, this figure was 11.4% and 10.8%, respectively, showing a degree of stabilisation. Among those between 15 and 49 years old, the estimated HIV prevalence was 16.9% in 2008. The survey found the prevalence among children aged 2-14 to be 2.5%, down significantly since 2002, when prevalence was 5.6%.
Estimated HIV prevalence (%) among South Africans aged 2 years and older, by age, 2002-2008
Age 2002 2005 2008
Children (2-14 years)
5.6 3.3 2.5
Youth (15-24 years)
9.3 10.3
8.7
Adults (25 and older)
15.5 15.6
16.8
15-49 year olds
15.6 16.92
16.9
Total (2 and older)
11.4 10.8
10.9
Estimated HIV prevalence among South Africans, by age and sex, 2008
Age
Male prevalence % Female prevalence %
2-14 3.0
2.0
15-19 2.5
6.7
20-24 5.1 21.1
25-29 15.7 32.7
30-34
25.8
29.1
35-39
18.5
24.8
40-44
19.2 16.3
45-49
6.4
14.1
50-54
10.4
10.2
55-59
6.2
7.7
60+
3.5
1.8
Total 7.9 13.6

Among females, HIV prevalence is highest in those between 25 and 29 years old; among males, the peak is in the group aged 30-34 years.
HIV prevalence (%) by province 2002-2008
Province 2002 2005 2008
KwaZulu-Natal 11.7 16.5
15.8
Mpumalanga 14.1 15.2
15.4
Free State 14.9 12.6
12.6
North West 10.3 10.9 11.3
Gauteng 14.7 10.8
10.3
Eastern Cape 6.6 8.9
9.0
Limpopo 9.8 8.0
8.8
Northern Cape 8.4 5.4
5.9
Western Cape 10.7 1.9
3.8
National
11.4 10.8 10.9

The results of this study suggest that KwaZulu-Natal, Mpumulanga and Free State have the highest HIV prevalence. However, the relatively small sample sizes may limit precision, and in several cases the ranges of uncertainty overlap.
HIV prevalence by population group, 2008
Population group Prevalence (%)
African 13.6
White 0.3
Coloured 1.7
Indian 0.3
Studies of AIDS deaths
All reported deaths

In October 2008, Statistics South Africa published the report "Mortality and causes of death in South Africa, 2006". This large document contains tables of how many people died from each cause according to death notification forms.

The report reveals that the annual number of registered deaths rose by a massive 91% between 1997 and 2006. Among those aged 25-49 years, the rise was 170% in the same nine-year period. Part of the overall increase is due to population growth. However, this does not explain the disproportionate rise in deaths among people aged 25 to 49 years. In 1997, this age group accounted for 29% of all deaths, but in 2006 it accounted for 42%.
Reported deaths from all causes, 1997 to 2006
Year of death Age (years) Total
0-9 10-24 25-49 50+ Unspecified
1997 35,441 22,639 92,829 160,076 5,574 316,559
1998 41,172 25,808 114,249 178,776 5,104 365,109
1999 41,835 27,690 129,916 178,892 2,704 381,037
2000 42,843 29,583 150,562 189,566 2,214 414,768
2001 44,902 31,452 173,226 202,009 1,920 453,509
2002 50,767 34,439 201,153 211,693 1,928 500,082
2003 56,708 37,499 229,418 227,778 2,796 554,199
2004 62,898 38,405 244,129 224,115 3,073 572,620
2005 67,715 38,389 250,897 233,101 3,235 593,337
2006 68,292 39,003 251,067 245,963 1,155 605,480
Increase 1997-2006 93% 72% 170% 54% -79% 91%

The influence of population growth can be removed by looking at death rates per 100,000 people, which are provided by Statistics South Africa in another report called "Adult mortality (age 15-64) based on death notification data in South Africa: 1997-2004". These data show that between 1997 and 2004, the death rate among men aged 30-39 more than doubled, while that among women aged 25-34 more than quadrupled. The changes are even more pronounced when deaths from natural causes only are examined. Over the same period there was relatively little change in the death rates among people aged over 55 and those aged 15-20. In their report, Statistics South Africa call such developments "astounding", "alarming" and "disturbing".
Misclassification

In 2006, HIV was recorded as a cause of death in only 14,783 cases. However, according to researchers from the Medical Research Council of South Africa (MRC), this figure is a massive underestimate, because the majority of deaths due to HIV are misclassified.

People whose deaths are caused by HIV are not killed by the virus alone, but HIV should be recorded as an underlying cause if it "initiated the chain of morbid events leading directly to death". In other words, if someone contracts tuberculosis and dies from it because their immune system has been weakened by HIV then HIV should be included among the underlying causes. The MRC researchers claim that in many cases, this does not happen; instead, the doctor records only the immediate cause of death such as tuberculosis or respiratory infection. This could be because the doctor does not know the deceased person's HIV status. Alternatively, they may seek to conceal HIV infection to spare stigmatisation of relatives, or to avoid invalidating life insurance claims. As The Lancet notes, authorities are largely to blame:

“Social stigma associated with HIV/AIDS, tacitly perpetuated by the Government's reluctance to bring the crisis into the open and face it head on, prevents many from speaking out about the causes of illness and deaths of loved ones and leads doctors to record uncontroversial diagnoses on death certificates.... The South African Government needs to stop being defensive and show backbone and courage to acknowledge and seriously tackle the HIV/AIDS crisis of its people.”1

The MRC team analysed a 12% sample of death certificate data from the year 2000-2001, and compared it to all the data from 1996. When they looked at deaths for which HIV was a reported cause, they saw that rates (deaths per thousand) had increased according to a distinctive age-specific pattern. The greatest increases were in the age groups 0-4 and 25-49 years, while death rates among teenagers and older people remained more or less unchanged.

The researchers observed that nine other causes of death had increased substantially according to the same distinct age pattern as HIV. They then estimated how much of the increases were likely to be caused by HIV, and concluded that 61% of deaths related to HIV had been wrongly attributed to other causes in 2000-2001. In adults, tuberculosis accounted for 43% of misclassified deaths, and lower respiratory infections for another 32%. Among infants, most of the excess deaths had been misclassified as lower respiratory diseases or diarrhoeal diseases. According to the MRC results, HIV caused the deaths of 53,185 men aged 15-59 years, 59,445 women aged 15-59 years, and 40,727 children under 5 years old in the year 2000-2001.

The MRC estimates come very close to those made by a computer model of the Actuarial Society of South Africa, called ASSA2003. According to ASSA2003 calculations, HIV caused 108,170 deaths in 2000 and 147,525 deaths in 2001.

Statistics South Africa have analysed the MRC study and found that its methods and conclusions are generally sound.
Other recent estimates

The head of the MRC has stated that AIDS killed around 336,000 South Africans between mid-2005 and mid-2006.2

The ASSA2003 provincial model calculates that 345,640 people died because of AIDS in 2006 - comprising 47% of all deaths. Among adults aged 15-49 years, it estimates that 71% of all deaths were due to AIDS.3

UNAIDS/WHO estimate that AIDS claimed 350,000 lives in 2007 - nearly 1,000 every day.4
Comparing the prevalence studies

It is possible to compare the results of the National HIV Survey 2008 with those of the Department of Health Study 2005.

HIV prevalence according to the Department of Health Study 2005:

* 29.1-31.2% amongst antenatal clinic attendees (30.2% is the best estimate)

HIV prevalence according to the National HIV Survey 2008:

* 10.0-11.9% in the whole population (10.9% is the best estimate)
* 15.5-18.4% amongst all people aged 15-49 years old (16.9% is the best estimate).

The rates found among pregnant women are significantly higher that those found among all adults - so why could this be?
Limitations of the Department of Health Study

Antenatal surveillance is internationally recognised as the most useful way of assessing HIV prevalence in countries with generalised epidemics. Pregnant women are sexually active and constitute an easily identifiable, accessible and stable population. They are more likely than any other single group to be representative of the general adult population. Nevertheless, there are a number of limitations to the Department of Health's technique.

The greatest difference between the two studies concerns prevalence among women aged 15-19 years old, for which the antenatal survey produces a rate much higher than the household survey (15.9% compared to 9.4%). This is, at least in part, probably because not all young women are sexually active, and those represented in the antenatal data are by definition engaging in unprotected sex, which puts them at higher risk of HIV infection. Overestimation of HIV prevalence in this age group is a known bias in antenatal studies.

It is possible that overestimation occurs in older age groups as well, particularly as those who use condoms or abstain from sex stand less chance of both HIV infection and pregnancy. On the other hand, underestimation might also occur: for example, studies have shown that HIV lowers fertility.
Limitations of the National HIV Survey

The advantage of the National HIV Survey is that it can give a better idea of HIV prevalence levels among men, children and non-sexually active women. The survey also recorded a vast amount of other data besides the age and location of respondents (most of which is beyond the scope of this page), including information on race, wealth and education. Participants were also interviewed about factors that might influence their risk of HIV infection, such as behaviour, knowledge and risk awareness.

Although the study attempted to survey as representative a population sample as possible, it recognises that some groups were excluded. Only people living in homes or hostels were contacted, so there was no representation of homeless people and those living in police and army barracks, prisons, hospitals and educational institutions. This probably resulted in underestimation of some prevalence figures. Additionally, by excluding all children below 2 years of age (because they cannot be reliably tested for HIV using antibody tests), the survey missed a significant proportion of children who acquired HIV from their mothers. The survey's design also meant some groups that may be of particular interest for the understanding of the epidemic could not be captured in sufficient numbers, including men who have sex with men, injecting drug users and sex workers.

The survey had also had a fairly high rate of non-response with just 64% of all eligible participants agreeing to an HIV test. The effect of non-response on accuracy is uncertain. It is difficult to conclude whether those who refuse to be tested are more or less likely to have HIV. The only certain effect of the low response rate is that it increases uncertainty.5

The National HIV Survey is the the third of its kind to be conducted across the whole of South Africa.
Conclusion of the comparison

Neither prevalence study sets out to mislead or to contradict the other. Each uses a standard surveillance technique and clearly explains all of its methods and calculations. Most of the observed differences are the result of choosing different groups of people to be tested, since these groups differ in how well they are able to represent the general population.

In such a large and diverse country as South Africa, no-one can know exactly what the true figures are. What is essential is that the limitations of each study are acknowledged whenever their results are interpreted. To illustrate why this is so important, this page has suggested a few reasons why the figures might vary, though this is by no means an exhaustive list.

UNAIDS and WHO recommend that antenatal and population-based studies should both be conducted at regular intervals. In countries with generalised epidemics, antenatal clinic attendees are thought to represent the adult population with good accuracy. Moreover, when conducted regularly such surveys can reveal long-term trends in prevalence. On the other hand, household surveys tell us more about the nature of the epidemic by providing prevalence data according to gender, race, wealth and other characteristics. Such information informs better interpretation of antenatal data.
National estimates based on all surveys

Based on a wide range of data, including the household and antenatal studies, UNAIDS/WHO in July 2008 published an estimate of 18.1% prevalence in those aged 15-49 years old at the end of 2007. Their high and low estimates are 15.4% and 20.9% respectively. According to their own estimate of total population (which is another contentious issue), this implies that around 5.7 million South Africans were living with HIV at the end of 2007, including 280,000 children under 15 years old.6

The ASSA2003 model produces a similar estimate of 5.4 million people living with HIV in mid-2006, or around 11% of the total population. It predicts that the number will exceed 6 million by 2015, by which time around 5.4 million South Africans will have died of AIDS.7
Conclusion

What is clear from every study is that there is an exceptionally severe epidemic of HIV/AIDS in South Africa. This epidemic affects all parts of the population, though women are more likely to be infected than men. Many tens of thousands of people are dying.

For South Africa there are tremendous challenges remaining in the fields of HIV education, prevention and care. To read more about what has already happened and what is being done now, take a look at the page HIV & AIDS in South Africa.

HIV & AIDS in Botswana

2009-12-17T07:37:00.003-08:00

Botswana has been hard hit by AIDS. In 2007 there were an estimated 300,000 people living with HIV - almost one-in-four adults. Considering Botswana’s population is below two million, the epidemic has reached disturbing proportions. The country has an estimated adult HIV prevalence of 23.9%, the second highest in the world after Swaziland.1

HIV and AIDS has had a devastating impact on Botswana. Life expectancy at birth fell from 65 years in 1990-1995 to less than 40 years in 2000-2005, a figure about 28 years lower than it would have been without AIDS.2 The loss of adults in their productive years has serious economic implications,3 with families being pushed into poverty through the costs of HIV and AIDS medical care, loss of income, and funerals. The economic output of Botswana has been reduced by the loss of workers and skills; agriculture and mining are among the worst affected sectors.
Map of botswana including population and life expectancy.

The loss of adults to AIDS has also had a significant affect on children in Botswana: an estimated 95,000 children have lost at least one parent to the epidemic.4 It is vital these children have access to education, but this is problematic in families already weakened by AIDS where children may be providing care for ill relatives or supporting siblings.

In an address to the UN assembly in June 2001, President Festus Mogae summed up the situation by saying:

"We are threatened with extinction. People are dying in chillingly high numbers. It is a crisis of the first magnitude."5

In response to this emergency, Botswana became the first African country to aim to provide antiretroviral drugs to all its needy citizens. The success of this treatment programme has made Botswana an example for other African nations to follow. Yet even with universal treatment access, the country continues to suffer greatly from AIDS. If it is ever to defeat the epidemic, Botswana must find a way to halt the spread of HIV.
History of HIV and AIDS in Botswana

Botswana's first AIDS case was reported in 1985. The country's response to the emerging HIV and AIDS epidemic can be divided into three stages:

* The early stage (1987-89) focused mainly on the screening of blood to eliminate the risk of HIV transmission through blood transfusion.
* The second stage (1989-97), and the first Medium Term Plan (MTP), saw the introduction of information, education and communication programmes, but the response was still quite narrowly focused. During this stage, in 1993, the Government adopted the Botswana National Policy on AIDS.6
* During the third stage (1997 onwards), the response to HIV/AIDS was expanded in many different directions to include education, prevention and comprehensive care including the provision of antiretroviral treatment. The second Medium Term Plan (MTP II) aimed to involve many stakeholders who had previously been excluded, with the overall goal of not only reducing HIV infection and transmission rates, but also reducing the impact of HIV and AIDS at all levels of society.7

The National AIDS Co-ordinating Agency (NACA) was formed in 1999 and given responsibility for mobilising and coordinating a multi-sectoral national response to HIV and AIDS. NACA works under the National AIDS Council, which is chaired by the President and has representatives from across society including the public and private sectors, and civil society.

Early in 2001 the Government decided to initiate a rapid assessment of the feasibility of providing antiretroviral drugs through the public sector. The treatment programme began at a single site in January 2002 and after a slow start expanded rapidly. By the end of 2006, almost all of those in need were receiving medication.8

In 2003 Botswana completed a National Strategic Framework which will guide its response to HIV and AIDS until 2009.9
Government and international funding for AIDS in Botswana

In 2007 the Botswana national government was providing 79.8% of funding for HIV/AIDS programmes.10 The most significant initiatives, which are supported by foreign donors, are the African Comprehensive HIV/AIDS Partnerships (ACHAP) and the BOTUSA project.

ACHAP is a collaboration between the Government of Botswana, the Bill & Melinda Gates Foundation and the Merck Company Foundation. ACHAP was established in July 2000 and is dedicated to supporting Botswana's HIV/AIDS response through 2009. The Bill and Melinda Gates Foundation and the Merck Company Foundation have committed $106.5 million towards the project, and Merck has donated its antiretroviral drugs Stocrin and Crixivan to the programme. In November 2008, Merck expanded its donation to include Atripla and Isentress.11

President George W. Bush meets with President Festus Mogae of Botswana in Gaborone, Botswana

In 1995 the US Centers for Disease Control and Prevention (CDC) and the Botswana Government began a collaboration called BOTUSA, to work on public health research and programmes to combat TB as well as HIV/AIDS. BOTUSA has grown substantially since 2000, and is now part of the President's Emergency Plan for AIDS Relief (PEPFAR).12 PEPFAR contributed $55 million to HIV/AIDS programmes in Botswana in Fiscal Year 2006 alone.13

With help from these and other partners - including the Global Fund, the Harvard School of Public Health, the Bristol-Myers Squibb Foundation, and numerous faith-based and community-based organisations - Botswana is mounting one of Africa's most comprehensive programmes of HIV/AIDS prevention, treatment and care.
HIV prevention in Botswana

There are a number of different types of HIV prevention programme taking place in Botswana. These include:

* Public education & awareness
* AIDS education for young people
* Condom distribution & education
* Targeting of high risk adult populations
* Improvement of blood safety
* Prevention of mother-to-child transmission of HIV (PMTCT)

Public education & awareness

Public awareness and education has previously been based on the "ABC" of AIDS: Abstain, Be faithful and, if you have sex, Condomize. Botswana has safe-sex billboards and posters everywhere, but it is unclear whether anyone pays attention:

A roadside ABC sign in Botswana

"This country has been bombarded with HIV messages, but there hasn't been a change in behaviour."Oscar Motsumi, programme officer in Serowe.14

Now the aim is to target the right message to the right people. One recent initiative has been the development of a radio drama, Makgabaneng, dealing with culturally specific HIV/AIDS-related issues and encouraging changes in sexual behaviour. Another initiative has involved workplace peer counselling, including the development, piloting and distribution of a facilitator's manual. HIV education has also been taken to people's doorsteps by the Total Community Mobilization programme.15
Education for young people

Prevalence rates among young people are particularly high, especially among young women, who out-number young men living with HIV by more than two to one.16 17 It is therefore crucial that young people are provided with HIV education and prevention messages to help protect themselves from infection. Among those performing this role in Botswana is the Youth Health Organisation (YOHO), a youth-run non-governmental organisation that conveys its messages through art festivals, dramas and group discussions. School-based learning plays one of the most important parts in educating young people about HIV and AIDS, and Botswana-specific HIV/AIDS materials have been developed for students with the Ministry of Education.18

A teacher-capacity building programme has been developed jointly by the Ministry of Education of Botswana and the United Nations Development Programme (UNDP), in collaboration with the Government of Brazil and with support from ACHAP. The programme is trying to improve the teachers' knowledge, to demystify and destigmatise HIV/AIDS, and to break down cultural beliefs about sex and sexuality. As part of the project, all primary and secondary schools have been equipped with a television, video recorder, satellite dish and decoder and an interactive AIDS education programme called Talk Back is broadcast twice weekly by Botswana Television.19 20
Condom distribution & education

Successful social marketing and subsidisation have substantially increased condom use in Botswana. Population Services International (PSI) has helped to promote the 'Lovers Plus' condom since 1993 and the 'Care' female condom since 2002. One of PSI's key strategies for marketing condoms has been peer education, which has been conducted in a variety of settings such as fairs and festivals, shopping malls, workplaces and bars.21

In 2003 the Government of Botswana, with funding and technical support from ACHAP, launched an extensive condom distribution and marketing campaign, providing for the installation of 10,500 condom dispensers in traditional and non-traditional outlets throughout the country. Millions of condoms have been procured for free distribution.22 23
Targeting of high risk adult populations

Populations at high risk in Botswana include migrant workers, diamond miners and sex workers. In Botswana the spread of HIV is overwhelmingly through heterosexual sex rather than sex between men or injecting drug use.

Highly mobile populations, including migrant workers, are often especially likely to be exposed to HIV. Therefore the Botswana Government, American Government agencies, NACA, ACHAP and several other partners are initiating a prevention programme linked to the Corridors of Hope project (which is also being implemented in other Southern African countries). The programme will target all highly mobile populations nationwide, concentrating on the treatment of sexually transmitted infections, condom promotion and prevention education. One key focus will be on encouraging safe sex practices through peer education and outreach activities.24

The success of the diamond mining industry has also been closely linked to the spread of HIV. A 2003 study in the densely populated mining town Selebi-Phikwe, showed an overall prevalence of 52.2%,25 the highest in the country. The dangerous nature of this work means that many men view unprotected sex as a minor hazard relative to the day to day dangers of working in the mines.26 Mining has shown to bring men into increased contact with multiple partners.27 Sex work has become increasingly common around these richer mining towns as this offers the best livelihood for some young, poor and vulnerable women.
Improvement of blood safety

The Ministry of Health, the Safe Blood for Africa Foundation and other partners, with funding from ACHAP and PEPFAR, have helped to improve the safety of blood transfusions in Botswana. The national supply of HIV-free blood doubled in size in the two years up to September 2005. Over the same period, the amount of HIV-infected blood given by donors fell by half, largely because of better screening of donors and counselling.

One of the projects contributing to the improvement in blood safety is called "Pledge 25". This project recruits young people to become blood donors and teaches them how to prevent HIV infection. The young people are encouraged to pledge to donate blood 25 times during their lifetime.28
Prevention of mother-to-child transmission of HIV (PMTCT)

The 2002 survey of pregnant women attending antenatal clinics in Botswana found an average HIV prevalence rate of 35.4%.29 In the absence of any interventions, around a third of babies born to HIV-positive mothers will become infected with HIV during pregnancy and delivery or through breastfeeding. This rate can be cut substantially through the use of antiretroviral treatment and safer feeding practices.

A prevention of mother-to-child transmission (PMTCT) programme was the first programme to distribute antiretroviral drugs in Botswana, with the drug zidovudine (AZT) being provided free by the company GlaxoSmithKline.30 When early enrollment of women in PMTCT programmes was disappointingly low,31 the Government responded with training and recruitment programmes for PMTCT counsellors, and later with routine HIV testing of all pregnant women. HIV positive mothers who choose to avoid breastfeeding are given a year's free supply of infant formula.

Thanks to the commitment of the Government and its partners, Botswana's PMTCT programme is now one the most effective in the developing world, serving over 95% of all women in need.32 Services have been established in all public facilities through the Maternal Child Health/Family Planning system, which serves over 90% of all pregnant women. Test results from between November 2006 and February 2007 indicate that less than 4% of babies born to HIV positive mothers were infected - a rate comparable with the USA and Western Europe.33

AVERT.org has more about preventing mother-to-child transmission of HIV worldwide.
HIV testing and counselling in Botswana
Voluntary testing

Voluntary HIV counselling and testing (VCT) plays a key part in HIV-related prevention and care. It is particularly important as a starting point for accessing other HIV/AIDS-related services.

Since 2000, the Government of Botswana and the CDC (through BOTUSA) have supported the Tebelopele network of VCT centres, which provide immediate, confidential VCT services for sexually active Batswana aged 18-49. By October 2005, the network had expanded to sixteen centres and eight satellites, and had provided free VCT services to over 230,000 visitors. Tebelopele became an independent non-governmental organisation in 2004.34 35

The Tebelopele centres have been supported by the "Know Your Status" and "Show You Care" campaigns, part of the VCT marketing strategy developed by the CDC in collaboration with Population Services International (PSI). These campaigns have been marketed through billboards, bus stops, banners, print advertisements and regular radio programmes throughout Botswana.36

ACHAP in partnership with the Botswana Christian AIDS Intervention Programme (BOCAIP) has established eleven additional counselling centres. By September 2005, these centres had offered training to 447 counselors and provided services to over 70,000 people.37
Routine testing

Since the beginning of 2004, HIV tests have been offered as a routine part of checkups in public and private clinics in Botswana. The testing is part of the standard routine but people who do not want to be tested can 'opt out'.

Botswana was the first country in Africa to have a national policy of routinely offering an HIV test at clinics. Health officials believe that routine testing is a good way to help prevention programmes and to enable people to access treatment at an earlier stage of disease. There is still a lot of stigma attached to sexually transmitted diseases in Botswana and officials believe this stigma can be reduced by treating the HIV test like any other routine medical procedure.

"Our single largest problem is the lack of knowledge of HIV status... When you have that many people who don't know their status, anything could happen. If each person infected another person, they you could have 35 prevalence turn into 70 percent prevalence. It's insane."Dr Ernest Darkoh.38

In the first six months of 2005, some 74,134 people were tested via the routine testing programme.39
HIV and AIDS treatment in Botswana
The need for treatment

In August 2000, President Festus Mogae said that new funding from ACHAP would allow his country to provide antiretroviral therapy to all HIV-infected pregnant women and children born with the virus.40 In March 2001, the President announced his Government hoped to implement a national treatment programme before the end of the year. The Government was conducting a needs assessment, and would pay a "substantial" portion of the programme's costs.41

The expected benefits were fourfold:

1. To enable people with HIV to live longer, healthier lives
2. To offer an incentive for HIV testing, and to lower the rate of HIV transmission
3. To decrease the number of children orphaned each year by AIDS
4. To maintain skills in the workforce necessary for economic development

This was the first time any African country had proposed such an ambitious programme, and some doubted whether it was really feasible.

"We see before us the most dramatic experiment on the continent. If it succeeds, it will give heart to absolutely every country worldwide."Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa.

The birth of MASA

By January 2002, the aim was to provide medication during the coming year to 19,000 of the 110,000 infected people whom it was considered could benefit. As a result of poor resources - laboratory capacity, staff and infrastructure - it was decided to initially target four population groups: pregnant women with AIDS, HIV-positive child in-patients, HIV-positive people with tuberculosis, and adult in-patients with AIDS.

The national antiretroviral therapy programme was given the name MASA, the Setswana word for "dawn", and the first antiretroviral drugs were provided at the Princess Marina Hospital in Gaborone in January 2002. ACHAP is a key partner in the programme providing extensive financial and technical assistance.42

When MASA started, there were already warnings about the financial sustainability of the programme. It was estimated that it would cost US$24.5 million to include 19,000 people in 2002 (around $1,300 per patient), and then an additional 20,000 people would be admitted each year.

"The programme is most likely not sustainable at that level. Our hope is that over time, as the anti-AIDS messages sink in - our youth are starting to listen - the rate of infections will fall and there will be a smaller number of people needing the drugs."President Mogae.43

But as MASA started to enrol more people during the year, other problems became apparent.

"We are short of doctors. We are short of nurses. We are short of pharmacists. We are short of health technicians."President Mogae.44

Challenges faced during treatment scale-up

Access to antiretroviral treatment in Botswana

By June 2002, an estimated 1,000 people had been enrolled in MASA. Of these, 500 were on therapy, while the remainder were having their requirements assessed. Although the numbers were disappointingly small, the indications were that few people were having difficulty adhering to the antiretroviral regime. There had been a major concern that poorly educated people would struggle to understand the importance of taking the complex cocktail of drugs on time for the rest of their lives. To help people with adherence, NACA came up with a "buddy system" whereby each patient is encouraged to form a special bond with someone close to them, who makes sure that they follow their medication schedule. The patients in turn counsel others to come forward for testing and treatment.45

It soon become clear that enrolling people was a lengthy process. It involved counselling at testing centres, screening blood once a person knew their status, taking a white blood cell count and then eventually enrolling in the programme. The introduction of antiretroviral therapy had required broadening the infrastructure including testing centres and storage facilities, equipping existing clinics and hospitals and training medical personnel. But the shortage of trained staff was still acute.

"The bottom line is: we need help. The epidemic has put additional demands on us but is at the same time draining us of skilled people. We are recruiting here and abroad. We're getting 100 Cuban doctors. Even the Peace Corps are coming back."Dr Khan, head of NACA.46

The slowness of enrollment was also adding to the pressure on existing staff.

"The need for treatment far outstrips our ability to deliver it. There is a lot of pressure on us, because if we fail, people will say: Botswana had everything going for it and it failed, so why should we help anyone else in Africa?"Dr Moffat, superintendent of the Princess Marina clinic.47

By January 2003 there were about 3,200 people enrolled in MASA. It was becoming clearer that although much had been accomplished, much more remained to be done.

"You could provide treatment under a tree if you had to. It's follow-up and continuity of care that is the real work."Dr Ernest Darkoh, operations manager of MASA.48

"It's mind-blowing. We're achieving miracles, and it's totally insufficient."Dr Donald de Korte, ACHAP project leader.49

The shortage of staff was the single biggest constraint on treatment scale-up. Many skilled professionals had been lured away from Botswana's public health system by offers of better pay and benefits, and some had moved abroad. To compensate, Botswana recruited workers from poorer parts of Africa, as well as from India and Cuba.50 As a result, most of the doctors were foreign and did not speak the national Setswana language.51

When each new site opened, many of the first patients to enrol were already very sick, and so required a lot more time and resources.

"If you spend all your time and capacity on the very sick people, you can never get to those who are not sick, and unfortunately, that sets up a loop of perpetually insatiable demand."Dr Ernest Darkoh.52

HIV-related stigma and denial was also a major barrier to people accessing services.53

"People are still reluctant to come forward to be tested. They don't come forward because of the fear of discrimination and the stigma associated with HIV. And unless you're tested, you don't know whether or not you're positive and therefore might benefit from treatment."Dr Linda M. Distlerath, Merck's Vice-President for Global Health Policy.54

"I'm very frustrated. We think because of the stigma attached to this sexually transmitted virus, and because some of our religious people have said this is a curse or those who have it are sinners, that people are afraid to get tested."President Mogae.55

As 2003 drew to a close, MASA was still a long way short of the 19,000 target originally set for the end of 2002. Some observers argued the programme had been mismanaged and was not a good example for other African countries to follow.56 An American newspaper reported that despite all the support it had received, Botswana's treatment programme was "barely making a dent".57
Botswana's treatment success

The number of people receiving antiretroviral treatment through the public sector continued to rise gradually during 2003, reaching around 8,000 at ten clinics by the end of the year.58 Then in 2004 MASA entered a new stage of rapid expansion.

By May 2004, more than 24,000 people had been enrolled on MASA, of whom 14,000 were receiving antiretroviral treatment.59

"The response has been tremendous. People are coming forward and the sites are overwhelmed."Dr Ernest Darkoh.60

By the end of the year, it was estimated that between 36,000 and 39,000 people were receiving antiretroviral treatment, including those using the private sector, who made up around one quarter of the total. MASA was achieving good rates of treatment adherence in terms of self-reporting, pill counts and attending scheduled appointments, and this was confirmed by measuring viral load suppression.61

"What is even more heartening is that we are beginning to see a change in attitude. Botswana are finally understanding that regardless of their HIV status they have viable options available to them to continue seeking and living fulfilled lives."Dr Ernest Darkoh.62

By June 2005, the total had risen to 43,000 people receiving treatment - more than half of the 75,000 in need, according to the World Health Organisation. The Princess Marina Hospital in the capital Gaborone was the largest single provider of antiretroviral therapy in Africa, and 31 other sites in Botswana were offering free treatment, including at least one in each of the 24 health districts. About three quarters of those receiving treatment were doing so through the public sector, but an increasing number of private companies were also offering treatment to their employees, including the Botswana Power Corporation and Barclays Bank.63

By September 2005, according to Health Minister Sheila Tlou, the total number on treatment had reached 54,378, and 4,582 children were receiving treatment through MASA.64 According to World Health Organisation figures, 85% of people in need of the drugs were receiving them at the end of the year, including those using the private sector.65 Coverage exceeded 94% by the end of 2008, when around 117,000 were receiving treatment.66
How was such a rapid increase possible?

When considering the progress of MASA, there are a number of factors worth taking into account:

* Experience shows that the number of people on treatment at each site does not grow at a uniform rate. Expansion starts slowly then accelerates as the local health workers gain confidence, commitment and experience, and as organisational "teething problems" are overcome. Eventually the rate of growth will slow down again as everyone in need is enrolled.67
* Routine testing has increased demand for treatment, especially among people without symptoms.
* A social mobilisation campaign has raised awareness of the availability and effectiveness of antiretroviral treatment, and has helped to reduce stigma and discrimination.
* The programme has been well supported. As of mid-2005, Government expenditure on treatment scale-up was expected to be around $62.1 million in 2004-5. An additional $3.3 million was expected from the Global Fund, $6.4 million from PEPFAR and $20 million from non-governmental organisations, charities and foundations.68
* Botswana has more money, better infrastructure and a better health system than most other sub-Saharan African countries.
* Ways were found to ease the shortage of trained staff, as explained below.

Easing the shortage of trained staff

In 2000, the Harvard AIDS Initiative and the Botswana Ministry of Health set up the KITSO Training Program, which provides training in HIV and AIDS care tailored specifically for Botswana's health professionals. Participants are allowed to remain in their posts while receiving the training, so as not to leave their clinics short-staffed. Major support for KITSO is provided by ACHAP.69 By September 2005, KITSO had trained 1,941 health care workers in HIV/AIDS clinical care fundamentals.70
Access to antiretroviral (ARV) treatment in Botswana

Access to antiretroviral (ARV) treatment in Botswana

Another important development has been the clinical preceptorship programme. This scheme brings HIV specialist doctors from the USA and Europe to work in Botswana for periods of at least three months, providing hands-on training to local medical staff.

The Government pays private doctors to test for infection, carry out the laboratory work, and supply treatment to people unable to access it through the public sector, particularly those in rural areas. NACA has tried to develop a system of lay counsellors to ease the workload of some nurses.

"Even when I did find a doctor willing to come to the country, [he or she] wasn't willing to live in remote rural areas... So the answer must be that we use already existing people who are living in these communities - in new and creative ways."Dr Ernest Darkoh.71

The way forward

Botswana's national treatment programme is now seen as a successful model for other African countries to follow. Though progress was initially slower than expected, the programme made rapid progress in 2004 and 2005, and patient responses have been comparable to those seen in Europe and the USA.

MASA has demonstrated that antiretroviral treatment can be provided on a national scale through the public health system of a sub-Saharan African country - not just through localised projects run by foreign aid workers or researchers. In Botswana's case, almost all of the actual cost of treatment has been paid by the Government, while other partners have given support by providing laboratory equipment, staff training or patient monitoring services.

"The Government of Botswana has demonstrated a very high level of political commitment to addressing the HIV/AIDS epidemic... Botswana's success provides a fine example of how antiretroviral therapy can be provided on a large scale in resource-constrained settings."World Health Organisation.72

But the struggle to provide universal access to treatment in Botswana is far from over. All of those already enrolled must continue to receive drugs and monitoring services for the rest of their lives, and people who develop resistance to their current medications must have access to alternatives, which can be more expensive and complex than first-line therapy.

It is much easier to provide treatment in towns than in rural areas, and MASA will need to be further decentralised to ensure that all areas are covered. The shortage of skilled staff will continue to be a great challenge to MASA, and the programme will continue to be very expensive. The need for help from the rest of the world is as urgent as ever.

Providing treatment for an increasing number of HIV patients simply isn’t economically sustainable in the long term. After Botswana lost over half of an $18.6 million grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria in 2008, resources were stretched to the limit, and Mogae warned:

“We are fast approaching a situation where we cannot afford what we are doing even now.” President Mogae73

This warning has been echoed by his successor President Ian Khama. Khama emphasised the responsibility of individual citizens, to ensure funding is not wasted, by reducing treatment failures through adherence to ARVs{!ref: “Botswana expects HIV treatment numbers to reach 225,000 by 2016” Aidsmap, 10.12.2008 !}.

Antiretroviral treatment alone cannot solve Botswana's devastating HIV and AIDS crisis. In his address at the 17th International Aids Conference in Mexico 2008 former President Mogae stressed that whilst the government must remain committed to Botswana’s comprehensive treatment programme, hopes of ever overcoming AIDS in Botswana lie in halting transmission:

"Prevention of new infections should be our priority number one, priority number two and priority number three".former President Mogae74.

Botswana's long-term vision is to have no new HIV infections by 2016, when the nation will celebrate 50 years of independence. This will never be achieved without a massive and sustained HIV prevention campaign.

The History of HIV/AIDS in India

2009-12-17T07:36:00.000-08:00

India is one of the largest and most populated countries in the world, with over one billion inhabitants. Of this number, it's estimated that around 2.3 million people are currently living with HIV.1

HIV emerged later in India than it did in many other countries. Infection rates soared throughout the 1990s, and today the epidemic affects all sectors of Indian society, not just the groups – such as sex workers and truck drivers – with which it was originally associated.

In a country where poverty, illiteracy and poor health are rife, the spread of HIV presents a daunting challenge.
The History of HIV/AIDS in India

At the beginning of 1986, despite over 20,000 reported AIDS cases worldwide,2 India had no reported cases of HIV or AIDS.3 There was recognition, though, that this would not be the case for long, and concerns were raised about how India would cope once HIV and AIDS cases started to emerge. One report, published in a medical journal in January 1986, stated:

“Unlike developed countries, India lacks the scientific laboratories, research facilities, equipment, and medical personnel to deal with an AIDS epidemic. In addition, factors such as cultural taboos against discussion of sexual practices, poor coordination between local health authorities and their communities, widespread poverty and malnutrition, and a lack of capacity to test and store blood would severely hinder the ability of the Government to control AIDS if the disease did become widespread.”4

Later in the year, India’s first cases of HIV were diagnosed among sex workers in Chennai, Tamil Nadu.5 It was noted that contact with foreign visitors had played a role in initial infections among sex workers, and as HIV screening centres were set up across the country there were calls for visitors to be screened for HIV. Gradually, these calls subsided as more attention was paid to ensuring that HIV screening was carried out in blood banks.6 7

In 1987 a National AIDS Control Programme was launched to co-ordinate national responses. Its activities covered surveillance, blood screening, and health education.8 By the end of 1987, out of 52,907 who had been tested, around 135 people were found to be HIV positive and 14 had AIDS.9 Most of these initial cases had occurred through heterosexual sex, but at the end of the 1980s a rapid spread of HIV was observed among injecting drug users (IDUs) in Manipur, Mizoram and Nagaland - three north-eastern states of India bordering Myanmar (Burma).10

At the beginning of the 1990s, as infection rates continued to rise, responses were strengthened. In 1992 the government set up NACO (the National AIDS Control Organisation), to oversee the formulation of policies, prevention work and control programmes relating to HIV and AIDS.11 In the same year, the government launched a Strategic Plan for HIV prevention. This plan established the administrative and technical basis for programme management and also set up State AIDS bodies in 25 states and 7 union territories. It was able to make a number of important improvements in HIV prevention such as improving blood safety.
A human daisy chain on World Aids Day in India, December 2004.

A human daisy chain on World Aids Day in India, December 2004.

By this stage, cases of HIV infection had been reported in every state of the country.12 Throughout the 1990s, it was clear that although individual states and cities had separate epidemics, HIV had spread to the general population. Increasingly, cases of infection were observed among people that had previously been seen as ‘low-risk’, such as housewives and richer members of society.13 In 1998, one author wrote:

“HIV infection is now common in India; exactly what the prevalence is, is not really known, but it can be stated without any fear of being wrong that infection is widespread… it is spreading rapidly into those segments that society in India does not recognise as being at risk. AIDS is coming out of the closet.”14

In 2001, the government adopted the National AIDS Prevention and Control Policy. During that year, Prime Minister Atal Bihari Vajpayee addressed parliament and referred to HIV/AIDS as one of the most serious health challenges facing the country. The Prime Minister also met the chief ministers of the six high-prevalence states to plan the implementation of strategies for HIV/AIDS prevention.15

HIV had now spread extensively throughout the country. In 1990 there had been tens of thousands of people living with HIV in India; by 2000 this had risen to millions. 16
Current estimates

In 2006 UNAIDS estimated that there were 5.6 million people living with HIV in India, which indicated that there were more people with HIV in India than in any other country in the world.17 In 2007, following the first survey of HIV among the general population, UNAIDS and NACO agreed on a new estimate – between 2 million and 3.1 million people living with HIV.18

In 2008 the figure was confirmed to be 2.5 million,19 which equates to a prevalence of 0.3%. While this may seem a low rate, because India's population is so large, it is third in the world in terms of greatest number of people living with HIV. With a population of around a billion, a mere 0.1% increase in HIV prevalence would increase the estimated number of people living with HIV by over half a million.

The national HIV prevalence rose dramatically in the early years of the epidemic, but a study released at the beginning of 2006 suggests that the HIV infection rate has recently fallen in southern India, the region that has been hit hardest by AIDS.20 In addition, NACO released figures in 2008 suggesting that the number of people living with HIV has declined.21

Some AIDS activists are doubtful that the situation is improving:

“It is the reverse. All the NGOs I know have recorded increases in the number of people accepting help because of HIV. I am really worried that we are just burying our head in the sand over this.” Anjali Gopalan, the Naz Foundation, Delhi22

Peter Piot, Executive Director of UNAIDS, stresses:

“the statement that India has the AIDS problem under control is not true. There is a decline in prevalence in some of the Southern states… In the rest of the county, there are no arguments to demonstrate that AIDS is under control”23

For more detailed information on HIV prevalence and AIDS deaths, see our HIV and AIDS statistics for India.
The HIV/AIDS situation in different states
Map of India

Map of India showing the worst affected states.

The vast size of India makes it difficult to examine the effects of HIV on the country as a whole. The majority of states within India have a higher population than most African countries, so a more detailed picture of the crisis can be gained by looking at each state individually.

The HIV prevalence data for most states is established through testing pregnant women at antenatal clinics. While this means that the data are only directly relevant to sexually active women, they still provide a reasonable indication as to the overall HIV prevalence of each area.24

The following states have recorded the highest levels of HIV prevalence at antenatal and sexually transmitted disease (STD) clinics over recent years.
Andhra Pradesh

Andhra Pradesh in the southeast of the country has a total population of around 76 million, of whom 6 million live in or around the city of Hyderabad. The HIV prevalence at antenatal clinics was 1% in 2007. This figure is smaller than the reported 1.26% in 2006, but is still highest out of all states.25 HIV prevalence at STD clinics was very high at 17% in 2007. Among high-risk groups, HIV prevalence was highest among men who have sex with men (MSM) (17%), followed by female sex workers (9.7%) and IDUs (3.7%).26
Goa

Goa, a popular tourist destination, is a very small state in the southwest of India (population 1.4 million). In 2007 HIV prevalence among antenatal and STD clinic attendees was 0.18% and 5.6% respectively.27 The Goa State AIDS Control Society reported that in 2008, a record number of 26,737 people were tested for HIV, of which 1018 (3.81%) tested positive.28
Karnataka

Karnataka, a diverse state in the southwest of India, has a population of around 53 million. HIV prevalence among antenatal clinic attendees exceeded 1% from 2003 to 2006, and dropped to 0.5% in 2007.29 Districts with the highest prevalence tend to be located in and around Bangalore in the southern part of the state, or in northern Karnataka's "devadasi belt". Devadasi women are a group of women who have historically been dedicated to the service of gods. These days, this has evolved into sanctioned prostitution, and as a result many women from this part of the country are supplied to the sex trade in big cities such as Mumbai.30 The average HIV prevalence among female sex workers in Karnataka was just over 5% in 2007, and 17.6% of men who have sex with men were found to be infected.31
Maharashtra

Maharashtra is a very large state of three hundred thousand square kilometres, with a total population of around 97 million. The capital city of Maharashtra - Mumbai (Bombay) - is the most populous city in India, with around 14 million inhabitants. The HIV prevalence at antenatal clinics in Maharashtra was 0.5% in 2007.32 At 18%, the state has the highest reported rates of HIV prevalence among female sex workers.33 Similarly high rates were found among injecting drug users (24%) and men who have sex with men (12%).34
Tamil Nadu

With a population of over 66 million, Tamil Nadu is the seventh most populous state in India. Between 1995 and 1997 HIV prevalence among pregnant women tripled to around 1.25%.35 The State Government subsequently set up an AIDS society, which aimed to focus on HIV prevention initiatives. A safe-sex campaign was launched, encouraging condom use and attacking the stigma and ignorance associated with HIV. Between 1996 and 1998 a survey showed that the number of men reporting high-risk sexual behaviour had decreased.36

In 2007 HIV prevalence among antenatal clinic attendees was 0.25%.37 HIV prevalence among injecting drug users was 16.8%, third highest out of all reporting states. HIV prevalence among men who have sex with men and female sex workers was 6.6% and 4.68% respectively.38
Manipur

Manipur is a small state of some 2.4 million people in northeast India. Manipur borders Myanmar (Burma), one of the world's largest producers of illicit opium. In the early 1980s drug use became popular in northeast India and it wasn't long before HIV was reported among injecting drug users in the region.39 Although NACO report a state-wise HIV prevalence of 17.9% among IDUs, studies from different areas of the state find prevalence to be as high as 32%.40

HIV is no longer confined to IDUs, but has spread further to the general population. HIV prevalence at antenatal clinics in Manipur exceeded 1% in recent years, but then declined to 0.75% in 2007.41 Estimated adult HIV prevalence is the highest out of all states, at 1.57%.42
Mizoram

The small northeastern state of Mizoram has fewer than a million inhabitants. In 1998, an HIV epidemic took off quickly among the state's male injecting drug users, with some drug clinics registering HIV rates of more than 70% among their patients.43 In recent years the average prevalence among this group has been much lower, at around 3-7%.44 HIV prevalence at antenatal clinics was 0.75% in 2007.45
Nagaland

Nagaland is another small northeastern state where injecting drug use has again been the driving force behind the spread of HIV. In 2003 HIV prevalence among IDUs was 8.43%, but has since declined to 1.91% in 2007. HIV prevalence at antenatal clinics and STD clinics was 0.60% and 3.42% respectively in 2007.46
Who is affected by HIV and AIDS in India?

People living with HIV in India come from incredibly diverse cultures and backgrounds. The vast majority of infections occur through heterosexual sex, and most of those who become infected would not fall into the category of ‘high-risk groups’ - although members of such groups, including sex workers, men who have sex with men, truck drivers and migrant workers, do face a disproportionately higher risk of infection. See our page on affected groups in India for more information.
HIV prevention

Educating people about HIV/AIDS and how it can be prevented is complicated in India, as a number of major languages and hundreds of different dialects are spoken within its population. This means that, although some HIV/AIDS prevention and education can be done at the national level, many of the efforts are best carried out at the state and local level.

Each state has its own AIDS Prevention and Control Society, which carries out local initiatives with guidance from NACO. Under the second stage of the government’s National AIDS Control Programme (NACP-II), which finished in March 2006, state AIDS control societies were granted funding for youth campaigns, blood safety checks, and HIV testing, among other things. Various public platforms were used to raise awareness of the epidemic - concerts, radio dramas, a voluntary blood donation day and TV spots with a popular Indian film-star. Messages were also conveyed to young people through schools. Teachers and peer educators were trained to teach about the subject, and students were educated through active learning sessions, including debates and role-play.47
AIDS awareness banners in Sangli, India - 2005

AIDS awareness banners in Sangli, India - 2005

The third stage of the National AIDS Control Programme (NACP-III), was launched in July 2007 and runs until 2012.48 The programme has a budget of around $2.6 billion, two thirds of which is for prevention and one sixth for treatment.49 Aside from the government, this money will come from non-governmental organisations, companies, and international agencies, such as the World Bank and the Bill and Melinda Gates Foundation. 50

The government has announced that this campaign will place a strong focus on condom promotion. It has already supported the installation of over 11,000 condom vending machines in colleges, road-side restaurants, stations, gas stations and hospitals. With support from the United States Agency for International Development (USAID), the government has also initiated a campaign called ‘Condom Bindas Bol!’, which involves advertising, public events and celebrity endorsements. It aims to break the taboo that currently surrounds condom use in India, and to persuade people that they should not be embarrassed to buy them.51

In one unique scheme, health activists in West Bengal are attempting to promote condom use through kite flying, which is popular before the state’s biggest festival, Durga Puja:

"The colourful kites carry the message that using a condom is a simple and instinctive act… they can fly high in the sky and land at distant places where we cannot reach." - 52

This initiative is an example of how HIV prevention campaigns in India can be tailored to the situations of different states and areas. In doing so, they can make an important impact, particularly in rural areas where information is often lacking. Small-scale campaigns like this are often run or supported by non-governmental organisations, which play a vital role in preventing infections throughout India, particularly among high-risk groups. In some cases, members of these risk groups have formed their own organisations to respond to the epidemic.

The government has however funded a small number of national campaigns to spread awareness about HIV/AIDS to complement the local level initiatives. On World AIDS Day 2007 India flagged off its largest national campaign to date, in the form of a seven-coach train.53 A year later the train journey was completed, having travelled to 180 stations in 24 states and reaching around 6.2 million people with HIV/AIDS education and awareness.54
Testing

The general consensus among those fighting AIDS worldwide is that HIV testing should be carried out voluntarily, with the consent of the individual concerned. This view has been supported by the Indian government and NACO, who have helped to establish hundreds of integrated counselling and testing centres (ICTCs) in India. By the end of 2008 there were 4817 ICTCs in India,55 compared to just 62 in 1997.56 In 2007 these centres tested 5.9 million people for HIV, an increase from 0.14 million in 2001.57
Health Clinic near Sangli, India - 2005

Health Clinic near Sangli, India - 2005

Although voluntary testing is officially supported in India, some states have tried to implement policies that would force people to be tested for HIV against their will. In Goa, the state government recently planned to make HIV tests compulsory before marriage, and in Punjab it has been proposed that all people wishing to obtain or retain a driver’s license should be tested for HIV.58 Neither of these plans have come to pass, but they have concerned activists, who argue that HIV testing should never be imposed on people against their wishes.

Unfortunately, cases of people being tested without their consent or knowledge are common in Indian hospitals. In one 2002 study, it was suggested that over 95% of patients listed for surgical procedures are tested against their will, often resulting in their surgery being cancelled.59 Hospital staff and health professionals, much like the rest of the Indian population, are often unaware of the facts about HIV. This leads to unnecessary fears and, in some cases, causes them to stigmatise HIV positive people and discriminate against them, including testing them without consent.
Treatment for people living with HIV

Antiretroviral drugs (ARVs), which can significantly delay the progression from HIV to AIDS – have been available in developed countries since 1996. Unfortunately, as in many resource-poor areas, access to this treatment is severely limited in India; an estimated 235,000 people were receiving ARVs by the end of 2008.60 Some of these people manage to access the drugs through private health facilities, which dominate India’s healthcare sector, but the vast majority of people cannot afford to buy treatment privately.

While the coverage of treatment remains unacceptably low, improvements are being made. The government has started to expand access to ARVs in a number of areas; by 2007 there were 137 reported sites providing antiretroviral therapy.61

Increasing access to ARVs also means that an increasing number of people living with HIV in India are developing drug resistance. When HIV becomes resistant to the ARVs the treatment regimen needs to be changed to 'second-line' ARVs. As with many other parts of the world, second line treatment in India is far more expensive than first line treatment.

In 2008, NACO began to roll out government funded second-line antiretroviral treatment in two centres in Mumbai and Chennai. At the beginning of 2009 second-line therapy was available in a total of eight states.62 However, the large scale of India’s epidemic, the diversity of its spread, and the country’s lack of finances and resources all present barriers to India’s antitretroviral treatment programme.

Ironically, India is a major provider of cheap generic copies of ARVs to countries all over the world.

“It is a sad irony that India is one of the biggest producers of the drugs that have transformed the lives of people with AIDS in wealthy countries. But for millions of Indians, access to these medicines is a distant dream” Joanne Csete, Director of the HIV/AIDS programme at Human Rights Watch. 63

To read about the challenges faced in increasing access to antiretroviral drugs around the world, see our Universal access to AIDS treatment page.
Stigma and discrimination in India

In India, as elsewhere, AIDS is often seen as “someone else’s problem” – as something that affects people living on the margins of society, whose lifestyles are considered immoral. Even as it moves into the general population, the HIV epidemic is still misunderstood among the Indian public. People living with HIV have faced violent attacks, been rejected by families, spouses and communities, been refused medical treatment, and even, in some reported cases, denied the last rites before they die.64
Schoolteacher fired after testing HIV-positive is embraced by daughter

A schoolteacher fired after testing HIV-positive

is embraced by daughter

As well as adding to the suffering of people living with HIV, this discrimination is hindering efforts to prevent new infections. While such strong reactions to HIV and AIDS exist, it is difficult to educate people about how they can avoid infection. AIDS outreach workers and peer-educators have reported harassment,65 and in schools, teachers sometimes face negative reactions from the parents of children that they teach about AIDS:

“When I discussed with my mother about having an AIDS education program, she said, ‘you learn and come home and talk about it in the neighbourhood, they will kick you’. She feels that we should not talk about it.” Female student, Chennai66

Discrimination is also alarmingly common in the health care sector. Negative attitudes from health care staff have generated anxiety and fear among many people living with HIV and AIDS. As a result, many keep their status secret. It is not surprising that for many HIV positive people, AIDS-related fear and anxiety, and at times denial of their HIV status, can be traced to traumatic experiences in health care settings.

"There is an almost hysterical kind of fear ... at all levels, starting from the humblest, the sweeper or the ward boy, up to the heads of departments, which make them pathologically scared of having to deal with an HIV positive patient. Wherever they have an HIV patient, the responses are shameful." - 67

A 2006 study found that 25% of people living with HIV in India had been refused medical treatment on the basis of their HIV-positive status. It also found strong evidence of stigma in the workplace, with 74% of employees not disclosing their status to their employees for fear of discrimination. Of the 26% who did disclose their status, 10% reported having faced prejudice as a result.68 People in marginalized groups - female sex workers, hijras (transgender) and gay men - are often stigmatised not only because of their HIV status, but also because they belong to socially excluded groups.69

To learn more about the way that prejudice is hindering the global fight against AIDS, see our Stigma and discrimination page.
The future of HIV and AIDS in India

Various groups have made predictions about the effect that AIDS will have on India and the rest of Asia in the future, and there has been a lot of dispute about the accuracy of these estimates. For instance, a 2002 report by the CIA's National Intelligence Council predicted 20 million to 25 million AIDS cases in India by 2010 - more than any other country in the world.70 India's government responded by calling these figures "completely inaccurate", and accused those who cited them of "spreading panic".71 The government has also disputed predictions that India’s epidemic is "on an African trajectory", although it claims to acknowledge the seriousness of the crisis. 72

Indeed, recent surveys do suggest that national HIV prevalence has probably fallen slightly in recent years. This trend is mainly due to a drop in infections in southern states; in other areas there has been no significant decline.

“In the north-east, the dual HIV epidemic driven by unsafe sex and injecting drug use is highly concerning. Moreover, there are many areas in the northern states where HIV is increasing, particularly among injecting drug users.” Sujatha Rao, Director General of NACO 73

Even if the country's epidemic does not match the severity of those in southern Africa, it is clear that HIV and AIDS will have a devastating effect on the lives of millions of Indians for many years to come. It is essential that effective action is taken to minimise this impact.

“The challenges India faces to overcome this epidemic are enormous. Yet India possesses in ample quantities all the resources needed to achieve universal access to HIV prevention and treatment… defeating AIDS will require a significant intensification of our efforts, in India, just as in the rest of the world”

The impact of HIV & AIDS in Africa

2009-12-17T07:34:00.001-08:00

Two-thirds of all people infected with HIV live in sub-Saharan Africa, although this region contains little more than 10% of the world’s population.1 AIDS has caused immense human suffering in the continent. The most obvious effect of this crisis has been illness and death, but the impact of the epidemic has certainly not been confined to the health sector; households, schools, workplaces and economies have also been badly affected.

During 2008 alone, an estimated 1.4 million adults and children died as a result of AIDS in sub-Saharan Africa.2 Since the beginning of the epidemic more than 15 million Africans have died from AIDS.3

Although access to antiretroviral treatment is starting to lessen the toll of AIDS, fewer than half of Africans who need treatment are receiving it.4 The impact of AIDS will remain severe for many years to come.
The impact on the health sector

In all heavily affected countries the AIDS epidemic is adding additional pressure on the health sector. As the epidemic matures, the demand for care for those living with HIV rises, as does the toll of AIDS on health workers. In sub-Saharan Africa, the direct medical costs of AIDS (excluding antiretroviral therapy) have been estimated at about US$30 per year for every person infected, at a time when overall public health spending is less than US$10 per year for most African countries.5
The effect on hospitals
Kisiizi Hospital's bedroom

Nurses working on the HIV ward at Kisiizi Hospital in Uganda

As the HIV prevalence of a country rises, the strain placed on its hospitals is likely to increase. In sub-Saharan Africa, people with HIV-related diseases occupy more than half of all hospital beds.6 Government-funded research in South Africa has suggested that, on average, HIV-positive patients stay in hospital four times longer than other patients.7

Hospitals are struggling to cope, especially in poorer African countries where there are often too few beds available. This shortage results in people being admitted only in the later stages of illness, reducing their chances of recovery.
Health care workers

While AIDS is causing an increased demand for health services, large numbers of healthcare professionals are being directly affected by the epidemic. Botswana, for example, lost 17% of its healthcare workforce due to AIDS between 1999 and 2005. A study in one region of Zambia found that 40% of midwives were HIV-positive.8 Healthcare workers are already scarce in most African countries. Excessive workloads, poor pay and migration to richer countries are among the factors contributing to this shortage.

Although the recent increase in the provision of antiretroviral drugs (which significantly delay the progression from HIV to AIDS) has brought hope to many in Africa, it has also put increased strain on healthcare workers. Providing antiretroviral treatment to everyone who needs it requires more time and training than is currently available in most countries.
The impact on households

The toll of HIV and AIDS on households can be very severe. Although no part of the population is unaffected by HIV, it is often the poorest sectors of society that are most vulnerable to the epidemic and for whom the consequences are most severe. In many cases, the presence of AIDS causes the household to dissolve, as parents die and children are sent to relatives for care and upbringing. A study in rural South Africa suggested that households in which an adult had died from AIDS were four times more likely to dissolve than those in which no deaths had occurred.9 Much happens before this dissolution takes place: AIDS strips families of their assets and income earners, further impoverishing the poor.
Household income

In Botswana it is estimated that, on average, every income earner is likely to acquire one additional dependent over the next ten years due to the AIDS epidemic. A dramatic increase in destitute households – those with no income earners – is also expected.10

Other countries in the region are experiencing the same problem, as individuals who would otherwise provide a household with income are prevented from working – either because they are ill with AIDS themselves or because they are caring for another sick family member.

Such a situation is likely to have repercussions for every member of the family. Children may be forced to abandon their education and in some cases women may be forced to turn to sex work ('prostitution'). This can lead to a higher risk of HIV transmission, which further exacerbates the situation.
Basic necessities

A study in South Africa found that poor households coping with members who are sick from HIV or AIDS were reducing spending on necessities even further. The most likely expenses to be cut were clothing (21%), electricity (16%) and other services (9%). Falling incomes forced about 6% of households to reduce the amount they spent on food and almost half of households reported having insufficient food at times.11

"She then led me to the kitchen and showed me empty buckets of food and said they had nothing to eat that day just like other days."12

Food production

The AIDS epidemic adds to food insecurity in many areas, as agricultural work is neglected or abandoned due to household illness. In Malawi, where food shortages have had a devastating effect, it has been recognised that HIV and AIDS are diminishing the country’s agricultural output.13 It is thought that by 2020, Malawi’s agricultural workforce will be 14% smaller than it would have been without HIV and AIDS. In other countries, such as Mozambique, Botswana, Namibia and Zimbabwe, the reduction is likely to be over 20%.14

A study in Kenya demonstrated that food production in households in which the head of the family died of AIDS were affected in different ways depending on the sex of the deceased. As in other sub-Saharan African countries, it was generally found that the death of a male reduced the production of ‘cash crops’ (such as coffee, tea and sugar), while the death of a female reduced the production of grain and other crops necessary for household survival.15
Healthcare expenses and funeral costs

Taking care of a person sick with AIDS is not only an emotional strain for household members, but also a major strain on household resources. Loss of income, additional care-related expenses, the reduced ability of caregivers to work, and mounting medical fees push affected households deeper into poverty. It is estimated that, on average, HIV-related care can absorb one-third of a household’s monthly income.16

The financial burden of death can also be considerable, with some families in South Africa easily spending seven times their total household monthly income on a funeral. Furthermore, although many South Africans contribute to some sort of funeral insurance plan, many of these are inadequately funded, and it is arguable that such financial arrangements detract from other savings plans or health insurance.17

Aside from the financial burden, providing home based care can impose demands on the physical, mental and general health of carers – usually family and friends of the sick person. Such risks are amplified if carers are untrained or unsupported by a home-based care organisation.
How do HIV/AIDS-affected households cope in Africa?

Three main coping strategies appear to be adopted among affected households. Savings are used up or assets sold; assistance is received from other households; and the composition of households tends to change, with fewer adults of prime working age in the households.

Almost invariably, the burden of coping rests with women. Upon a family member becoming ill, the role of women as carers, income-earners and housekeepers is stepped up. They are often forced to step into roles outside their homes as well. In parts of Zimbabwe, for example, women are moving into the traditionally male-dominated carpentry industry. This often results in women having less time to prepare food and for other tasks at home.

"I used to stay with the children, but now it is a problem. I have to work in the fields. Last year I had more money to hire labour so the crops got weeded more often. This year I had to do it myself.” Angelina, Zimbabwe18

A video of the Gogo Getters, a group of grandmothers in the Eastern Cape, South Africa

Older people are also heavily affected by the epidemic; many have to care for their sick children and are often left to look after orphaned grandchildren. Older people left caring for the sick face the burden of providing financial, emotional and psychological support at a time when they would usually be expecting to receive more support as their energy levels drop with older age. Due to the amount of time spent caring for dependents, older people may become isolated from their peers as they no longer have the time to dedicate to their social networks that need to be fostered to prevent isolation and loneliness.

Tapping into savings if available and taking on more debt are usually the first options chosen by households struggling to pay for medical treatment or funerals. Then as debts mount, precious assets such as bicycles, livestock and even land are sold. Once households are stripped of their productive assets, the chances of them recovering and rebuilding their livelihoods become even slimmer.

The number of working adults in a family will often decrease.

“Our fields are idle because there is nobody to work them. We don't have machinery for farming, we only have manpower - if we are sick, or spend our time looking after family members who are sick, we have no time to spend working in the fields." Toby Solomon, commissioner for the Nsanje district, Malawi19

One of the more unfortunate responses to a death in poorer households is removing the children (especially girls) from school. Often the school uniforms and fees become unaffordable for the families and the child's labour and income-generating potential are required in the household.

“Because I’m a poor African woman, I can’t raise enough money for three orphans. The one in secondary school, sometimes she misses first term because I’m looking for tuition. The others miss schools for two or three days at a time. I had a cow I used to milk, but as time went on the cow died, so I can’t find any other income…” Barbara, Uganda 20

The impact on children

It is hard to overemphasise the trauma and hardship that children affected by HIV and AIDS are forced to bear. The epidemic not only causes children to lose their parents or guardians, but sometimes their childhood as well.

As parents and family members become ill, children take on more responsibility to earn an income, produce food, and care for family members. It is harder for these children to access adequate nutrition, basic health care, housing and clothing. Fewer families have the money to send their children to school.

Often both of the parents are HIV positive in Africa. Consequently, more children have been orphaned by AIDS in Africa than anywhere else. Many children are now raised by their grandparents or left on their own in child-headed households.

As projections of the number of AIDS orphans rise, some have called for an increase in institutional care for children. However this solution is not only expensive but also detrimental to the children. Institutionalisation stores up problems for society, which is ill equipped to cope with an influx of young adults who have not been socialised in the community in which they have to live. There are other alternatives available. One example is the approach developed by church groups in Zimbabwe, in which community members are recruited to visit orphans in their homes, where they live either with foster parents, grandparents or other relatives, or in child-headed households.

The way forward is prevention. Firstly, it is crucial to prevent children from becoming infected with HIV at birth as well as later in life. Secondly, if efforts are made to prevent adults becoming infected with HIV, and to care for those already infected, then fewer children will be orphaned by AIDS in the future.

To learn more, see our children HIV & AIDS page.
The impact on the education sector

The relationship between AIDS and the education sector is circular – as the epidemic worsens, the education sector is damaged, which in turn is likely to increase the incidence of HIV transmission. There are numerous ways in which AIDS can affect education, but equally there are many ways in which education can help the fight against AIDS. The extent to which schools and other education institutions are able to continue functioning will influence how well societies eventually recover from the epidemic.

"Without education, AIDS will continue its rampant spread. With AIDS out of control, education will be out of reach." Peter Piot, Director of UNAIDS21

Fewer children receiving a basic education
Children at a school in Illinge, South Africa, many of which are affected by HIV and AIDS

Children at a school in Illinge, South Africa. Many are affected by HIV and AIDS.

A decline in school enrolment is one of the most visible effects of the epidemic. This in itself will have an effect on HIV prevention, as a good, basic education ranks among the most effective and cost-effective means of preventing HIV.22

There are numerous barriers to school attendance in Africa. Children may be removed from school to care for parents or family members, or they may themselves be living with HIV. Many are unable to afford school fees and other such expenses – this is particularly a problem among children who have lost their parents to AIDS, who often struggle to generate income.

Studies have suggested that young people with little or no education may be around twice as likely to contract HIV as those who have completed primary education.23 In this context, the devastating effect that AIDS is having on school enrolment is a big concern. In Swaziland and the Central African Republic, it has been reported that school enrolment has fallen by 25-30% due to AIDS.24
The impact on teachers

HIV and AIDS are having a devastating affect on the already inadequate supply of teachers in African countries; for example, a study in South Africa found that 21% of teachers aged 25-34 are living with HIV.25

Teachers who are affected by HIV and AIDS are likely to take periods of time off work. Those with sick families may also take time off to attend funerals or to care for sick or dying relatives, and further absenteeism may result from the psychological effects of the epidemic.26

When a teacher falls ill, the class may be taken on by another teacher, may be combined with another class, or may be left untaught. Even when there is a sufficient supply of teachers to replace losses, there can be a significant impact on the students. This is particularly concerning given the important role that teachers can play in the fight against AIDS.

The illness or death of teachers is especially devastating in rural areas where schools depend heavily on one or two teachers. Moreover, skilled teachers are not easily replaced. Tanzania has estimated that it needs around 45,000 additional teachers to make up for those who have died or left work because of HIV and AIDS. The greatest proportion of staff that have been lost, according to the Tanzania Teacher’s Union, were experienced staff between the ages of 41 and 50.27
The impact on enterprises and workplaces

HIV and AIDS dramatically affect labour, setting back economic and social progress. The vast majority of people living with HIV in Africa are between the ages of 15 and 49 - in the prime of their working lives.

AIDS damages businesses by squeezing productivity, adding costs, diverting productive resources, and depleting skills. Company costs for health-care, funeral benefits and pension fund commitments are likely to rise as the number of people taking early retirement or dying increases. Also, as the impact of the epidemic on households grows more severe, market demand for products and services can fall. The epidemic hits productivity through increased absenteeism. Comparative studies of East African businesses have shown that absenteeism can account for as much as 25-54% of company costs.28

A study in several Southern African countries has estimated that the combined impact of AIDS-related absenteeism, productivity declines, health-care expenditures, and recruitment and training expenses could cut profits by at least 6-8%.29 Another study of a thousand companies in Southern Africa found that 9% had suffered a significant negative impact due to AIDS. In areas that have been hit hardest by the epidemic, it found that up to 40% of companies reported that HIV and AIDS were having a negative effect on profits.

Some companies, though, have implemented successful programmes to deal with the epidemic. An example is the gold-mining industry in South Africa. The gold mines attract thousands of workers, often from poor and remote regions. Most live in hostels, separated from their families. As a result a thriving sex industry operates around many mines and HIV is common. In recent years, mining companies have been working with a number of organisations to implement prevention programmes for the miners. These have included mass distribution of condoms, medical care and treatment for sexually transmitted diseases, and awareness campaigns. Some mining companies have started to replace all-male hostels with accommodation for families, in order to reduce the transmission of HIV and other sexually transmitted diseases.30

In Swaziland, an employers' anti-AIDS coalition has been set up to promote voluntary counselling and testing. The coalition not only includes larger companies but also small and medium sized enterprises.31 In Botswana, the Debswana diamond company offers all employees HIV testing, and provides antiretroviral drugs to HIV positive workers and their spouses.32 This policy was introduced in 1999 when the company found that many of their workforce were HIV positive. With a skilled workforce, it is financially worth their while to protect the health and therefore the productivity of their workers. Nevertheless, workplace programmes for HIV treatment and prevention remain scarce in Africa.33
The impact on life expectancy
man standing in front of his workshop

A coffin maker and his workshop in Nkhata Bay, Malawi

In many countries of sub-Saharan Africa, AIDS is erasing decades of progress in extending life expectancy. In the worst affected countries, average life expectancy has fallen by twenty years because of the epidemic.34 Life expectancy at birth in Swaziland is just 31 years - less than half of what it would be without AIDS.35

The impact that AIDS has had on average life expectancy is partly attributed to child mortality, as increasing numbers of babies are born with HIV infections acquired from their mothers. The biggest increase in deaths, however, has been among adults aged between 20 and 49 years. This group now accounts for 60% of all deaths in sub-Saharan Africa, compared to 20% between 1985 and 1990, when the epidemic was in its early stages.36 By affecting this age group so heavily, AIDS is hitting adults in their most economically productive years and removing the very people who could be responding to the crisis.
The economic impact

Through its impacts on the labour force, households and enterprises, AIDS has played a more significant role in the reversal of human development than any other single factor.37 One aspect of this development reversal has been the damage that the epidemic has done to the economy, which, in turn, has made it more difficult for countries to respond to the crisis.

One way in which AIDS affects the economy is by reducing the labour supply through increased mortality and illness. Amongst those who are able to work, productivity is likely to decline as a result of HIV-related illness. Government income also declines, as tax revenues fall and governments are pressured to increase their spending to deal with the expanding HIV epidemic.

The abilities of African countries to diversify their industrial base, expand exports and attract foreign investment are integral to economic progress in the region. By making labour more expensive and reducing profits, AIDS limits the ability of African countries to attract industries that depend on low-cost labour and makes investments in African businesses less desirable. HIV and AIDS therefore threaten the foundations of economic development in Africa.38

The impact that AIDS has had on the economies of African countries is difficult to measure. The economies of the worst affected countries were already struggling with development challenges, debt and declining trade before the epidemic started to affect the continent. AIDS has combined with these factors to further aggravate the situation. It is thought that the impact of AIDS on the gross domestic product (GDP) of the worst affected countries is a loss of around 1.5% per year; this means that after 25 years the economy would be 31% smaller than it would otherwise have been.39
The future impact of HIV/AIDS

This page has outlined just some of the ways in which the AIDS epidemic has had a significant impact on countries in sub-Saharan Africa. Although both international and domestic efforts to overcome the crisis have been strengthened in recent years, there is little sign of the epidemic diminishing. The people of sub-Saharan Africa will continue to feel the effects of HIV and AIDS for many years to come. It is clear that as much as possible needs to be done to minimise this impact.

As access to treatment is slowly expanded throughout the continent, millions of lives are being extended and hope is being given to people who previously had none. Unfortunately though, the majority of people in need of treatment are still not receiving it, and campaigns to prevent new infections (which must remain the central focus of the fight against AIDS) are lacking in many areas.

AIDS in Africa is linked to many other problems, such as poverty and poor public infrastructures. Efforts to fight the epidemic must take these realities into account, and look at ways in which the general development of Africa can progress. As the evidence discussed in this page makes clear, however, AIDS is acting as the single greatest barrier to Africa’s development. Much wider access to HIV prevention, treatment and care services is urgently needed.

AIDS AROUND THE WORLD

2009-12-17T07:19:00.000-08:00

When AIDS first emerged, no one could have predicted how the epidemic would spread across the world and how many millions of lives it would change. There was no real idea what caused it and consequently no real idea how to protect against it.

Now we know from bitter experience that AIDS is caused by the HIV virus, and that it can devastate families, communities and whole continents. We have seen the epidemic knock decades off countries' national development, widen the gulf between rich and poor nations and push already stigmatized groups closer to the margins of society. We are living in an 'international' society, and HIV has become the first truly 'international' epidemic, easily crossing oceans and borders.

However, experience has also shown us that the right approaches, applied quickly enough with courage and resolve, can and do result in lower national HIV infection rates and less suffering for those affected by the epidemic. We have learned that if a country acts early enough, a national HIV crisis can be averted.
Three AIDS orphans in Zambia, Southern Africa

Three AIDS orphans in Zambia, Southern Africa

It has been noted that a country with a very high HIV prevalence rate will often see this rate eventually stabilise, and even decline. In some cases this indicates, among other things, that people are beginning to change risky behaviour patterns, because they have seen and known people who have been killed by AIDS. Fear is the worst and last way of changing people's behaviour and by the time this happens it is usually too late to save a huge number of that country's population.

Already, more than twenty-five million people around the world have died of AIDS-related diseases. In 2008, 2.7 million people were newly infected with HIV, and 2 million men, women and children lost their lives. 33.4 million people around the world are now living with HIV.

It is disappointing that the global numbers of people infected with HIV continue to rise, despite the fact that effective prevention strategies already exist.
Africa

It is in Africa, in some of the poorest countries in the world, that the impact of the virus has been most severe. At the end of 2007, there were 9 countries in Africa where more than one tenth of the adult population aged 15-49 was infected with HIV. In three countries, all in the southern cone of the continent, at least one adult in five is living with the virus. In Botswana, a shocking 23.9% of adults are now infected with HIV, while in South Africa, 18.1% are infected. With a total of around 5.7 million infected, South Africa has more people living with HIV than any other country.
A mural in Ghana challenging HIV-related stigma

A mural in Ghana challenging HIV-related stigma

Rates of HIV infection are still extremely high in sub-Saharan Africa, and an estimated 1.9 million people in this region became newly infected in 2007. This means that there are now an estimated 22 million Africans living with HIV/AIDS. In this part of the world, particularly, women are disproportionately at risk. As the rate of HIV infection in the general population rises, the same patterns of sexual risk result in more new infections simply because the chances of encountering an infected partner become higher.

Although West Africa is less affected by HIV infection, the prevalence in some large countries is creeping up. Côte d'Ivoire is already among the fourteen worst affected countries in the world, and in Nigeria around 2.6 million adults and children are infected with HIV.

Infection rates in East Africa, once the highest on the continent, hover above those in the West but have been exceeded by the rates now seen in the southern cone. In 2007, HIV prevalence among adults in Kenya, Tanzania and Uganda exceeded 5%.

Increasing prevalence rates are not inevitable. In Uganda the estimated prevalence rate fell to around 5% from a peak of about 15% in the early 1990s. This trend is thought in part to have resulted from strong prevention campaigns, and there are encouraging signs of the same effect happening in parts of Zambia, Kenya and Zimbabwe. Yet the suffering generated by HIV infections acquired years ago continues to grow, and a drop in HIV prevalence is generally associated with a massive number of AIDS deaths. Under half of those in sub-Saharan Africa in need of antiretroviral treatment were receiving it at the end of 2008.

It is widely thought that North Africa managed to sidestep the global AIDS epidemic - perhaps due to its strict rules governing sexual behaviour. However, the latest UNAIDS estimates indicate that 35,000 people in North Africa and the Middle East acquired an HIV infection in 2008, bringing the total number of people living with HIV/AIDS in the Middle East and North Africa to an estimated 310,000. AIDS killed a further 20,000 people in this region in 2008.
Asia

The diversity of the AIDS epidemic is even greater in Asia than in Africa. The epidemic of AIDS in Asia appears to be of more recent origin, and many Asian countries lack accurate systems for monitoring the spread of HIV. Half of the world's population lives in Asia, so even small differences in the infection rates can mean huge increases in the absolute number of people infected.

In 2007, there were 2.4 million people living with HIV in India. Other large epidemics are present in China (700,000), Thailand (610,000) and Myanmar (240,000). The total number of people living with HIV in Asia is thought to be around 4.7 million.
HIV positive migrant workers in Mumbai, India

HIV positive migrant workers in Mumbai, India

National adult prevalence is under 1% in all Asian countries except Thailand. However some of the countries in this region are very large and national averages may obscure serious epidemics in some smaller provinces and states. India accounts for half of Asia's HIV epidemic.

In most Asian countries the epidemic is centred among particular high-risk groups, particularly men who have sex with men, injecting drug users, sex workers and their partners. However the epidemic has already begun to spread beyond these groups into the wider population. Some Asian countries, such as Thailand, have responded rapidly to the epidemic with extensive campaigns to educate the public and prevent the spread of HIV – and have succeeded in cutting prevalence. Other very populous regions, such as China, have only recently admitted that the spread of HIV threatens their populations, and as a result their prevention work is lagging behind the spread of the virus. Unless rapid and effective action is taken in this part of the world, then the size of the epidemic to come will dwarf the many deaths that have already occurred.

The epidemic in Asia has ample room for growth. The sex trade and the use of illicit drugs are extensive, and so are migration and mobility within and across borders. The fluidity in international markets and especially the lack of economic stability in Asia has erupted into non-stop movement within countries and among countries, facilitating the spread of HIV. India, China, Thailand and Cambodia, to name only a few, have highly mobile populations within their borders, with people moving from state to state and from rural to urban areas. In China, permanent and temporary migrants may total as many as 120 million people.
Eastern Europe & Central Asia

The AIDS epidemic in Eastern Europe & Central Asia is rapidly increasing. In 2008, some 1.5 million people were living with HIV, compared to 900,000 in 2001. AIDS claimed an estimated 87,000 lives during 2008, over three times 2001's figure.

In any country where rates of injecting drug use and needle sharing are high, a fresh outbreak of HIV is liable to occur at any time. This is especially true of the countries in Eastern Europe where the HIV epidemics are still young and have so far spared some cities and sub-populations. Heroin smuggled into the West crosses through a number of Eastern European countries, and its path is marked by a high concentration of injecting drug users, and a high HIV prevalence.

The Russian Federation, Ukraine, and the Baltic states (Estonia, Latvia, and Lithuania) are the worst affected, although HIV continues to spread in Belarus, Moldova and Kazakhstan, and more recent epidemics are emerging in Kyrgyzstan and Uzbekistan. An estimated 940,000 HIV-infected people were living in the Russian Federation at the end of 2007. However, as reporting of HIV cases in many areas of Russia is at best patchy, it is difficult to determine a precise figure. The epidemic in Eastern Europe is primarily driven by injecting drug use, and the criminalisation of this practice makes it difficult to gain an accurate picture of the proportion of drug users who are living with HIV.
Caribbean
AIDS activists in Haiti

AIDS activists in Haiti

HIV is ravaging the populations of several Caribbean island states. Indeed some have worse epidemics than any other country in the world outside sub-Saharan Africa. In the most affected countries of the Caribbean, the spread of HIV infection is driven by unprotected sex between men and women, although infections associated with injecting drug use are common in some places, such as Puerto Rico.

The Bahamas is the worst affected nation in the region, with a prevalence of 3%. Haiti, where the spread of HIV may well have been fuelled by decades of poor governance and conflict, has also been hard hit by the AIDS epidemic. An estimated 2.2% of Haitian adults were living with HIV at the end of 2007, though rates vary considerably between regions. HIV transmission in Haiti is overwhelmingly heterosexual, and both infection and death are concentrated in young adults. Many tens of thousands of Haitian children have lost one or both of their parents to AIDS. Among pregnant women in urban areas, HIV prevalence appears to have fallen by half between the mid-1990s and 2003-2004. Probably much of this decline is due to an increase in the AIDS death rate, though behaviour change might also have played a part. There is still an urgent need for intensified prevention efforts in Haiti.

On the Caribbean coast of South America, Suriname and Guyana had adult HIV prevalence rates of 2.4% and 2.5% respectively at the end of 2007. There are only limited data on HIV in Guyana, but it appears the country has a rapidly growing epidemic, which is becoming established within the general population.

The heterosexual epidemics of HIV infection in the Caribbean are driven by the deadly combination of early sexual activity and frequent partner exchange by young people. A study published in 2005 found that in Trinidad and Tobago, HIV infection levels are six times higher among 15-19 year old females than among males of the same age. In another survey in Barbados, one quarter of 15-29 year old women said they had been sexually active by the age of 15, and almost one in three men aged 15-29 years reported multiple sexual partnerships in the previous year.

AIDS is now high on the agendas of many governments in this region, as they are beginning to notice the significant impact of the epidemic on their medical systems and labour force. Cuba's comprehensive testing and prevention programmes have helped to keep its HIV infection rate below 0.2%, and the country provides free AIDS treatment to all those in need. In Barbados and Bermuda, wider access to antiretroviral treatment has cut AIDS deaths in half. Other countries are now seeking to emulate such successes.
Latin America

Around 2 million people were living with HIV in Latin America at the end of 2008. During that year, around 77,000 people died of AIDS and an estimated 170,000 were newly infected. The HIV epidemics in Latin America are highly diverse, and are fuelled by varying combinations of unsafe sex (both between men, and between men and women) and injecting drug use. In nearly all countries, the highest rates of HIV infection are found among men who have sex with men, and the second highest rates are found among female sex workers.

The Central American nation of Belize has a well-established epidemic, with the adult HIV prevalence rate above 2%. The virus is mainly spread through unprotected sex, particularly commercial sex and sex between men.

Commercial sex and sex between men are the major drivers of smaller epidemics elsewhere in Central America, where national HIV prevalence rates vary between 0.2% and 1%. Men who become infected via these routes are likely to pass the virus on to their wives and girlfriends.

Brazil had an adult HIV prevalence rate of 0.6% at the end of 2007, but, because of its large overall population, this country accounts for nearly half of all people living with HIV in Latin America. In Brazil, heterosexual transmission, injecting drug use and sex between men account for roughly equal numbers of infections.

HIV in Argentina was initially seen as a disease of male injecting drug users and men who have sex with men. Now the virus is spread mostly through heterosexual intercourse, and is affecting a rising number of women. The other Andean countries are currently among those least affected by HIV, although risky behaviour has been recorded in many groups.
Jorge Saavedra, head of Mexico's HIV prevention agency

Jorge Saavedra, head of Mexico's HIV prevention agency

One of the defining features of the Latin American epidemic is that several populous countries, including Argentina, Brazil and Mexico, are attempting to provide antiretroviral therapy to all those who need it. The governments of these countries have encouraged local pharmaceutical manufacturers to produce cheaper generic copies of patented medicines. This allows them to distribute drugs to a much greater proportion of their population that they would otherwise be able to help.

Treatment coverage still varies widely, but these efforts are having a definite impact. While they are improving both the length and the quality of people's lives, they are also increasing the proportion of people living with HIV, and thus HIV prevalence figures. Some concern has been voiced over the harm that HIV prevention activities may suffer if much effort and money is devoted to providing treatment.
High-income countries

In high-income nations, HIV infections have historically been concentrated principally among injecting drug users and gay men. These groups are still at high risk, but heterosexual intercourse accounts for a growing proportion of cases. In the United States, more than a quarter of people diagnosed with HIV in 2006 were female, and more than three quarters of these women were probably infected as a result of heterosexual sex. In several countries in Western Europe, including the United Kingdom, heterosexual contact is the most frequent cause of newly diagnosed infections.

Very early in the epidemic, once information and services for prevention had been made available to most of the population, the level of unprotected sex fell in many countries and the demand rose for reproductive health services, HIV counselling and testing and other preventive services. However prevention activities are now lagging behind as the epidemics move beyond their traditional at-risk groups.

Prevention work in high-income countries has declined, and sexual-health education in schools is still not universally guaranteed, in spite of the fact that the risks of HIV are well-known to governments. Political factors have been allowed to control the HIV prevention work that is done, and politicians are commonly keen to avoid talking about any sexual issues. Furthermore, it is very hard to show that a number of people are not HIV positive who otherwise would be – and politicians like the electorate to see results.

Among gay men, the virus had spread widely before it was even identified and had established a firm grip on the population by the early 1980s. With massive early prevention campaigns targeted at gay communities, risk behaviour was substantially reduced and the rate of new infections dropped significantly during the mid- and late 1980s. Recent information suggests, however, that risky behaviour may be increasing again in some communities. People think that the danger is over because of lack of media coverage of the issues around HIV and AIDS - and many new infections continue to occur.

Some communities and countries have initiated aggressive HIV prevention efforts, particularly among high-risk groups such as injecting drug users. But in many places the political cost of implementing needle exchange and other prevention programmes has been considered too high for them to be started or maintained. As a result, there are continuing high prevalence rates among injecting drug users in many high-income countries, particularly Italy, Spain and Portugal.

Many high-income countries suffer from the belief that HIV is something that affects other people, not their own populations. On a national level, this belief prevents policy makers and budget setters from seeing the epidemic on their own doorsteps, looking instead to the situation in areas such as Africa. Some high-income countries fund medication provision for low-income countries whilst failing to provide medicines for their own citizens who have AIDS. For example, many people cannot afford HIV treatment in America.
Where do we go from here?
Spending

Money is finally being spent on both treating the disease and on preventing new infections from occurring. This spending needs to increase both in its magnitude and its effectiveness. Many people fail to realise that actually spending money, in the very large sums the fight against HIV requires, is a difficult task, and one of which many organisations have little experience.

The Global Fund, an organisation created to channel money to where around the world it is most needed, is an already-existing way of effectively spending money. Many governments, however, wish to exert control over how their donations are spent and on what projects, so they prefer to channel their funding through other channels.

In January 2003, President Bush announced a bold new initiative known as PEPFAR, through which the USA will spent $18 billion over five years on HIV/AIDS prevention, treatment and care programmes in other countries. In 2008, Bush reauthorised PEPFAR, pledging a further US$39 billion to tackle the global AIDS epidemic.
Prevention and education

Education has already been proved to be effective and necessary, both for people who are not infected with HIV - to enable them to protect themselves from HIV - and for people who are HIV positive - to help them to live with the virus. There is a huge wealth of educational resources available around the world, and yet in many places people still lack the knowledge they need to protect themselves.

AIDS is a preventable disease, but to avoid HIV infection people need more than just factual information. People need empowerment to negotiate safe and responsible sexual relationships; gender inequalities must be confronted; and those who choose to have sex need access to condoms. Needle exchanges should be encouraged, as they have proven highly effective at preventing HIV transmission among injecting drug users.
Medication

Antiretroviral AIDS medication is now being distributed to low-income, high prevalence countries, but it is taking a long time to actually reach the people who need it. Access to HIV treatment must greatly improve if millions of deaths are to be avoided. One of the greatest challenges is a shortage of health workers to carry out HIV tests, administer the medicines, and teach people how to use them.
Conclusion

HIV has finally been recognised as a global threat, and people are beginning to take action to prevent it killing many millions more than those who have already died. This action needs to be speeded up considerably. The HIV epidemic is growing, and efforts to fight it need to grow at an even greater rate if they are to be successful.

An ever-growing AIDS epidemic is not inevitable. However, unless action against the epidemic is scaled up drastically, the damage already done will seem minor compared with what lies ahead. This may sound dramatic, but it is hard to play down the effects of a disease that stands to kill more than half of the young adults in the countries where it has its firmest hold. Entire families, communities and countries will begin to collapse if this situation is allowed to occur.

HIV and AIDS in Africa

2009-12-17T07:16:00.000-08:00

Sub-Saharan Africa is more heavily affected by HIV and AIDS than any other region of the world. An estimated 22.4 million people are living with HIV in the region - around two thirds of the global total. In 2008 around 1.4 million people died from AIDS in sub-Saharan Africa and 1.9 million people became infected with HIV. Since the beginning of the epidemic more than 14 million children have lost one or both parents to AIDS.1

In the absence of massively expanded prevention, treatment and care efforts, it is expected that the AIDS death toll in sub-Saharan Africa will continue to rise. This means the impact of the AIDS epidemic on these societies will be felt most strongly in the course of the next ten years and beyond. Its social and economic consequences are already widely felt, not only in the health sector but also in education, industry, agriculture, transport, human resources and the economy in general. The AIDS epidemic in sub-Saharan Africa threatens to devastate whole communities, rolling back decades of development progress.

Sub-Saharan Africa faces a triple challenge:

* Providing health care, antiretroviral treatment, and support to a growing population of people with HIV-related illnesses.
* Reducing the annual toll of new HIV infections by enabling individuals to protect themselves and others.
* Coping with the impact of over 20 million AIDS deaths, on orphans and other survivors, communities, and national development.

How are different countries in Africa affected by HIV and AIDS?
Mother and child, both HIV positive, at Nsanje district hospital in Malawi

Mother and child, both HIV positive, at Nsanje district hospital in Malawi

Both HIV prevalence rates and the numbers of people dying from AIDS vary greatly between African countries.

In Somalia and Senegal the HIV prevalence is under 1% of the adult population, whereas in Namibia, South Africa, Zambia and Zimbabwe around 15-20% of adults are infected with HIV. In three southern African countries, the national adult HIV prevalence rate now exceeds 20%. These countries are Botswana (23.9%), Lesotho (23.2%) and Swaziland (26.1%).2

West Africa has been less affected by HIV and AIDS, but some countries are experiencing rising HIV prevalence rates. In Cameroon HIV prevalence is now estimated at 5.1% and in Gabon it stands at 5.9%. In Nigeria, HIV prevalence is low (3.1%) compared to the rest of Africa. However, because of its large population (it is the most populous country in sub-Saharan Africa), this equates to around 2.6 million people living with HIV.3

Adult HIV prevalence in East Africa exceeds 5% in Uganda, Kenya and Tanzania.4

Overall, rates of new HIV infections in sub-Saharan Africa appear to have peaked in the late 1990s, and HIV prevalence seems to have declined slightly, although it remains at an extremely high level. History of AIDS in Africa has more information about how HIV prevalence has changed over time.
What is the impact of AIDS on Africa?

HIV and AIDS are having a widespread impact on many parts of African society. The points below describe some of the major effects of the AIDS epidemic. For a more detailed examination, visit our African impact page.

* The effect on life expectancy. In many countries of sub-Saharan Africa, AIDS is erasing decades of progress made in extending life expectancy. Millions of adults are dying from AIDS while they are still young, or in early middle age. Average life expectancy in sub-Saharan Africa is now 47 years, when it could have been 62 without AIDS.
* The effect on households. The effect of the AIDS epidemic on households can be very severe. Many families are losing their income earners. In other cases, people have to provide home based care for sick relatives, reducing their capacity to earn money for their family. Many of those dying from AIDS have surviving partners who are themselves infected and in need of care. They leave behind orphans, grieving and struggling to survive without a parent's care.
* The effect on healthcare. In all affected countries, the epidemic is putting strain on the health sector. As the epidemic develops, the demand for care for those living with HIV rises, as does the number of health care workers affected.
* The effect on schools. Schools are heavily affected by AIDS. This a major concern, because schools can play a vital role in reducing the impact of the epidemic, through HIV education and support.
* The effect on productivity. The HIV and AIDS epidemic has dramatically affected labour, which in turn slows down economic activity and social progress. The vast majority of people living with HIV and AIDS in Africa are between the ages of 15 and 49 - in the prime of their working lives. Employers, schools, factories and hospitals have to train other staff to replace those at the workplace who become too ill to work.
* The effect on economic growth and development. The HIV and AIDS epidemic has already significantly affected Africa's economic development, and in turn, has affected Africa's ability to cope with the epidemic.

HIV prevention in Africa
HIV/AIDS awareness billboard in Lundazi, Zambia

HIV/AIDS awareness billboard in Lundazi, Zambia

A number of African countries have conducted large-scale HIV prevention initiatives in an effort to reduce the scale of their epidemics. Senegal, for example, responded early to the emergence of HIV with strong political and community leadership.5 It is impossible to predict how Senegal's epidemic would have progressed without intervention, but Senegal now has one of the lowest HIV prevalence rates in sub-Saharan Africa.

The situation in Uganda is similarly successful. HIV prevalence among pregnant women in Uganda fell from a high of around 30% in the early 1990s to around 10% in 2001;6 a change which is thought to be largely a result of intensive HIV prevention campaigns. Declines in HIV prevalence have also been seen in Kenya, Zimbabwe and urban areas of Zambia and Burkina Faso.

However, not all African countries have had such successful HIV prevention campaigns. In South Africa, the government's failure to respond to the AIDS crisis has lead to an unprecedented number of people living with HIV. An estimated 70,000 babies are born with HIV every year, reflecting significant failures in prevention of mother-to-child transmission initiatives.
Condom use and HIV

Condoms play a key role in preventing HIV infection around the world. In sub-Saharan Africa, most countries have seen an increase in condom use in recent years. In studies carried out between 2001 and 2005, eight out of eleven countries in sub-Saharan Africa reported an increase in condom use.7

The distribution of condoms to countries in sub-Saharan Africa has also increased: in 2004 the number of condoms provided to this region by donors was the equivalent of 10 for every man,8 compared to 4.6 for every man in 2001.9 In most countries, though, many more condoms are still needed. For instance, in Uganda between 120 and 150 million condoms are required annually, but less than 40 million were provided in 2005.10

Relative to the enormity of the HIV/AIDS epidemic in Africa, providing condoms is cheap and cost effective. Even when condoms are available, though, there are still a number of social, cultural and practical factors that may prevent people from using them. In the context of stable partnerships where pregnancy is desired, or where it may be difficult for one partner to suddenly suggest condom use, this option may not be practical.
Provision of Voluntary HIV Counselling & Testing (VCT)
Chief Chikanta at a VCT sign in Zambia

Chief Chikanta at a VCT sign in Zambia

The provision of voluntary HIV counselling and testing (VCT) is an important part of any national prevention programme. It is widely recognised that individuals living with HIV who are aware of their status are less likely to transmit HIV infection to others, and are more likely to access treatment, care and support that can help them to stay healthy for longer. VCT also provides benefit for those who test negative, in that their behaviour may change as a result of the test.

The provision of VCT has become easier, cheaper and more effective as a result of the introduction of rapid HIV testing, which allows individuals to receive a test and the results in the same day. VCT could – and needs to be – made more widely available in most sub-Saharan African countries.
Mother-to-child transmission of HIV

Around 390,000 children in sub-Saharan Africa became infected with HIV in 2008.11 The vast majority of these children have been infected with HIV during pregnancy, childbirth or breastfeeding, as a result of their mother being infected with the virus.

Without interventions, there is a 20-45% chance that an HIV-positive mother will pass infection on to her child. If a woman is supplied with antiretroviral drugs, however, this risk can be significantly reduced. Before these measures can be taken the mother must be aware of her HIV infection, so testing also plays a vital role in the prevention of MTCT.

In many developed countries, these steps have helped to virtually eliminate MTCT. Yet sub-Saharan Africa continues to be severely affected by the problem, due to a lack of drugs, services and information, and the shortage of testing facilities. In 2006, preventive drugs reached only 31% of HIV-infected pregnant women in Eastern and Southern Africa, and only 7% in West and Central Africa.12

Given the scale of the MTCT crisis in Africa, it is remarkable that more is not being done (by both the international community and domestic governments) to prevent the rising numbers of children becoming infected with HIV, and dying from AIDS. AVERT is calling for vast improvements in preventing MTCT strategies through our Stop AIDS in Children campaign. This crisis is discussed in more detail in our PMTCT worldwide page.
HIV/AIDS related treatment and care in Africa

Antiretroviral drugs (ARVs) - which significantly delay the progression of HIV to AIDS and allow people living with HIV to live relatively normal, healthy lives – have been available in richer parts of the world since around 1996. Distributing these drugs requires money, a well-structured health system and a sufficient supply of healthcare workers. The majority of developing countries are lacking in these areas and have struggled to cope with the increasing numbers of people requiring treatment.

For most Africans living with HIV, ARVs are still not available - just under half of those in need of treatment are receiving it.13 Millions are not even receiving treatment for opportunistic infections, which affect individuals whose immune systems have been weakened by HIV infection. These facts reflect the world’s continuing failure, despite the progress of recent years, to mount a response that matches the scale and severity of the global AIDS epidemic.
Access to antiretroviral treatment in Botswana

Access to antiretroviral treatment in Botswana

Botswana pioneered the provision of ARVs in Africa, starting its national treatment programme in January 2002. By 2005 this programme was providing treatment to the vast majority of those in need. According to World Health Organisation figures, 93,000 people were receiving treatment in Botswana at the end of 2007 - a coverage rate of around 80%.14 Among the other countries that have made advances are Rwanda and Namibia, where more than 70% of people in need of ARVs are receiving them.

While most African countries have now started to distribute ARVs, progress in providing sufficient quantities of the drugs has been uneven and Botswana’s success has not been emulated elsewhere. In Cameroon, Côte d’Ivoire, Kenya, Malawi and Nigeria, between 25% and 45% of people requiring antiretroviral drugs were receiving them in December 2007. While South Africa is the richest nation in sub-Saharan Africa and should have led the way in ARV distribution, its government was slow to act, and so far, only 28% of those in need of treatment in South Africa are receiving it. In other countries, such as Chad, Congo, Ghana, Sudan and Zimbabwe, the figure is less than 20%.15

Nonetheless, the overall situation is slowly improving; the number of people receiving ARVs in Africa doubled in 2005 alone.16 International support has helped this increase, with numerous governments and international organisations encouraging progress. In 2003 the World Health Organisation (WHO) initiated the ‘3 by 5’ programme, which aimed to have three million people in developing countries on ARVs by the end of 2005. While this target was not reached, a number of African nations made substantial progress under the scheme. The latest international target, ‘All by 2010’, is aiming at universal access to treatment by 2010. In pursuit of this goal it is hoped that considerable progress will be made in Africa's fight against AIDS.

There are still, however, a number of impediments to ARV provision. One major challenge is the fact that the majority of African countries have a poor healthcare infrastructure and a shortage of medical professionals. A considerable emphasis needs to placed not only on the availability of ARVs, but also the availability of professionals who are able to administer the drugs.

Another major challenge is ensuring that drugs are not only supplied to a lot of areas, but that sufficient quantities of drugs are supplied to those areas. This is critically important, because once an individual starts to take ARVs they have to take them for the rest of their life. If, for instance, their local hospital runs out of ARVs, the interruption that this causes in their treatment could result in drug resistance. To improving treatment programs, African countries face the double challenge of getting new people to start treatment and maintaining the supply of treatment to those who are already receiving ARVs.

Treatment and care for HIV consists of a number of different elements apart from ARVs. These include voluntary counselling and testing, food and management of nutrition, follow-up counselling, protection from stigma and discrimination, treatment of other sexually transmitted infections, and the prevention and treatment of opportunistic infections. Alongside antiretroviral treatment, all of these elements should be made available for all people living with HIV.
What needs to be done to make a difference in Africa?
International support
UN staff members form the AIDS ribbon

UN staff members form the AIDS ribbon

One of the most important ways in which the situation in Africa can be improved is through increased funding for HIV/AIDS. More money would help to improve both prevention campaigns and the provision of treatment and care for those living with HIV. Developed countries have increased funding for the fight against AIDS in Africa in recent years, perhaps most significantly through the Global Fund. The Global Fund was started in 2001 to co-ordinate international funding and has since approved grants totalling US $7.2 billion to help fight AIDS, TB and Malaria in 137 countries.17 This funding is making a significant difference, but given the massive scale of the AIDS epidemic more money is still needed.

The US Government has shown a commitment to fighting AIDS in Africa through the President’s Emergency Plan For AIDS Relief (PEPFAR). Started in 2003, PEPFAR provides money to fight AIDS in numerous countries, including 15 focus countries, most of which are African. In Fiscal Year 2009, PEPFAR allocated almost US $6.5 billion for combating AIDS, TB and Malaria.18 The US Government is also the largest contributor to the Global Fund.

Among other things, organisations like PEPFAR and the Global Fund provide vital support to local and community groups that are working 'on the ground' to provide relief in Africa. These groups are directly helping people in need, and many rely on international funding in order to operate. Getting money from large, international donors to small, 'grassroots organisations' can present a number of difficulties though, as money is lost or delayed as it is passed down large funding chains.
Domestic commitment

More than money is needed if HIV prevention and treatment programmes are to be scaled up in Africa. In order to implement such programmes, a country’s health, education and communication systems and infrastructures must be sufficiently developed. In some African countries these systems are already under strain and are at risk of collapsing as a result of AIDS. Money can also only be used efficiently if there are sufficient human resources available, but there is an acute shortage of trained personnel in many parts of Africa.

In many cases, African countries also need more commitment from their governments. There are promising signs that some governments are starting to respond and becoming more involved in the fight against AIDS, and this commitment needs to be sustained if the severe impact of Africa's AIDS epidemic is to be reduced.
Reducing stigma and discrimination

HIV-related stigma and discrimination remains an enormous barrier to the fight against AIDS. Fear of discrimination often prevents people from getting tested, seeking treatment and admitting their HIV status publicly. Since laws and policies alone cannot reverse the stigma that surrounds HIV infection, AIDS education in Africa needs to be scaled-up to combat the ignorance that causes people to discriminate. The fear and prejudice that lies at the core of HIV and AIDS discrimination needs to be tackled at both community and national levels.
Helping women and girls

In many parts of Africa, as elsewhere in the world, the AIDS epidemic is aggravated by social and economic inequalities between men and women. Women and girls commonly face discrimination in terms of access to education, employment, credit, health care, land and inheritance. These factors can all put women in a position where they are particularly vulnerable to HIV infection. In sub-Saharan Africa, around 59% of those living with HIV are female.

In many African countries, sexual relationships are dominated by men, meaning that women cannot always practice safer sex even when they know the risks involved. Attempts are currently being made to develop a microbicide – a cream or gel that can be applied to the vagina, preventing HIV infection – which could be a significant breakthrough in protecting women against HIV. It is likely to be some time before a microbicide is ready for use, though, and even when it is, women will only use it if they have an awareness and understanding of HIV and AIDS. To promote this, a greater emphasis needs to be placed on educating women and girls about AIDS, and adapting education systems to their needs. In some Southern African countries the rate of HIV among 23-24 year old females is far higher than that of 15-17 year old girls. This suggests prevention activities should target women at a young age and ensure they have the knowledge and skills to avoid HIV infection from when they become sexually active.19

Read more about women and HIV.
The way forward

Tackling the AIDS crisis in Africa is a long-term task that requires sustained effort and planning - both within African countries themselves and amongst the international community. One of the most important elements of the fight against AIDS is the prevention of new HIV infections. HIV prevention campaigns that have been successful within African countries need to be highlighted and repeated.

The other main challenge is providing treatment and care to those living with HIV in Africa, in particular ARVs, which can allow people living with HIV to live longer and healthier lives. Many African countries have made significant progress in their treatment programmes in recent years and it is likely that the next few years will see many more people receiving the drugs.

How to Help Fight HIV/AIDS

2009-12-17T07:11:00.001-08:00

On this World AIDS Day, there was a dramatic announcement from South Africa, which has the most HIV cases of any country -- and has spent years turning its back on the best science and drugs for the disease. All HIV-positive babies will now be treated, testing and treatment will be expanded for pregnant women, and President Jacob Zuma will take an HIV test.

But the toll AIDS has taken on South Africa is impossible to measure. David Muir met four children in Johannesburg -- enduring great loss. 17-year old Thozama and her teenage brother Thozamele where orphaned when their mother died of AIDS three years ago. They now take on the role of parents in caring for their two younger sisters who are still in elementary school. The four children live together without power or running water.

Nhlanhla Mosebi is the project manager of a group working to help children in the township where Thozama, Thozamele and their sisters live.

HIV science

2009-12-03T04:52:00.000-08:00

HIV stands for Human Immunodeficiency Virus. Like all viruses, HIV cannot grow or reproduce on its own. In order to make new copies of itself it must infect the cells of a living organism.
What does HIV look like?
HIV and CD4+ cell

In this computer generated image, the large object is a

human CD4+ white blood cell, and the spots on its surface

and the spiky blue objects in the foreground

represent HIV particles.

Outside of a human cell, HIV exists as roughly spherical particles (sometimes called virions). The surface of each particle is studded with lots of little spikes.

An HIV particle is around 100-150 billionths of a metre in diameter. That's about the same as:

* 0.1 microns
* 4 millionths of an inch
* one twentieth of the length of an E. coli bacterium
* one seventieth of the diameter of a human CD4+ white blood cell.

Unlike most bacteria, HIV particles are much too small to be seen through an ordinary microscope. However they can be seen clearly with an electron microscope.

HIV particles surround themselves with a coat of fatty material known as the viral envelope (or membrane). Projecting from this are around 72 little spikes, which are formed from the proteins gp120 and gp41. Just below the viral envelope is a layer called the matrix, which is made from the protein p17.
HIV structure

The proteins gp120 and gp41 together make up the spikes

that project from HIV particles, while p17 forms the matrix

and p24 forms the core.

The viral core (or capsid) is usually bullet-shaped and is made from the protein p24. Inside the core are three enzymes required for HIV replication called reverse transcriptase, integrase and protease. Also held within the core is HIV's genetic material, which consists of two identical strands of RNA.
What is RNA?

HIV belongs to a special class of viruses called retroviruses. Within this class, HIV is placed in the subgroup of lentiviruses. Other lentiviruses include SIV, FIV, Visna and CAEV, which cause diseases in monkeys, cats, sheep and goats. Almost all organisms, including most viruses, store their genetic material on long strands of DNA. Retroviruses are the exception because their genes are composed of RNA (Ribonucleic Acid).

RNA has a very similar structure to DNA. However, small differences between the two molecules mean that HIV's replication process is a bit more complicated than that of most other viruses.
How many genes does HIV have?

HIV has just nine genes (compared to more than 500 genes in a bacterium, and around 20,000-25,000 in a human). Three of the HIV genes, called gag, pol and env, contain information needed to make structural proteins for new virus particles. The other six genes, known as tat, rev, nef, vif, vpr and vpu, code for proteins that control the ability of HIV to infect a cell, produce new copies of virus, or cause disease.

At either end of each strand of RNA is a sequence called the long terminal repeat, which helps to control HIV replication.
HIV life cycle
Entry

A scientific video about the process of HIV cell entry.

HIV can only replicate (make new copies of itself) inside human cells. The process typically begins when a virus particle bumps into a cell that carries on its surface a special protein called CD4. The spikes on the surface of the virus particle stick to the CD4 and allow the viral envelope to fuse with the cell membrane. The contents of the HIV particle are then released into the cell, leaving the envelope behind.
Reverse Transcription and Integration

Once inside the cell, the HIV enzyme reverse transcriptase converts the viral RNA into DNA, which is compatible with human genetic material. This DNA is transported to the cell's nucleus, where it is spliced into the human DNA by the HIV enzyme integrase. Once integrated, the HIV DNA is known as provirus.
Transcription and Translation

HIV provirus may lie dormant within a cell for a long time. But when the cell becomes activated, it treats HIV genes in much the same way as human genes. First it converts them into messenger RNA (using human enzymes). Then the messenger RNA is transported outside the nucleus, and is used as a blueprint for producing new HIV proteins and enzymes.
Assembly, Budding and Maturation
HIV budding from a cell

This electron microscope photo shows newly formed HIV particles budding from a human cell.

Among the strands of messenger RNA produced by the cell are complete copies of HIV genetic material. These gather together with newly made HIV proteins and enzymes to form new viral particles, which are then released from the cell. The enzyme protease plays a vital role at this stage of the HIV life cycle by chopping up long strands of protein into smaller pieces, which are used to construct mature viral cores.

The newly matured HIV particles are ready to infect another cell and begin the replication process all over again. In this way the virus quickly spreads through the human body. And once a person is infected, they can pass HIV on to others in their bodily fluids.
HIV types, subtypes groups and strains
Introduction to HIV types, groups and subtypes

HIV is a highly variable virus which mutates very readily. This means there are many different strains of HIV, even within the body of a single infected person.

Based on genetic similarities, the numerous virus strains may be classified into types, groups and subtypes.
What is the difference between HIV-1 and HIV-2?

There are two types of HIV: HIV-1 and HIV-2. Both types are transmitted by sexual contact, through blood, and from mother to child, and they appear to cause clinically indistinguishable AIDS. However, it seems that HIV-2 is less easily transmitted, and the period between initial infection and illness is longer in the case of HIV-2.

Worldwide, the predominant virus is HIV-1, and generally when people refer to HIV without specifying the type of virus they will be referring to HIV-1. The relatively uncommon HIV-2 type is concentrated in West Africa and is rarely found elsewhere.
How many subtypes of HIV-1 are there?

The strains of HIV-1 can be classified into four groups: the "major" group M, the "outlier" group O and two new groups, N and P. These four groups may represent four separate introductions of simian immunodeficiency virus into humans.
HIV types, groups and subtypes

The different levels of HIV classification.

Group O appears to be restricted to west-central Africa and group N - a strain discovered in 1998 in Cameroon - is extremely rare. In 2009 a new strain closely relating to gorilla simian immunodeficiency virus was discovered in a Cameroonian woman. It was designated HIV-1 group P.1 More than 90% of HIV-1 infections belong to HIV-1 group M and, unless specified, the rest of this page will relate to HIV-1 group M only.

Within group M there are known to be at least nine genetically distinct subtypes (or clades) of HIV-1. These are subtypes A, B, C, D, F, G, H, J and K.

Occasionally, two viruses of different subtypes can meet in the cell of an infected person and mix together their genetic material to create a new hybrid virus (a process similar to sexual reproduction, and sometimes called "viral sex").2 Many of these new strains do not survive for long, but those that infect more than one person are known as "circulating recombinant forms" or CRFs. For example, the CRF A/B is a mixture of subtypes A and B.

The classification of HIV strains into subtypes and CRFs is a complex issue and the definitions are subject to change as new discoveries are made. Some scientists talk about subtypes A1, A2, A3, F1 and F2 instead of A and F, though others regard the former as sub-subtypes.
What about subtypes E and I?

One of the CRFs is called A/E because it is thought to have resulted from hybridization between subtype A and some other "parent" subtype E. However, no one has ever found a pure form of subtype E. Confusingly, many people still refer to the CRF A/E as "subtype E" (in fact it is most correctly called CRF01_AE).3

A virus isolated in Cyprus was originally placed in a new subtype I, before being reclassified as a recombinant form A/G/I. It is now thought that this virus represents an even more complex CRF comprised of subtypes A, G, H, K and unclassified regions. The designation "I" is no longer used.4
Where are the different subtypes and CRFs found?

The HIV-1 subtypes and CRFs are very unevenly distributed throughout the world, with the most widespread being subtypes A and C.

* Subtype A and CRF A/G predominate in West and Central Africa, with subtype A possibly also causing much of the Russian epidemic.5
* Historically, subtype B has been the most common subtype/CRF in Europe, the Americas, Japan and Australia. Although this remains the case, other subtypes are becoming more frequent and now account for at least 25% of new HIV infections in Europe.
* Subtype C is predominant in Southern and East Africa, India and Nepal. It has caused the world's worst HIV epidemics and is responsible for around half of all infections.
* Subtype D is generally limited to East and Central Africa. CRF A/E is prevalent in South-East Asia, but originated in Central Africa. Subtype F has been found in Central Africa, South America and Eastern Europe. Subtype G and CRF A/G have been observed in West and East Africa and Central Europe.
* Subtype H has only been found in Central Africa; J only in Central America; and K only in the Democratic Republic of Congo and Cameroon.

Are more subtypes likely to "appear"?

It is almost certain that new HIV genetic subtypes and CRFs will be discovered in the future, and indeed that new ones will develop as virus recombination and mutation continue to occur. The current subtypes and CRFs will also continue to spread to new areas as the global epidemic continues.
The implications of variability
Does subtype affect disease progression?

A study presented in 2006 found that Ugandans infected with subtype D or recombinant strains incorporating subtype D developed AIDS sooner than those infected with subtype A, and also died sooner, if they did not receive antiretroviral treatment. The study's authors suggested that subtype D is more virulent because it is more effective at binding to immune cells.6 This result was supported by another study presented in 2007, which found that Kenyan women infected with subtype D had more than twice the risk of death over six years compared with those infected with subtype A.7 An earlier study of sex workers in Senegal, published in 1999, found that women infected with subtype C, D or G were more likely to develop AIDS within five years of infection than those infected with subtype A.8

Several studies conducted in Thailand suggest that people infected with CRF A/E progress faster to AIDS and death than those infected with subtype B, if they do not receive antiretroviral treatment.9
Are there differences in transmission?

It has been observed that certain subtypes/CRFs are predominantly associated with specific modes of transmission. In particular, subtype B is spread mostly by homosexual contact and intravenous drug use (essentially via blood), while subtype C and CRF A/E tend to fuel heterosexual epidemics (via a mucosal route).

Whether there are biological causes for the observed differences in transmission routes remains the subject of debate. Some scientists, such as Dr Max Essex of Harvard, believe such causes do exist. Among their claims are that subtype C and CRF A/E are transmitted much more efficiently during heterosexual sex than subtype B.10 11 However, this theory has not been conclusively proven.12 13

More recent studies have looked for variation between subtypes in rates of mother-to-child transmission. One of these found that such transmission is more common with subtype D than subtype A.14 Another reached the opposite conclusion (A worse than D), and also found that subtype C was more often transmitted that subtype D.15 A third study concluded that subtype C is more transmissible than either D or A.16 Other researchers have found no association between subtype and rates of mother-to-child transmission.17 18 19 20
Is it possible to be infected more than once?

Until about 1994, it was generally thought that individuals do not become infected with multiple distinct HIV-1 strains. Since then, many cases of people coinfected with two or more strains have been documented.

All cases of coinfection were once assumed to be the result of people being exposed to the different strains more or less simultaneously, before their immune systems had had a chance to react. However, it is now thought that "superinfection" is also occurring. In these cases, the second infection occurred several months after the first. It would appear that the body's immune response to the first virus is sometimes not enough to prevent infection with a second strain, especially with a virus belonging to a different subtype. It is not yet known how commonly superinfection occurs, or whether it can take place only in special circumstances.21 22
Do HIV antibody tests detect all types, groups and subtypes?

Initial tests for HIV are usually conducted using the EIA (or ELISA) antibody test or a rapid antibody test.

EIA tests which can detect either one or both types of HIV have been available for a number of years. According to the US Centers for Disease Control and Prevention, current HIV-1 EIAs "can accurately identify infections with nearly all non-B subtypes and many infections with group O HIV subtypes."23 However, because HIV-2 and group O infections are extremely rare in most countries, routine screening programs might not be designed to test for them. Anyone who believes they may have contracted HIV-2, HIV-1 group O or one of the rarer subtypes of group M should seek expert advice.

Rapid tests - which can produce a result in less than an hour - are becoming increasingly popular. Most modern rapid HIV-1 tests are capable of detecting all the major subtypes of group M.24 Rapid tests which can detect HIV-2 are also now available.25
What are the treatment implications?

Although most current HIV-1 antiretroviral drugs were designed for use against subtype B, there is no compelling evidence that they are any less effective against other subtypes. Nevertheless, some subtypes may be more likely to develop resistance to certain drugs, and the types of mutations associated with resistance may vary. This is an important subject for future research.

The effectiveness of HIV-1 treatment is monitored using viral load tests. It has been demonstrated that some such tests are sensitive only to subtype B and can produce a significant underestimate of viral load if used to process other strains. The latest tests do claim to produce accurate results for most Group M subtypes, though not necessarily for Group O. It is important that health workers and patients are aware of the subtype/CRF they are testing for and of the limitations of the test they are applying.

Not all of the drugs used to treat HIV-1 infection are as effective against HIV-2. In particular, HIV-2 has a natural resistance to NNRTI antiretroviral drugs and they are therefore not recommended. As yet there is no FDA-licensed viral load test for HIV-2 and those designed for HIV-1 are not reliable for monitoring the other type. Instead, response to treatment may be monitored by following CD4+ T-cell counts and indicators of immune system deterioration. More research and clinical experience is needed to determine the most effective treatment for HIV-2.26
What are the implications for an AIDS vaccine?

The development of an AIDS vaccine is affected by the range of virus subtypes as well as by the wide variety of human populations who need protection and who differ, for example, in their genetic make-up and their routes of exposure to HIV. In particular, the occurrence of superinfection indicates that an immune response triggered by a vaccine to prevent infection by one strain of HIV may not protect against all other strains. The effectiveness of a vaccine is likely to vary in different populations unless some innovative method is developed which guards against many virus strains.

Inevitably, different types of candidate vaccines will have to be tested against various viral strains in multiple vaccine trials, conducted in both high-income and developing countries.

Animal testing (also known as vivisection) elicits strong opinions from both those for and those against the practice. Its role in developing HIV treatments and AIDS vaccines is no less controversial.

Developing therapeutic and diagnostic products for use in humans is a long and complex process. With HIV infection, the search for effective drugs and vaccines has proven particularly difficult, as HIV is exceptionally good at changing its structure and evading destruction. In an ideal world, scientists would be able to test thousands of different compounds on human participants to see if any cured, treated or vaccinated them against HIV. However, to do this would be both highly time consuming and dangerous, as most compounds would not be effective, and some might cause illness or even death.

Researchers therefore often use animals to help them test the efficacy of drugs and vaccines, and to make sure that these products are safe. There are of course many ethical implications to animal experimentation, and many people are strongly opposed to the use of animals in any sort of experiment or study that may cause them distress or harm. So is it really necessary to use animals in the production of HIV drugs and vaccines? And are there any alternatives to animal testing?
Why are tests performed on animals?

There are three reasons why animals may be used in scientific experimentation. The first is to ensure the safety of new drugs and other pharmaceutical products. The second is to see whether such products might be effective in humans. The third is for general research into the biology of an animal, or the function and action of certain diseases within its body.
Safety trials

In many countries it is a legal requirement that all drugs and vaccines (not just for HIV) are tested on animals to ensure safety. In the United Kingdom for example, the Medicines Act of 1968 1 states that all new pharmaceutical products must be tested on at least two different species of live mammal, one of which must be a large non-rodent. This legislation was introduced shortly after the discovery that the drug Thalidomide could cause serious physical deformities in babies born to mothers who had taken it during pregnancy. Thalidomide was not thoroughly tested on animals (particularly pregnant animals) before it was prescribed to women, and this case is the root of many countries’ animal testing safety laws today.
Thousands of mice and other small rodents are used in animal experiments every year

Thousands of mice and other small rodents are used in animal experiments
every year

Animal safety tests usually come at the end of a long process of safety data collection that may include testing the product ‘in vitro’ (i.e. in a test-tube) and using a computer program to simulate what might happen to the drug inside the body. The regulations on what safety data is required for a new product vary from country to country (and also from drug to drug), but most drug authorities require all three types of data - animal, in vitro and computer- generated - for trials to be allowed to continue.

All this means that at some point, all ‘antiretroviral’ (anti-AIDS) drugs will have been tested on animals for safety.

There is an argument however that animals are actually fairly poor substitutes for humans and that some compounds that may well cause no harm to a mouse, could kill a human being. This is particularly the case for drugs that interact with the complex human immune system, such as the anti-inflammatory drug that caused major organ failure in six men involved in a trial at Northwick Park Hospital in London, England in 2006. However, such occurrences are rare.
Efficacy trials

While all drugs and vaccines have to be tested on animals to establish their safety, testing them to establish their effectiveness is a different matter.

HIV is a retrovirus specific to humans (hence the name ‘Human Immunodeficiency Virus’), which means it is not naturally found in any other animal. Some African primates, such as chimpanzees and a few species of monkey, are naturally infected with SIV (Simian Immunodeficiency Virus), which is believed to be the virus from which HIV originated. Chimpanzees can also be artificially infected with HIV in a laboratory. However most monkeys and chimpanzees have very efficient immune responses to SIV (and HIV), and do not develop AIDS, even after many years of infection. This can make it very difficult to assess whether a drug or vaccine actually works, so primates are not used as widely as human substitutes as they once were.

This said, there is one primate still commonly used to conduct efficacy testing: the Rhesus macaque monkey. Because Rhesus macaques originate from Asia, rather than Africa, they have never been exposed to SIV, and thus have no natural immune responses to it. A Rhesus macaque that is infected with SIV will therefore develop AIDS type illnesses in a relatively short time 2.

For this reason (and because they are not an endangered species like some other Asian primates), macaques are often used in HIV research. A few HIV drugs, such as AZT and tenofovir (see our Introduction to Antiretroviral Treatment page for more information about these), have been tested on macaques for efficacy, though stricter rules on the use of primates in animal testing, and greater knowledge of HIV, mean that more modern antiretrovirals are generally only tested on animals for safety reasons.

Vaccine development on the other hand makes extensive use of primates. Because it could be seen as unethical to give a healthy human a vaccine, and then expose them to HIV to see if the vaccine works (if it doesn’t, they’ll end up with HIV), animals can be used as substitutes to establish whether a vaccine is effective or not. This method can also be used to test the usefulness of current AIDS drugs (such as tenofovir) in preventing HIV infection. Such work of course raises significant questions over whether it is any more ethical to give a monkey HIV than a human, when it too may become sick with AIDS and die.

A fundamental problem with using macaques in vaccine research has been that they have different immune systems to humans. This means they cannot be infected with HIV-1 (although they are susceptible to certain strains of HIV-2), however they can be infected with SIV, or an SIV-HIV combination (‘chimeric’ virus) known as SHIV. A drug or vaccine that is effective in Rhesus monkeys infected with SIV or SHIV may not therefore be effective in humans with HIV. Conversely, a drug or vaccine that may be effective in an HIV positive human may be dropped because it appears ineffective in animals. Scientists have now constructed a simian strain of HIV-1 that differs from the human virus by only one gene and mimics early HIV infection, however the infected macaques did not develop AIDS3. Further research on this genetically engineered virus is necessary, however if successful this may make testing vaccines in primates potentially more reliable.

Monkey research has yielded significant discoveries about HIV in recent years4, including major findings that have strengthened understanding of early SIV and HIV infection5.
General research

As well as the testing of new drugs and other products, animals may also be used for more general research that aims to gain a greater understanding of a disease. Rhesus macaques, chimpanzees and even cats (who can get Feline Immunodeficiency Virus) may be used as human substitutes to see how HIV-like viruses operate within the body.
Rhesus Macaques are commonly used in HIV research

Rhesus Macaques are commonly used in HIV research

They can also be used to study natural phenomena such as transmission or disease progression, and the effects of non-therapeutic substances on HIV.

One example would be a study carried out in Rhesus macaques in 2006 6. Scientists looking at the effects of alcohol on SIV found that feeding the monkeys large quantities of alcoholic beverages over a short space of time (effectively making them ‘binge’ drink) could significantly speed up the rate at which HIV progressed to AIDS. This may well lead to a greater emphasis on moderate drinking amongst HIV positive people, and a reassessment of safe levels of alcohol. However, whether the results of this experiment could have been recreated using methods that didn’t involve animals is open to debate.
Can animal testing be justified?

Animal testing is an extremely controversial and hotly debated area, and there are many groups around the world that are strongly opposed to animals being involved in any form of experiment, even if it involves simply keeping them in captivity. Equally, there are groups who say that there is no alternative to animal testing, and that animals have saved many human lives. Some of the scientific and moral arguments for and against animal testing include:

* FOR: Animal testing is justified because of the many human lives that it can save
* AGAINST: There is no firm evidence that animal testing has saved anyone’s life directly, particularly in the case of HIV – most drugs could probably have been developed without the use of animals.

* FOR: Humans are clearly unique amongst animals in our abilities and intellect. Animals do not experience pain and emotion in the same way that we do because they lack language and the power of abstract thought
* AGAINST: An animal’s life is equal to a human’s and we have no right to assume otherwise simply because animals cannot express their pain and suffering in words

* FOR: Animals are the best way to test vaccines, because it would be unethical to give a human a vaccine, and then to try to give them HIV to see if it works.
* AGAINST: It is no more ethical to give an animal a life-threatening illness than it is to give one to a human.

* FOR: SIV-infected chimps and Rhesus macaques are good substitutes for humans, and make drug and vaccine development far more simple
* AGAINST: Monkeys and chimpanzees do not have identical immune systems to humans, and may not respond to drugs or vaccines in the same way. Rhesus macaques also cannot be directly infected with HIV. No HIV vaccine has yet been developed, despite many years of animal involvement.

* FOR: Any differences between animal and human biology are generally known, and can be factored in to experiments
* AGAINST: This overlooks the effect that stress may have on the normal functioning of an animal’s body, which may in turn affect the results of the experiment

* FOR: Not testing new pharmaceutical products on animals is highly dangerous
* AGAINST: Animals are often poor substitutes for humans, and some compounds that may well cause no harm to an animal, could seriously harm a human being. Likewise, a drug that is toxic to the animal it is tested on, may have no toxicity, and even therapeutic benefits in humans.

* FOR: There are no viable alternatives to testing pharmaceutical products for safety on animals. Scientists already use in-vitro studies and computer models, and animal testing comes only after these tests have been performed. If a drug fails either test, it will not be given to animals anyway.
* AGAINST: Studies have suggested that ‘micro-dosing’ (where only a tiny amount of a product is given to a human through the skin) could be a new and very effective alternative to animal experiments 7. The recent news that scientists have grown a small piece of human liver tissue from stem cells could also mean that it may one day be possible to perform initial 'human' safety trials in a lab8.

* FOR: There are very strong laws in place to ensure that distress and pain in animals is kept to an absolute minimum
* AGAINST: Pain and suffering still occur, and simply being in captivity can cause great distress to an animal, just as it would to a human. Plus, animal testing facilities cannot be monitored at all times, so the sort of treatment animals receive on a daily basis can never truly be known.

* FOR: It is a legal requirement that drugs are tested on animals for safety in the majority of countries. Scientists have no choice in this matter.
* AGAINST: Perhaps if laws on the necessity for animal testing were relaxed, or animal safety-testing were banned, it would encourage scientists to develop other methods of testing toxicity that were equally effective. At the moment, they have no incentive to do so, so only a small handful of alternatives are being tested.

* FOR: No scientist wants to cause any more injury to an animal than is strictly necessary. Most scientists build up strong attachments to the animals they use in their experiments.
* AGAINST: This may be the case, but it is also very easy to become blasé about something that you do every day, and forget the pain and suffering your work is inflicting. Animals may well become little more than useful objects of study, rather than live creatures, and this can mean they are treated as disposable rather than indispensable.

What do HIV+ people think of animal testing?

Many HIV positive people condone, or remain neutral on animal testing because they are aware that the drugs they take to keep them alive have very likely been tested on animals at some point in the past.
Could human 'guinea pigs' be viable alternatives to real ones when testing new drugs?

Could human 'guinea pigs' be viable alternatives to real ones when testing new drugs?

In September 2005, six well-known AIDS organisations in the USA got together to form ‘Patient Advocates Against PETA’ (PAAP), a group that opposed the strong anti-animal testing stance of People for the Ethical Treatment of Animals (PETA) 9. Formed of ACT UP DC, ACT UP Southern California, AIDS Healthcare Foundation, AIDS/HIV Health Alternatives, AmASSI and the HIV Incarcerated Task Force, PAAP argued that PETA’s constant high-profile protests were hindering scientists in their search for effective HIV vaccines.

Their work was however opposed by a number of HIV positive individuals, who declared they were strongly opposed to animal testing, and did not condone PAAP’s actions. A consensus amongst HIV positive people themselves on the benefits of animal testing is obviously not very forthcoming.
What is the future for HIV and animal testing?

In recent years, scientists have begun to investigate the possibility of genetically altering the genes of some animals (particularly mice) to give them immune systems that more closely resemble a human’s, and are thus susceptible to HIV infection. Such small animal models could be useful, both for those developing new vaccines, and for those testing drugs for safety, but such work is strongly opposed by those who do not believe that genetically modifying animals is morally right or safe, as well as by those who oppose animal testing altogether.

Another alternative recently proposed is infecting ordinary mice with a chimeric form of HIV, similar to the 'SHIV' used to infect primates. This would allow efficacy trials of drugs and vaccines to be performed on small mammals, which could perhaps be combined with safety trials to reduce the time taken to reach regulatory approval. However, this would potentially increase rather than reduce the number of animals involved in clinical testing.10

Regulations on animal testing have been tightened considerably in recent years, and animals, particularly primates, are used in far fewer experiments than they once were. In most countries (particularly the UK, which has the tightest regulations on the use of animals for science) facilities where animals are held are inspected regularly to ensure that animals are being kept in hygienic, safe and comfortable conditions.

Nonetheless, animal testing is still very strongly opposed by many groups who believe that any form of animal exploitation is wrong. The majority of anti-vivisection groups stage peaceful protests that aim to raise awareness of the harm and pain that animal testing can inflict, and raise support amongst the public for a ban on the practice. However a small minority of animal rights activists have resorted to more extreme tactics, which have included intimidation of those directly involved in experimentation, intimidation of their families, suppliers and business partners, and criminal acts, ranging from harassment and vandalism to blackmail and arson 11, 12, 13.

Unfortunately, while such groups receive substantial media coverage, their extreme actions tend to drown out the messages of more moderate groups, who are simply calling for a reassessment of the law, or greater research and assessment of alternative methods. Their behaviour creates a counter-productive situation, whereby those who conduct experiments on animals become more determined to continue with their work because of the opposition they face, and the government refuses to launch a proper investigation into the current laws in case they are seen as ‘giving in’ to extremists. It also risks portraying all animal rights campaigners as extreme activists and all scientists as cruel animal abusers.

In reality, views on animal testing are not nearly as polarised as this. There are many moderate anti-vivisection groups, just as there are many scientists who would prefer not to test on animals if they had a choice. A meaningful debate between the two may well help to further progress into ending the reliance on animals for safety and efficacy testing, but while the issue remains connected to such controversy and extremism, discussions of this kind seem to be few and far between.

It may be that one day animal research produces a vaccine or a cure for HIV that saves millions of human lives. If this is the case, then some justification can perhaps be found in using animals for our own purposes. Until this time however, anti-vivisectionists need to remain focused on finding alternatives, informing and changing legislation and keeping testing on animals to an absolute minimum. It is only through such positive action that true progress can be made.

Evidence that HIV causes AIDS
Introduction

"AIDS is caused by infection with a virus called human immunodeficiency virus (HIV). This virus is passed from one person to another through blood-to-blood and sexual contact."1

That's the standard explanation of what causes AIDS. But what evidence do scientists have to support this theory? And why do some websites say that the world has got it terribly wrong – that HIV does not cause AIDS at all?

As an independent AIDS organisation founded in 1986, AVERT has taken a keen interest in the ongoing debate about what causes AIDS. As well as investigating the consensus position, we have followed and carefully considered the arguments of the dissident minority who claim that HIV is harmless or even that it might not exist. This topic is vitally relevant to how our organisation works to prevent people developing AIDS and to help those who are suffering.

It is AVERT's considered opinion that the evidence that HIV causes AIDS is abundant and conclusive. This page outlines some of that evidence, while also mentioning how some dissidents have interpreted things differently. In particular, we'll look for proofs of the following:

* AIDS is a new epidemic disease
* AIDS does not occur without HIV
* HIV infection is the only factor that predicts who will develop AIDS
* Surveillance statistics support the HIV theory
* Modern antiretroviral treatment is highly beneficial.

Who doubts that HIV causes AIDS?

By far the most significant scientist to question the HIV/AIDS theory is Professor Peter Duesberg, a virologist at the University of California at Berkeley, who first wrote about this topic in 1987. Throughout the 1990s and into the new millennium, as HIV/AIDS researchers announced many new discoveries and amassed huge volumes of data, Dr Duesberg remained unconvinced. He admits that HIV exists, but he maintains that it is harmless, and that AIDS is caused by non-contagious factors including drug abuse, malnutrition, and even the very drugs used to combat HIV.2

Other dissidents (often called "denialists" by their opponents) include the Perth Group of medical scientists and physicians from Australia. The Perth Group (led by Eleni Papadopulos) claims that nobody has conclusively proven the existence of HIV, so any proof that HIV causes AIDS has no foundation.3

Dissident arguments have received attention from the popular media, as well as from scientific journals. And with the rise of the Internet, alternative views have found a much wider audience, so that scarcely anyone interested in AIDS can have failed to hear of them.

Some of their followers are intrigued by conspiracy theories involving sinister drug companies or government persecution of minority groups. But alternative explanations can also appeal to those diagnosed with HIV or AIDS, who read that their condition might not be fatal, that they shouldn't take toxic drugs, and that unprotected sex poses no risks. Even a few AIDS service organisations have adopted non-HIV viewpoints.4

However, the proportion of scientists who doubt that HIV causes AIDS is tiny, and shows no sign of increasing. Interest in dissident views appears to have dwindled after the excitement surrounding Thabo Mbeki's AIDS panel and the Durban Declaration in 2000. It seems likely that new and better evidence, including the obvious benefits of modern drug treatments, has caused many former-dissidents to change their minds.
What is AIDS?

Before we can begin to look for a cause, we must first work out exactly what type of illness we are talking about.

In early 1981, doctors in New York and California began to report some bizarre new disease outbreaks. In both places, previously healthy young men were showing up with rare illnesses including Kaposi's sarcoma (a kind of tumour) and PCP (a type of pneumonia), which until then had been virtually unheard of among such people. Within months, dozens of similar cases had been reported in 23 American states and in the UK, representing the start of a massive and unprecedented epidemic.5

Doctors soon discovered a distinctive feature of these cases. More than anything else, the men were lacking a specific type of white blood cell, which is essential to a healthy immune system. Normally, people have between 600 and 1,500 "CD4+ cells" (also called T helper cells) in each cubic millimetre of their blood. But the men with the strange new disease typically had very much lower levels. This immune deficiency explained why they were so vulnerable to disease.

The cases were clearly related in time and by population group (initially gay men and injecting drug users). No cause of immune deficiency could be found, but it was clearly not inherited. Scientists therefore grouped together all of these strange new cases under the heading "Acquired Immune Deficiency Syndrome" – or AIDS for short.

In 1982, no-one claimed to know the cause of AIDS, so the first definition was based on the diagnosis of one of 13 rare diseases known to be linked to immune deficiency (including Kaposi's sarcoma and PCP) "occurring in a person with no known cause for diminished resistance to that disease".6 Over the years, the US definition has been refined as hundreds of thousands of similar cases have been documented, sometimes involving other diseases, but always associated with the same distinctive immune deficiency.7 Other definitions have also been developed to suit different situations elsewhere in the world.8

The latest US AIDS definition was created in 1993. Under this definition, someone has AIDS if they have one of 26 specific diseases (28 in children) but no known cause of immune deficiency other than HIV (with some diseases, a positive HIV test is required); or if they have a CD4+ cell count below 200 cells per cubic millimetre of blood, or less than 14% of all lymphocytes, plus a positive HIV test.9

Europe and Canada have similar AIDS definitions to the US, but do not include low CD4+ cell counts.
Problems with the definition?

The definition of AIDS usually requires a positive HIV test. This means that any connection between HIV and AIDS is artificially strengthened because any cases of "HIV-free AIDS" are discounted. In other words, the definition already assumes that HIV causes AIDS, so it can't be used to prove that theory. However, it is possible to redefine AIDS without reference to HIV or even to any other diseases.

The alternative definition of AIDS requires a CD4+ cell count consistently below 200 cells per cubic millimetre of blood, which cannot be explained by any factor other than HIV (such as cancer, malnutrition, radiation or chemotherapy). No HIV test is required.

It turns out that the vast majority of people diagnosed with AIDS fit these criteria. They form a population that barely existed before 1980, but which now numbers hundreds of thousands in the USA and Europe alone. People with such severe immune deficiency are at very high risk of developing serious illnesses and usually die within months (unless they take antiretroviral drugs).10 11 12 We can use this simple, unambiguous definition to test the association between HIV and AIDS.13 14
How can we prove that HIV causes AIDS?
Koch's Postulates

In the nineteenth century, the German scientist Robert Koch developed a set of four "postulates" to guide people trying to prove that a germ causes a disease. Scientists agree that if HIV satisfies all of these conditions with regard to AIDS then it must be the cause of AIDS:15

* Koch 1: The germ must be found in every person with the disease
* Koch 2: The germ must be isolated from someone who has the disease and grown in pure culture
* Koch 3: The germ must cause the disease when introduced into a healthy person
* Koch 4: The germ must be re-isolated from the infected person

Other evidence

Even Koch recognized that in some cases not all of his conditions could be met, so other evidence should also be considered. This is particularly true when the germ is a virus rather than a bacterium.16 Modern scientists are willing to consider a wide range of evidence. In particular, we can ask five key questions:

* Do surveillance statistics show a relationship between HIV and AIDS?
* How well does HIV infection predict illness and death?
* Do drugs designed to combat HIV benefit people with AIDS?
* Are there any credible causes besides HIV?
* What can we learn from Africa?

We'll address these questions after looking at Koch's Postulates.
Koch 1: The germ must be found in every person with the disease

The US Centers for Disease Control and Prevention (CDC) defines a condition called idiopathic CD4+ T-lymphocytopenia, or ICL for short. Someone is diagnosed with ICL if they have a CD4+ cell count below 300 cells per cubic millimeter, or 20% of all T lymphocytes, on at least two occasions, but have no detectable HIV infection, nor any other known cause of immune deficiency (such as cancer therapy). As many dissidents have pointed out, this is essentially a definition of HIV-free AIDS. So just how common is this condition?

In 1993, a CDC task force published the results of an exhaustive survey of ICL in the USA. They had reviewed 230,179 AIDS-like cases reported since 1983 and identified 47 patients with ICL (plus 127 uncertain cases). All of the other people with AIDS who had received an HIV test produced a positive result. What's more, the team closely investigated the ICL cases and discovered that they didn't fit the usual AIDS profile. There were 29 male and 18 female patients, and 39 of them were white (4 others were of Asian descent). In 29 cases, the researchers couldn't fit the people into conventional risk groups for AIDS (homosexual men, haemophiliacs, injecting drug users, and the sexual partners of such groups). Whatever these 47 cases represent, they don't seem to be typical of the massive epidemic that we're interested in.17

The findings of the ICL survey are backed up by large-scale monitoring studies, including the Multicenter AIDS Cohort Study (MACS). During the MACS, scientists monitored the health of 2,713 gay and bisexual men who tested negative for HIV antibodies. Over several years, only one of these men had persistently low CD4+ cell counts, and he was undergoing cancer therapy designed to weaken his immune system. Similar results have been found among blood donors, recipients of blood and blood products, injecting drug users and other groups: severe immune deficiency is virtually non-existent among those who test HIV-negative.18

As Dr Duesberg has pointed out, quite a lot of people (mostly in the early 1980s) have been diagnosed with AIDS in the USA despite never taking an HIV test, and nobody knows whether these people were HIV-positive or not. However, based on the much larger sample of people who have been tested, Koch's first postulate has certainly been satisfied. The only way by which dissidents have been able to come up with significant numbers of HIV-free "AIDS" cases is by using much looser definitions of AIDS. Such definitions include many people with milder immune deficiency, which is generally not fatal.19 20
What about false positive test results?

Diagnosis of infection using antibody testing is one of the best-established concepts in medicine. The World Health Organisation and the US National Institutes of Health agree that modern HIV tests are extremely reliable, and are even more accurate than most other infectious disease tests.21 22

Nevertheless, some dissidents have tried to dismiss the association between AIDS and HIV by claiming that many of those who test positive are not really infected with HIV. In particular, Christine Johnson has listed dozens of conditions reported to have produced false positive reactions on at least one occasion (under particular circumstances, using particular test kits).23

It is true that no test is perfect. However, what the dissidents usually don't mention is how rare the reports of false positive results have been, especially in recent years. Nor do they mention that every person who uses a test kit is trained to spot the telltale signs of a suspicious result, and to keep testing by various methods until no doubt remains. The conditions that cause false positive results are not only very uncommon, but are also typically short-lived, whereas HIV infection does not go away.24 25

The dissident theory cannot satisfactorily explain why scientists have been able to use various techniques to detect the virus itself in virtually everyone with AIDS, as well as in most people with positive antibody test results, as explained in the next section. These methods (including DNA PCR, RNA PCR and viral culture) are not affected by any of the factors said to produce false positive results in antibody testing.

Nor can the alternative theory fully explain why the association between AIDS and antibody test results is so exceptionally strong: virtually everyone with AIDS tests positive, while more than 99% of the US public tests negative. And it cannot explain why the proportion of people testing HIV positive should have increased so dramatically over time. For example, the proportion of South African women testing HIV positive in annual antenatal surveys rose from 0.8% in 1990 to 10.4% in 1995, 24.5% in 2000 and 29.5% in 2004. The age distribution of these data is similar to that of other sexually transmitted infections.26
Koch 2: The germ must be isolated from someone who has the disease and grown in pure culture

Koch required that the germ be isolated from all other material that could possibly cause disease, so that his third and fourth postulates could be properly tested.

In May 1983, Luc Montagnier and his colleagues in France reported the isolation of a virus they named LAV, which infected and killed CD4+ cells. A year later, the American Robert Gallo announced he had isolated a virus called HTLV-III and found a way to grow it in culture. It was later discovered that the two viruses were genetically indistinguishable, and they were renamed HIV.27

Researchers have been able to isolate and culture HIV from most AIDS patients whom they have examined (as well as from many other people with HIV antibodies).28 They have isolated the virus from blood cells, blood plasma, lymph nodes, semen, vaginal fluids, amniotic fluids, bone marrow, brain, cerebrospinal fluid, intestines, breast milk, saliva and urine, and cultured it in various cell types.29 Images taken using electron microscopy and other techniques have shown virus-like particles that have the size, shape, structure, density, proteins and behaviour expected of retroviruses.30 31 32

Techniques developed in the mid-1990s have made it much easier to extract and sequence the complete genetic material (genome) of an isolated virus.33 34 The Los Alamos database now contains hundreds of full-length HIV genomes from around the world, each containing the same nine genes.35 Based on genetic similarities and differences, these sequences have been used to define family trees of HIV types, groups and subtypes as well as hybrids called recombinant forms.36

Whole or partial HIV genomes have been detected in numerous AIDS patients, using a technique called PCR (the same technology is used to find DNA evidence with which to convict murderers or to settle paternity suits, as well as to detect the germs that cause hepatitis, tuberculosis and other diseases). Almost everyone who tests positive for HIV genetic material also tests positive for HIV antibodies, and vice versa, while those who test negative for one thing also lack the other.37 People who have been exposed to the same source of infection contain genetically very similar HIV strains – similar enough for court convictions.38

Scientists have used a standard technique of genetic science called molecular cloning to obtain highly purified HIV. Genetic material extracted using PCR or other techniques has been introduced into bacteria or other cells (usually using phages or plasmids), which then produce many exact copies (clones) of the viral genes. If cloned viral genomes are inserted (transfected) into human cells then they produce a new generation of infectious HIV particles, which are free from contamination.39

Virtually all experts agree that HIV has been isolated according to the most rigorous standards of modern virology, meaning that Koch's second postulate has without doubt been satisfied.
What about the Perth Group?

A small band of Australian scientists and physicians claims that HIV has never been properly isolated. The Perth Group has never said that HIV doesn't exist; rather they say that HIV has never been conclusively proven to exist. They don't trust any HIV tests, because they have not been verified using their "gold standard" of isolated virus. The Group uses the isolation argument to dismiss just about every type of evidence that HIV causes AIDS.40

Virtually all virologists believe that the Perth Group's conditions are unnecessary. They say nobody has ever used such rules to isolate any type of virus, and that other techniques are much more effective. According to the Perth Group's rules, nobody has isolated or proven the existence of the viruses said to cause small pox, influenza, measles, mumps and yellow fever.

Experts argue that the Group's rules are unreasonably demanding and impossible to satisfy fully, even though their main requirements have already been met.41 42 Dr Duesberg is among those who have tried in vain to persuade the Perth Group that HIV definitely exists and has been isolated using the most rigorous methods available.43 44 45

The Perth Group appears to have only two active members: a medical physicist called Eleni Papadopulos-Eleopulos and an emergency physician called Valendar Turner. In late 2006, Papadopulos-Eleopulos and Turner testified in the appeal trial of Andre Chad Parenzee, an HIV-positive man convicted of endangering life by having sex with three women without informing them of his infection. The two witnesses intended to demonstrate that HIV had not been proven to exist; that HIV tests were unreliable; and that there was no evidence of HIV transmission through sex.

The presiding judge concluded that the Perth Group members had no qualifications or practical experience in virology, immunology or epidemiology, and were not qualified to express opinions about the existence of HIV, or whether it had been shown to cause AIDS. The judge found that the pair relied entirely on the work of others, which they often took out of context and misrepresented. Their arguments were found to lack plausibility and cogency, and to have "minimal" probative value. "I am satisfied that no jury would conclude that there is any doubt that the virus HIV exists," said Justice Sulan. "I consider no jury would be left in any doubt that HIV is the cause of AIDS or that it is sexually transmissible."46
Koch 3 and 4: The germ must cause the disease when introduced into a healthy person, and the germ must be re-isolated from the infected person

The third and fourth postulates are much harder to prove. It's considered unethical to deliberately infect someone with pure HIV, so such an experiment has never taken place. However, there is no reason why the transmission has to be deliberate.

There have been three reports of lab workers developing immune deficiency after accidentally exposing themselves to purified, cloned HIV. As mentioned above, such cloned virus is free of all contamination from the original source. None of these people fitted conventional risk groups for the disease. In each case, HIV was isolated from the individual and, by genetic sequencing, was found to be the strain to which they'd been exposed. One of these workers developed PCP and had a CD4+ cell count below 50 cells before starting antiretroviral treatment.47

Still, three examples don't make a totally conclusive proof, so it's worth looking for more evidence.

One line of argument can be based on animal experiments.48 In some studies, chimpanzees deliberately infected with HIV-1 have gone on to develop AIDS-like conditions (though this appears to be rare),49 while HIV-2 has had the same effect on baboons.50 Macaque monkeys have developed AIDS after being infected with a hybrid virus called SHIV, which contains genes taken from HIV.51 And in mice engineered to have a human immune system, HIV produces the same patterns of disease as in humans.52

If we're prepared to bend the rules a bit further, we can look at people who've been infected with non-purified HIV. Such cases at least suggest that AIDS is infectious, though they don't rule out the possibility that more than one germ is involved.

Scientists have documented numerous cases of people developing AIDS after becoming infected with HIV as a result of blood transfusions, drug use, mother-to-child transmission, occupational exposure and sexual transmission. In such cases, they have recorded the development of HIV antibodies (seroconversion) using a series of blood tests, before progression to AIDS. Seroconversion is often accompanied by a mild flu-like illness or swollen glands.53

Until the mid-1990s, nobody claimed that HIV had fulfilled Koch's last two postulates. Even today, the proof is not quite perfect. But most scientists believe the evidence is now strong enough to put the case beyond all reasonable doubt.54
Surveillance statistics

Most countries with high rates of HIV have conducted regular national HIV surveillance studies since the early 1990s. AIDS case reporting began much earlier, in the early 1980s. All of the data are available to the public online.
HIV and AIDS in Thailand, 1984-2000

HIV and AIDS in Thailand, 1984-2000

AIDS case statistics are generally expected to underestimate the scale of AIDS epidemics, especially in African countries, because many cases go unreported. However, it is reasonable to assume that trends in the number of reports should roughly correspond to trends in the overall epidemic.

Of all countries, Thailand has one of the best records of HIV surveillance, with around 70 sites included each year since 1990. Thailand also has relatively good infrastructure for the reporting of AIDS cases. On the right is a graph showing trends in Thai statistics between 1984 and 2000.55

The graph shows that during the 1990s there was a dramatic increase in AIDS case reports. This increase came after a sharp rise in HIV prevalence, with a time lag of a few years (nearly 200,000 HIV tests conducted between 1985 and 1987 produced fewer than 100 positive results).56 Such a time lag is exactly what the HIV theory predicts, because most people are expected to live with HIV for some time before developing AIDS.

Thailand is not unique. Exactly the same pattern can be seen in statistics worldwide, from Albania (where HIV and AIDS are both very rare) to Zimbabwe (where AIDS case reports soared during 1987-95, following the trend in HIV prevalence).57 58

This trend can also be seen within individual countries as regions, cities or population groups with higher HIV prevalence report a higher rate of AIDS.59
How well does HIV infection predict illness and death?

A mountain of evidence shows that much can be predicted from a positive test result. For example:

* Around half of people develop AIDS-defining conditions within 10 years of HIV infection, if they don't take antiretroviral drugs. Only a few do not develop AIDS within 20 years.60 61

* HIV-positive Americans and Canadians are over 1,000 times more likely to develop AIDS-defining diseases (such as PCP and Kaposi's sarcoma) than those who test negative.62 63

* A study in Uganda found that HIV-positive people were 16 times more likely to die over five years than those who tested negative. For those aged 25-34 years old, HIV infection raised the death rate by a factor of 27.64 Numerous other studies have found similar results in Tanzania, Malawi, Rwanda and other parts of Africa.65 66 67 68

* A study of female sex workers in Thailand found the death rate to be over 50 times greater among those who tested positive. All of the positive women died of conditions associated with immune deficiency, compared with none of the negative women.69

* During a 16-year, large-scale monitoring study of homosexual and bisexual men in the US, 60% of HIV-positives died compared with 2.3% of HIV-negatives.70

* In the UK between 1979 and 1992, death rates increased massively among HIV-positive haemophiliacs, but remained unchanged among the rest.71 Similar research in the USA found that HIV-positive haemophiliacs were 11 times more likely to die over a ten-year period, compared with those who tested negative.72

* In a European study of babies born to HIV-positive women, none of those who tested negative developed AIDS, compared to 30% of those who tested positive. By their first birthday, 17% of the HIV-positive babies had died.73 A similar study in Uganda found that more than half of HIV-positive babies died before their second birthdays, compared to one sixth of those who were HIV-negative.74

Alternative theories cannot explain why HIV tests should be so effective at predicting illness and death in so many diverse groups of people from all parts of the world.

It is even possible to predict the likelihood that someone will soon develop AIDS by measuring the amount of HIV in their blood, which is known as "viral load". Such measurements can be made using PCR, branched-DNA signal-amplification (bDNA) or quantitative microculture techniques. For example, the table below - based on a long term study of 1,604 patients - illustrates just how useful bDNA forecasts can be:75
Viral load (RNA copies per millilitre of blood plasma) Proportion of patients developing AIDS within six years
less than 500 5.4%
501-3,000 16.6%
3,001-10,000 31.7%
10,001-30,000 55.2%
more than 30,000 80.0%

Dr Kary Mullis, who invented the PCR process, has questioned its ability to measure viral load. However, his arguments have been theoretical, and are not backed up by large-scale surveys, which have repeatedly shown a clear association between viral load and progression to AIDS (in all parts of the world).76 77 Dr Mullis' objections do not apply to the unrelated bDNA and quantitative microculture techniques. Modern bDNA tests produce very similar viral load counts to modern PCR tests (though this was less true of some earlier models).78 79 As with antibody tests, there is no convincing alternative explanation for why viral load counts should be such useful indicators.
Effective drug treatments

The first drug licensed for fighting HIV was zidovudine, better known as AZT, which gained approval in 1987. Multiple studies found that AZT reduced opportunistic infections and increased CD4+ cell counts and survival among people with AIDS. However, the positive effects of AZT did not last very long, and a major investigation known as the Concorde Study found that people who started taking the drug at an early stage of HIV infection, before the onset of symptoms, received little or no long-term benefit (though neither did they fare any worse).80 81 82

Since the mid-1990s, other types of anti-HIV drugs have also been available, including protease inhibitors, which were designed specifically to target HIV proteins.83 It has been found that when different drugs are taken together, they bring much longer-lasting benefits than AZT alone.

Numerous large-scale, controlled studies have consistently shown that the right combination of drugs can dramatically reduce incidence of AIDS and death. One drug is better than none, and two is better than one, but a combination of three drugs (from two different classes) is much better still. Virologists explain that this is because HIV finds it a lot harder to evolve resistance to several drugs at the same time. Modern three-drug combinations reduce the risk of AIDS and death by over 80%.84 85 86 87

Many recent studies in Africa have found that treatment is just as effective there as it is in Europe and America.88

In most people, the drugs cause a sharp fall in viral load. However, some patients do not experience such an effect, and these people are far more likely to develop AIDS or to die. This fact in itself very strongly suggests that HIV causes AIDS.89
HIV and AIDS in the United Kingdom, 1988-2002HIV and AIDS in the United Kingdom, 1988-2002

The benefits of more effective drug treatments can be seen in national statistics from rich countries in which most people have had access to them. On the right is a graph of HIV diagnoses, AIDS diagnoses and AIDS deaths in the UK between 1988 and 2002. This graph shows that the numbers of AIDS diagnoses and deaths fell by more than half between the end of 1995 and the end of 1998. This trend followed the widespread introduction of combination therapy.90

Similar patterns can be seen in statistics from other European countries, Canada, Australia and the USA.91 However, it should be noted that American statistics were distorted during the period 1990-1996 because of a major expansion in the AIDS surveillance case definition in 1993. For the first time, people could be diagnosed with AIDS on the basis of a low CD4+ cell count. The majority of these people would have gone on to develop AIDS-defining diseases before death, so would have been included in the statistics anyway, but the change in definition meant they were diagnosed earlier, and this skewed the statistics.

The distortion caused by the change in definition was temporary, and cannot account for the major declines in AIDS diagnoses and deaths that occurred in the USA during the late 1990s. Nor can the declines be explained by trends in HIV incidence.92 93 94 95 Incidence of AIDS-defining infections like PCP rose during the early 1990s and then decreased significantly between 1995 and 1998.96 97

The ability of antiretroviral drugs to prevent mother-to-child HIV transmission has been demonstrated around the world.98 Following the widespread introduction of these drugs during pregnancy, the number of reported AIDS cases among American children has fallen to around 100 per year, compared to nearly 1,000 per year in the early 1990s.99

Antiretroviral therapy, alongside treatment for opportunistic infections, is thought to have saved at least three million years of life in the USA alone.100
Drug abuse and other factors

Dissidents who claim that HIV does not cause AIDS have felt compelled to come up with alternative causes. These generally include recreational drugs (including heroin, cocaine, amphetamines and nitrite inhalants known as "poppers"), malnutrition, lack of clean drinking water, clotting factors used in blood transfusions, and anti-HIV drugs such as AZT. Some groups also suggest semen, "immune overload", antibiotics, benzene, stress, or lack of sleep.

In the early 1980s, when only a small number of AIDS cases had been reported, the medical establishment gave some of these possible causes very serious consideration. But such theories quickly lost favour as more cases emerged among men, women and children who did not fit the established risk groups, and it was established that affected people had been exposed to the bodily fluids of other affected people.101 Epidemiological data pointed to an infectious cause before HIV was ever isolated.102

Today, most scientists agree that controlled studies of drug users, heterosexuals, homosexuals, haemophiliacs and twin babies have consistently shown that HIV is the only factor that predicts who will develop AIDS. Associations in time and place between trends in drug use or promiscuity and trends in AIDS diagnoses are considered much too weak to prove causation.103 104

Dr Duesberg has claimed that some HIV-negative drug users have developed AIDS-like immune abnormalities and diseases. But his definition of "AIDS-like" is very vague, and none of these cases would merit an AIDS diagnosis.105 106 107

Antiretroviral drugs can have toxic side effects. However, there is no evidence that anti-HIV drugs cause the severe immune deficiency typical of AIDS, and there is abundant evidence that currently recommended courses of antiretroviral therapy can improve the length and quality of life of HIV-positive people.108 109 110 111

Certain AIDS-related diseases are more common among some population groups than among others. This is not surprising, and it does not mean that they cannot all have the same underlying cause.112 113

Severe malnutrition is a known cause of immune deficiency (though not the specific type of immune deficiency that is characteristic of AIDS). That is why all definitions of AIDS specify that there must be no evidence of severe malnutrition. Poor nutrition is also thought to make people with HIV more vulnerable to illness, so improving diet is an essential component of programmes to help HIV-infected people around the world. Still, such actions are not by themselves sufficient, because thousands of Africans who are well fed and cared for continue to die from AIDS. As the next section explains, there is no evidence that deterioration in diet or living standards can explain AIDS in Africa, which appears to be a totally new epidemic disease.
AIDS in Africa

Some dissidents claim there is no great new AIDS epidemic in Africa, just the same old diseases caused by poverty, hunger and poor sanitation. They say that official statistics are misleading because AIDS in Africa may be diagnosed on the basis of various clinical symptoms without an HIV test if none is available.114 We'll challenge these claims using four lines of argument.

Firstly, medical records from a number of African countries show marked increases in a number of AIDS-related diseases during the late 1970s and early 1980s. These records suggest that AIDS was probably rare or non-existent before that time.115

Secondly, as discussed above, numerous studies have found that people who test positive for HIV face a much higher risk of illness and death. Surveillance studies show that HIV prevalence rates have soared across sub-Saharan Africa since the early 1980s, and are now extremely high. It is therefore reasonable to estimate that millions are ill and dying.116

Thirdly, since the early 1980s, African countries with high HIV prevalence have suffered increased burdens of disease and death, as measured by censuses and surveys. For example:

* Between the 1980s and mid 1990s, adult death rates rose significantly in countries where HIV had been widespread for many years (such as Uganda, Zambia and Zimbabwe), but not in countries where rates had been lower.117 118

* Increases in death and disease have disproportionately affected young and middle-aged adults, especially those living in urban areas. Relatively well-paid professionals including teachers and doctors have been among the worst hit. This pattern is not typical of diseases caused by malnutrition or dirty water, which generally target the poor and the elderly.119 120 121

* In several countries, the number of orphans has risen so dramatically that communities can no longer cope, and child-headed households are now commonplace. Such changes indicate that sexually active adults are dying while children (and the elderly) are surviving. Household surveys have revealed a strong correlation between rates of orphanhood and adult HIV prevalence.122 123 124

* Patterns of disease have changed. For example, rates of Kaposi's sarcoma have soared,125 and tuberculosis - which was once confined to the poor, the weak and the elderly - today kills numerous well-fed Africans in the prime of life.126 127

Not all of sub-Saharan Africa has been equally affected by the recent changes. For example, Southern Africa has suffered much more than Western Africa, even though the regions have experienced similarly high levels of extreme poverty, malaria, food shortages and conflict. The only factor associated with the changes is HIV prevalence.128 129

Fourthly, the number of reported AIDS cases has risen across sub-Saharan Africa. Experts believe these statistics vastly underestimate the scale of the epidemics because the reporting systems are inadequate. This inadequacy is partly due to frequent misdiagnosis (compounded by AIDS-related stigma), but is mostly due to poor infrastructure and lack of access to healthcare. In addition, the quality of the reporting systems varies from one country to another. Nevertheless, it is possible to spot two clear patterns in the data.

The first obvious trend is that the number of reported AIDS cases increased everywhere during the 1980s. As in all other parts of the world, this increase followed a rise in HIV prevalence. The second trend concerns the number of AIDS cases reported per million of population. In general, the highest rates have been recorded by Southern African countries where HIV has been widespread for many years, while the lowest rates tend to come from Western African countries with historically much lower HIV prevalence. The lowest AIDS rate of all is reported by the island nation of Madagascar, where until recently HIV was extremely rare.130

The only major exception to the pattern in AIDS case rates is South Africa, which has reported relatively low figures. However, HIV prevalence did not reach very high levels in South Africa until the mid-1990s, several years later than in nearby countries such as Zambia and Zimbabwe. In addition, South Africa stopped reporting AIDS cases to the World Health Organisation in 1996, before most other African countries, and before the rise in HIV had had a chance to take effect.131

Compelling evidence of the impact of AIDS in South Africa since that time comes from studies of death certificates. These show that the annual number of reported deaths (from all causes) rose by 79% between 1997 and 2004. Among those aged 25-49 years old, the increase was 161%.132 Rates of death from AIDS-related conditions increased according to a distinctive age distribution, which peaked among the age groups 0-4 and 25-49 years. Other conditions showed no such pattern. The estimated number of AIDS deaths based on these data is similar to estimates based on HIV prevalence.133
What we don't know

There are still a few things we don't know about HIV and AIDS.

For example, we don't really know why both HIV and AIDS have become generally common in some African countries but not in Europe or the US – though we do have some theories. Contributing factors include the much higher prevalence of untreated sexually transmitted diseases in Africa (which greatly increase the chances of HIV transmission) and, quite possibly, differences between HIV subtypes.134 135 In addition, people who have poorer general health (including those who have malaria or tuberculosis) tend to have more HIV in their bodily fluids, which makes them more likely to transmit the virus.

Different patterns of sexual networking also have an effect. Viral loads are especially high during the first few weeks after infection, so the risk of transmission is then much higher. This means that people who have several concurrent sexual partners are able to spread the virus very efficiently before they test positive or fall ill. Studies suggest that, even though Africans do not report more sexual partners over a lifetime than other populations, concurrent partnerships are more common in Africa and most common in Southern Africa.136 137

Due to lack of access to HIV testing and treatment, as well as educational and cultural factors, the vast majority of Africans do not know their HIV status, and many people, especially women, find it very difficult to adopt strategies that would lower their risk of becoming infected or of infecting others. High levels of mobility, particularly of migrant workers, can also help to spread HIV.138

The concentration of an infectious disease among particular groups is not unusual. Hepatitis B is transmitted via much the same routes as HIV, and in Western countries it has similar risk groups. Hepatitis C (which is primarily spread via blood) is largely confined to injecting drug users, and recent increases in syphilis (usually sexually transmitted) have been fuelled by outbreaks among men who have sex with men. Surveillance statistics from throughout the Western world show that AIDS is becoming increasingly common outside the traditional risk groups, following a similar trend in HIV cases. In 2003, around a third of new American AIDS diagnoses, and two-thirds of those among women, occurred among non-drug using heterosexuals.139 Epidemiological evidence of male-to-female, male-to-male and female-to-male sexual transmission of HIV is abundant.140

Something else we don't fully understand is how HIV causes AIDS. Again, however, we do have some theories, which explain how the virus might be able to stop the immune system working properly in a number of ways, not just by directly killing cells.141 Ignorance about precisely how something happens is not proof that it does not happen.
Conclusion

There is no single scientific paper that proves HIV causes AIDS. Instead there are tens of thousands of papers containing a wide range of evidence that, taken together, make the case overwhelming.

People should be encouraged to question scientific orthodoxy. However, the views of AIDS dissidents, which have been well known for many years and thoroughly debated in scientific journals, have failed to win support. The core arguments of the Perth Group (that HIV has not been isolated according to their own particular rules) and Dr Duesberg (that no one fully understands how HIV causes AIDS) do not invalidate the wide range of evidence outlined on this page. The HIV theory is compelling because it provides a simple, unique cause that consistently accounts for all of the observed phenomena.

As an independent AIDS organisation, AVERT is primarily interested in what works. Studies have repeatedly shown that antibody testing is a highly effective way of predicting risk for AIDS; that modern antiretroviral treatment brings dramatic benefits; and that people who avoid exposure to HIV do not get AIDS. We will therefore continue wholeheartedly to recommend these things.

A cure for AIDS

There is no cure for AIDS. Although antiretroviral treatment can suppress HIV – the virus that causes AIDS – and can delay illness for many years, it cannot clear the virus completely. There is no confirmed case of a person getting rid of HIV infection. Sadly, this doesn’t stop countless quacks and con artists touting unproven, often dangerous “AIDS cures” to desperate people.

It is easy to see why an HIV positive person might want to believe in an AIDS cure. Access to antiretroviral treatment is scarce in much of the world. When someone has a life-threatening illness they may clutch at anything to stay alive. And even when antiretroviral treatment is available, it is far from an easy solution. Drugs must be taken every day for the rest of a person’s life, often causing unpleasant side effects. A one-off cure to eradicate the virus once and for all is much more appealing.

Distrust of Western medicine is not uncommon, especially in developing countries. The Internet abounds with rumours of the pharmaceutical industry or the U.S. government suppressing AIDS cures to protect the market for patented drugs. Many people would prefer a remedy that is “natural” or “traditional”.
Where’s the harm in fake AIDS cures?
Group of men looking at unproven AIDS cure

A man selling an unproven AIDS cure in Papua New Guinea

Unproven AIDS cures have been around since the syndrome emerged in the early 1980s. In most cases, they have only served to worsen suffering.

First of all, fake cures are a swindle. Someone who invests their savings in a worthless potion or an electrical zapper has less money to spend on real medicines and healthy food.

Many peddlers of bogus cures insist their clients avoid all other treatments, including antiretroviral medicines. By the time a patient realises the “cure” hasn’t worked, their prospects for successful antiretroviral treatment may well have diminished.

Fake cures may also cause direct harm to health. Inventors often refuse to reveal their recipes. Some so-called cures have been found to contain industrial solvents, disinfectants and other poisons. The dangers posed by the virgin cleansing myth – which advocates sex with children as a cure for AIDS – are only too clear.

Finally, the promotion of fake AIDS cures undermines HIV prevention. People who believe in a cure are less likely to fear becoming infected with HIV, and hence less likely to take precautions.
Why is it so difficult to cure AIDS?

Curing AIDS is generally taken to mean clearing the body of HIV, the virus that causes AIDS. The virus replicates (makes new copies of itself) by inserting its genetic code into human cells, particularly a type known as CD4 cells. Usually the infected cells produce numerous HIV particles and die soon afterwards. Antiretroviral drugs interfere with this replication process, which is why the drugs are so effective at reducing the amount of HIV in a person’s body to extremely low levels. During treatment, the concentration of HIV in the blood often falls so low that it cannot be detected by the standard test, known as a viral load test.

Unfortunately, not all infected cells behave the same way. Probably the most important problem is posed by “resting” CD4 cells. Once infected with HIV, these cells, instead of producing new copies of the virus, lie dormant for many years or even decades. Current therapies cannot remove HIV’s genetic material from these cells. Even if someone takes antiretroviral drugs for many years they will still have some HIV hiding in various parts of their body. Studies have found that if treatment is removed then HIV can re-establish itself by leaking out of these “viral reservoirs”.

A cure for AIDS must somehow remove every single one of the infected cells.
Reputable research on curing AIDS
Activating resting immune cells

Many researchers believe the best hope for eradicating HIV infection lies in combining antiretroviral treatment with drugs that flush HIV from its hiding places. The idea is to force resting CD4 cells to become active, whereupon they will start producing new HIV particles. The activated cells should soon die or be destroyed by the immune system, and the antiretroviral medication should mop up the released HIV.

Early attempts to employ this technique used interleukin-2 (also known as IL-2 or by the brand name Proleukin). This chemical messenger tells the body to create more CD4 cells and to activate resting cells. Researchers who gave interleukin-2 together with antiretroviral treatment discovered they could no longer find any infected resting CD4 cells. But interleukin-2 failed to clear all of the HIV; as soon as the patients stopped taking antiretroviral drugs the virus came back again.1 2

There is a problem with creating a massive number of active CD4 cells: despite the antiretroviral drugs, HIV may manage to infect a few of these cells and replicate, thus keeping the infection alive. Scientists are now investigating chemicals that don’t activate all resting CD4 cells, but only the tiny minority that are infected with HIV.

One such chemical is valproic acid, a drug already used to treat epilepsy and other conditions. In 2005 a group of researchers led by David Margolis caused a sensation when they reported that valproic acid, combined with antiretroviral treatment, had greatly reduced the number of HIV-infected resting CD4 cells in three of four patients. They concluded that:

“This finding, though not definitive, suggests that new approaches will allow the cure of HIV in the future.”3

Sadly, it seems such optimism was premature; more recent studies suggest that valproic acid has no long term benefits.4 5 In fact it’s quite possible that all related approaches are flawed because the virus has other hiding places besides resting CD4 cells. There is a lot about HIV that remains unknown.
Bone marrow transplants and gene therapy

In November 2008, a pair of German doctors made headlines by announcing they had cured a man of HIV infection by giving him a bone marrow transplant.6 The transplant - given as a treatment for leukemia - used cells from a donor with a rare genetic mutation known as Delta 32 that confers resistance to HIV infection. Twenty months after the procedure researchers reported they could find no trace of HIV in the recipient's bone marrow, blood and other organ tissues.

Other experts have said that more tests are required to verify this cure claim,7 though it is not the first of its kind. Of more than thirty HIV positive patients given bone marrow transplantation prior to 1996, two appeared to have been cured of their infection based on molecular testing and post-mortem biopsy samples.8 9

Even assuming it can be effective, bone marrow transplantation is too dangerous and costly for widespread use as a cure. Many patients die as a result of chemotherapy or reactions to the transplant, which is usually a last resort in treating life-threatening diseases. As Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, put it:

“It’s very nice, and it’s not even surprising. But it’s just off the table of practicality.”10

Nevertheless the German transplant does raise hope for related approaches. If scientists can find another way - such as gene therapy - to confer the same sort of protection against HIV as Delta 32 provides, then they may be able to stop the virus replicating. Research in this area is in its very early stages; it may be many years before a useful treatment is found, if at all.
Hope for the future

Some of the world’s top research institutions are today engaged in studies to learn more about the behaviour of HIV, resting CD4 cells and other hiding places. But the truth is that this field does not receive a lot of funding. Some people think the search for a cure is not worth much investment because the task may well be impossible.

Yet there are still those who remain hopeful, including the research charity amfAR, which in 2006 awarded nearly $1.5 million to AIDS cure researchers. Activist Martin Delaney is among those calling for an end to defeatism:

“Far too many people with HIV, as well as their doctors, have accepted the notion that a cure is not likely. No one can be certain that a cure will be found. No one can predict the future. But one thing is certain: if we allow pessimism about a cure to dominate our thinking, we surely won’t get one… We must restore our belief in a cure and make it one of the central demands of our activism.”11

How to spot fake AIDS cures and treatments

As already stated, there is no proven cure for AIDS. The best advice is to steer clear of anyone claiming otherwise. For those who find themselves tempted, here are a few pointers for spotting quack therapies.
Who makes the claims?

Try to find some information about the person or people promoting the product. What are their credentials? If someone claims to be a doctor then they should say what type of doctor, and where they got their qualifications.
What claims do they make?

Look at how the product is presented. Reputable scientists and doctors don’t use sensational terms such as “miracle breakthrough”. Also watch for evidence of poor scientific understanding; for example, no expert would refer to HIV as “the HIV virus” or “the AIDS virus”.

It is very rare for a medicine to be 100% effective for all patients. It is highly implausible that a single product could cure a wide range of unrelated diseases such as cancer, asthma, AIDS and diabetes. A real scientist would be extremely wary of making such claims.
What’s in the cure?

Many inventors won’t reveal what goes into their so-called cures. Ask yourself why this might be. Could it be that their methods wouldn’t stand up to scientific scrutiny?

It is important to remember that words like “natural” and “herbal” are no guarantee of safety. After all, hemlock and ricin (derived from castor beans) are both entirely natural and extremely toxic. As the U.S. Food and Drug Administration points out,

“Any product – synthetic or natural – potent enough to work like a drug is going to be potent enough to cause side effects.”12

What evidence do they offer?

To gain the approval of medical authorities, any new treatment must undergo very extensive testing. Countless products destroy HIV in the laboratory but are ineffective or dangerous when used by people. A proper trial involves a large group of volunteers divided randomly into two sets. One half uses the test product and the other receives a placebo (a harmless pretend medicine that looks like the real thing). During the trial, neither the scientists nor the volunteers should know who is getting which treatment. Afterwards, the results for the two groups are compared to see if the test product performed better than the placebo.

Virtually all promoters of “AIDS cures” cannot provide any data from large-scale, randomised human trials. Instead they rely on anecdotes, personal testimonies, laboratory experiments or small-scale trials with no placebo comparison. This type of evidence is always unreliable.

Personal testimonies are notoriously untrustworthy. Usually there is no way of knowing whether the people in question ever existed, let alone whether they were helped by the therapy. There have been cases of people being paid to pretend they’ve been cured. And even if a handful of people really did get better after they took the treatment, this doesn’t necessarily mean that it works; the improvements may just have been a coincidence. Many negative reports may have been left out of the promotional material.

Proving that HIV has been eradicated isn’t easy. Changes in symptoms or weight gain are not sufficient, and neither is a viral load test. Even if the test can’t detect HIV in the bloodstream (perhaps because the person has been on antiretroviral therapy), this doesn’t mean the virus has been cleared from all parts of the body. Much more thorough investigation is needed.
Beware of conspiracy theorists

Many sellers of fake medicines fall back on conspiracy theories to explain why their products haven’t undergone proper testing. They say that government agencies and the medical profession seek to suppress alternative treatments to safeguard the profits of the pharmaceutical industry.

This kind of allegation is a sure sign of a charlatan. In reality, leading scientists investigate all kinds of therapies that can’t be patented. For example, the U.S. government has funded research into using generic drugs (such as valproic acid) and human hormones (such as interleukin-2) as aids to ridding the body of HIV infection.
Do some research

Any important medical breakthrough will be reported in peer-reviewed journals such as Nature, Science or The Lancet. The mainstream media will pick up the story and leading experts will express their opinions.

Simply typing the name of a supposed cure into an Internet search engine and reading some of the resulting web pages will quickly establish whether it has widespread support. It is also worth searching an online medical database such as PubMed for scientific studies and reviews.
Consult an expert

Always talk to a doctor or other health professional before trying any medical treatment. If you need more information or a second opinion, try contacting a reputable health organisation or telephone helpline. Several American states have AIDS Fraud Task Forces dedicated to combating quackery, and local Food and Drug Administration offices can provide details of any action taken against a product or its manufacturer. Similar agencies operate in most other parts of the world.
Examples of false or unproven cures

What follows is a list of some products and methods that have attracted attention in recent years. It is safe to say that none of these is a cure for AIDS. Many of these so-called remedies are likely to do more harm than good.
President Jammeh’s AIDS cure

President Jammeh of The Gambia, a small country in West Africa, made a dramatic announcement in January 2007:

“I can treat asthma and HIV/AIDS and the cure is a day’s treatment. Within three days the person should be tested again and I can tell you that he/she will be negative... The mandate I have is that HIV/AIDS cases can be treated on Thursdays. That is the good news and the bad news is that I cannot treat more than ten patients every Thursday.”13

Three weeks later the president’s office released the results of viral load tests conducted on the first batch of patients. According to the official statement, “the herbal medicine and therapy administered by President Jammeh have yielded results beyond all reasonable doubts, that they are effective and can cure AIDS.”14 On closer inspection, however, the findings were far from convincing.

Of the four patients with HIV-1, one had a very high viral load, one high, one moderate, and one undetectable. Of the four patients with HIV-2, one had a low viral load and three had less than the detectable level.15

The fact that half of the patients still had detectable virus in their blood shows that the president’s cure cannot be 100% effective. More importantly, as already noted, an undetectable viral load does not prove that HIV has been eradicated. Some of the patients had previously been taking antiretroviral therapy, which often renders the virus undetectable. Apparently no evaluation was done before the president’s treatment began.

The viral load tests were conducted at a university in Dakar, Senegal, using samples of the patients’ blood. It has since emerged that the scientists who ran the tests were unaware of the samples’ origin. The Senegalese experts rebutted the president’s interpretation of their findings:

“There is no baseline ... you can’t prove that someone has been cured of AIDS from just one data point. It’s dishonest of the Gambian government to use our results in this way” Dr. Coumba Toure Kane16

“The interpretation by the Gambian authorities of the results of HIV antibody and viral load testing on blood samples sent to my laboratory is incorrect... Of those samples that were HIV-positive (66.66%), none could be described as cured.” Professor Souleymane Mboup17

The results of a second set of viral load tests, conducted by the National Institute of Hygiene in Morocco, were released in March 2007. For the first set of patients the numbers were similar to those found in Senegal. Among 31 other patients only six had undetectable viral loads.18

Clinical data for the third and fourth batch were released in October 2007. On this occasion the State House chose to withhold the name of the country in which the samples were tested. Twenty-seven of the seventy patients were found to have undetectable viral loads. Another twenty-seven had viral load counts above half a million, which is considered to be very high. The CD4 counts for twenty-seven of the seventy patients were below 200, which means they had progressed from HIV infection to AIDS. Curious repetitions within the viral load count data cast doubt on their accuracy.19

At least two of the president’s patients are known to have died.20

These unpromising outcomes have not shaken the president’s belief in his treatment, which is endorsed by the Gambian health ministry and is administered at state hospitals. President Jammeh, who has no medical qualifications, refuses to disclose exactly what goes into his cure. All he has revealed is that it involves seven herbs, “three of which are not from Gambia.”21 The treatment involves a green paste and a grey liquid each applied to the patient’s skin, and a yellowish tea-like drink. Even more important, according to President Jammeh, is the power of prayer:

“For everything that we do 90% we have to invoke the name of almighty Allah, and then 10% is what the herbs take care of.”22

Leading AIDS experts have expressed great concern about President Jammeh’s exploits. According to Dr. Pedro Cahn, President of the International AIDS Society:

“It is premature and unethical to label this product a cure if it has not been thoroughly tested and proven. Furthermore, to take patients off potent combination antiretroviral therapy, which has saved millions of lives since its introduction in 1996, is shocking and irresponsible.”23

A fifth batch of patients began treatment in February 2008.24 As of August 2008, the president was treating 122 people.25
Other herbal cures

Herbal mixtures comprise the most popular form of alternative AIDS therapy. Although it is possible that some of these treatments may benefit people with HIV, none is a proven cure.

* Comforter’s Healing Gift, a South African company, produces an extract of a plant called sonneblom (not sunflower). According to Freddie Isaacs, the inventor of the treatment and a co-director of the company, this product is a cure for AIDS.26 Other spokespersons have said such claims go against company policy, and the product should be described as a nutritional supplement until it has undergone proper testing. According to some reports one of South Africa’s leading attorneys, Christine Qunta, is closely connected with Comforter’s Healing Gift. South Africa’s opposition party has laid a charge against Qunta of authorising the sale of an unlicensed medicine.27
* Dr. Sebi (born Alfredo Bowman) says his “electric foods” can cure AIDS, cancer and many other illnesses. Sebi, who has offices in Honduras and the USA, has no medical qualifications and many of his views are totally at odds with basic principles of mainstream science. In Sebi’s opinion, AIDS (like all other diseases) occurs when “the mucous membrane has been compromised”.28 He says his plant extracts cure the illness by removing the mucous. Sebi was arrested in 1987 and again in 1997 for publishing false health claims and practising medicine without a licence.29 30 He has published no verifiable evidence to support his “AIDS cure”.
* IMOD was developed by scientists from Russia and Iran. When the Iranian government unveiled the drug in February 2007, many media sources, including Iran’s Fars News Agency, described IMOD as an “AIDS cure”.31 The official IMOD website makes no such claim, but does say that human trials of the drug found it increased CD4 counts in HIV positive people.32 No study reports have been published in medical journals. The research team did not respond to emails from the author of this article.
* Khomeini (or Khomein or Comein) was invented by Professor Sheik Allagholi Elahi of Iran, who set up a clinic in Uganda to sell this so-called AIDS cure for more than $1,500 per patient. The Ugandan Ministry of Health appointed a team of experts to monitor some of the few hundred people taking the treatment. After their study showed Elahi’s claims to be false, the government banned the use and distribution of Khomeini in April 2006, and Ehahi was arrested.33
* MAB Formula One and MAB Formula Two were developed by Ghanaian doctors and ethno-botanists led by Dr. Jacob Akumoah-Boateng. According to the researchers MAB Formula One kills HIV while MAB Formula Two boosts the immune system. Dr. Akumoah-Boateng says tests in the U.S. demonstrated the disappearance of HIV and HIV antibodies after the treatment was given, though none of the findings have been published in the medical literature.34
*
Ubhejane bottles on a shelf

The fake AIDS cure Ubhejane on sale in a South African pharmacy
Ubhejane, a brown liquid said to be made from 89 herbs, has been taken by many hundreds of HIV positive South Africans. Its creator, Zeblon Gwala, says Ubhejane reduces viral load and increases CD4 counts in HIV positive people. He advises that it should not be taken at the same time as antiretroviral treatment.

Ubhejane has often been referred to as a “cure for AIDS” and Gwala’s employees have reportedly promoted it as such, despite having no evidence from rigorous human trials.35 36 Scientists who have tested Ubhejane in the laboratory have stressed that they haven’t demonstrated any benefits to patients.37 South Africa’s opposition party has attempted to have Gwala prosecuted for fraud.38 In 2008, the Advertising Standards Authority of South Africa demanded the withdrawal of an advertisement stating that Ubhejane boosted immunity and reduced viral load, having found these claims to be unsubstantiated.39

Chemicals

Many people mistakenly believe that what destroys HIV in the test tube must also work in the human body. This is one reason why a number of disinfectants and other chemicals have been wrongly promoted as cures for AIDS.

* Armenicum (also known as iodine-lithium-alpha-dextrin or ILalphaD) is a type of iodophor, a chemical that slowly releases iodine when mixed with water. According to Armenian scientists Armenicum, injected into the bloodstream, acts as an antiretroviral drug by blocking the replication of HIV. They claim to have evidence that the substance reduces viral load and increases CD4 counts in HIV positive people. The inventor of Armenicum, Alexander Ilyen, once said he was convinced it would lead to an AIDS cure.40 No studies of HIV positive people treated with Armenicum have been published in peer-reviewed journals. In a report on an animal experiment published in June 2007 the Armenicum research team admits that, “The systemic therapeutic application of iodophores has not yet been accepted”.41 A BBC investigation of Armenicum in 1999 found that the health of two American men got worse after they took the drug.42 Nevertheless the Armenian government has invested most of its HIV treatment resources in Armenicum, which costs more than three times as much as antiretroviral therapy. By late 2008, ten years after the drug was introduced, around 800 people had taken Armenicum.43
* Colloidal silver is a suspension of extremely tiny silver particles in water. Many websites say this clear, colourless liquid effectively treats a wide range of bacterial and viral infections, including HIV infection. While it is true that colloidal silver kills germs in laboratory conditions, there is no reliable evidence of any benefit in people. Contrary to the claims of many retailers, colloidal silver is not harmless. Regular use can cause an irreversible bluish-grey discolouration of the skin, known as argyria.44 Consuming very large amounts of colloidal silver may lead to neurologic problems, kidney damage, stomach distress, headaches, fatigue, and skin irritation.45 There has been at least one reported case of a man falling into a coma after ingesting colloidal silver.46 In America it is illegal for retailers to make any health claims for this product.47
* Tetrasil (or Imusil) is a substance containing tetrasilver tetroxide. A patent held by Dr. Marvin S. Antelman claims that this simple chemical compound cures AIDS by “electrocuting” HIV.48 Dr. Antelman admits his approach to AIDS is “non-conventional” and he does not trust viral load tests: “Accordingly we have patients who display viral load reduction and those that do not who are nevertheless cured of AIDS”, he has said.49 Tetrasilver tetroxide is more commonly used for disinfecting swimming pools.50 After it was promoted as an AIDS cure in Zambia the government banned Tetrasil because it has no proven benefits for people living with HIV.51 In America it is illegal to promote Tetrasil for the treatment or prevention of any disease.52
* Virodene is based on the industrial solvent dimethylformamide (DMF). In the late 1990s this chemical was touted as a possible cure for AIDS. For several years senior members of the South African government, including Thabo Mbeki, vehemently supported research into Virodene as an AIDS treatment, against the advice of medical experts. South Africa’s drug regulators have long prohibited use of Virodene as it has no proven benefits. Laboratory studies have found that DMF does not destroy HIV or inhibit its replication. The only trial of its effectiveness in humans, conducted in Tanzania, found that Virodene did not reduce viral load and had only marginal effects on the immune system.53 DMF is considered a toxic substance; workers are advised to avoid skin contact with the chemical because it may cause serious liver damage.54 55 Imunoxx, which a Namibian company markets as an immune booster, is essentially identical to Virodene.

Oxygen therapy

* Hydrogen peroxide, diluted in water, is commonly used as a bleach and a disinfectant. Some alternative health practitioners advocate drinking, injecting or bathing in weak solutions of this chemical as a cure for AIDS, flu, cancer and other illnesses. There is no evidence to support these claims. Several people have died as a result of swallowing or injecting hydrogen peroxide.56 57
* Ozone is an unstable form of oxygen gas. Ozone therapy has been proposed as a treatment or cure for many illnesses, including HIV infection. One delivery method is autohemotherapy, which involves removing some of a patient’s blood, exposing it to ozone, and then putting it back into the patient. Alternatives include pumping the gas into the rectum, drinking water containing ozone bubbles (ozonized water, which contains hydrogen peroxide), or injecting the gas into the bloodstream. Studies of ozone autohemotherapy in HIV positive people have found it has no significant effect on CD4 counts and other outcomes.58 59 According to the U.S. Food and Drug Administration, “Ozone is a toxic gas with no known useful medical application in specific, adjunctive, or preventive therapy. In order for ozone to be effective as a germicide, it must be present in a concentration far greater than that which can be safely tolerated by man and animals.”60 It is illegal for retailers in America to make any health claims for ozone generators.

Electrical zappers

* Dr. Hulda Clark (who is not a licensed medical doctor) promotes a range of products said to cure AIDS including an electrical “zapper” which, by generating low voltage electricity, is supposed to kill parasites, bacteria and viruses in the body. No proper studies of the zapper have been conducted. Dr. Clark’s methods of diagnosing HIV are highly unconventional; she believes that HIV comes from intestinal worms in the presence of benzene, and that HIV can be found in snails.61 It is therefore doubtful whether the people she claims to have cured of HIV infection were ever really infected.62 Dr. Clark left America after being taken to court for practising medicine without a licence.63 She now runs a clinic in Tijuana, Mexico, where she has also run into trouble with the authorities.64
* The Bob Beck Protocol involves a set of therapies devised by the late Dr. Bob Beck (who was not a medical doctor) that are supposed to cure AIDS, cancer and all other diseases. The four components are electric currents, magnetic pulses, colloidal silver and ozonized water. There is no good evidence that electricity can cure any infection. Claims about the healing powers of Bob Beck’s devices are based entirely on test tube studies and unverifiable anecdotes.

Immune boosters

Some so-called AIDS cures are meant to stimulate the human immune system. Since HIV makes new copies of itself by infecting active immune cells, there is a real danger that such therapies will hasten the spread of the virus rather than contain it.

* Dr. Gary R. Davis got his idea for an AIDS cure from a goat that appeared in his dreams. The late Dr. Davis never prescribed his goat serum treatment (known as BB7075) to HIV positive Americans due to legal restrictions. In 1998 one young girl, Precious Thomas, was given the serum by her mother, who stole it from Davis’ office. Some websites say the girl was cured of HIV infection, based on a viral load test conducted soon afterwards.65 In a 2006 interview, however, Precious Thomas made clear that she was still infected with HIV.66 After being denied approval in America, Dr. Davis and his associates tried to conduct goat serum trials in Ghana. Again he was stopped because “the supporting evidence for asking for registration and use of the serum was totally inadequate”.67 In late 2006, a few months before Dr. Davis’ death, the BBC exposed an attempt by a British company to test the substance on dozens of people in Swaziland, despite the lack of toxicity tests and other necessary preliminary studies.68
* The Antidote – a drug derived from a crocodile protein – has been promoted via spam email and websites with the promise that “It kills all known deadly viruses and bacteria in the body”.69 Absolutely no scientific evidence has been offered to support this claim.
* V-1 Immunitor (or V-AIM or Immureboost) is a pink pill containing antigens taken from the pooled blood of HIV positive people. A clinic in Thailand began distributing V-1 in 2001. Demand soared when the pill’s inventor, Vichai Jirathitikal, said it had eliminated HIV in two patients.70 The Thai Ministry of Public Health responded by conducting a study of those receiving V-1; the findings were not encouraging. According to a government minister, “the pill does not have any effect on the body’s immune system, white blood cell count and amount of the virus in the blood”.71 Other studies of the so-called vaccine – all carried out by employees of its manufacturer – do not provide convincing evidence of benefit. AIDS patients treated with V-1 typically survive for a matter of weeks, as opposed to the years achieved through antiretroviral treatment.72 Although the company has said that people treated with V-1 have “serodeconverted” from HIV-positive to HIV-negative,73 this claim is based on unreliable evidence and is not taken seriously by the scientific community.74 The manufacturing and sales licences for V-1 in Thailand were revoked in April 2003.75 76 Apparently undaunted, Vichai Jirathitikal and a company called Immureboost have continued to promote the product under the new name V-AIM, describing it as a therapeutic vaccine rather than a cure for AIDS.77

Faith-based cures

Religious bodies have done much to help the response to AIDS, especially by caring for the sick. Sadly a small minority of religious leaders have abused the trust placed in them by promising to cure AIDS through faith, sometimes in exchange for money or gifts. Most reports come from sub-Saharan Africa, where evangelical Americans are among those implicated.78

One of the most startling examples of recent times concerns an Ethiopian church where thousands of HIV positive people have sought a cure in showers of holy water. At one time, pilgrims were told to trust in faith alone and to refuse medication.79 Church patriarch Abune Paulos has since endorsed the use of antiretroviral treatment:

“What we are saying is taking the drugs is neither a sin nor a crime. Both the Holy Water and the medicine are gifts of God. They neither contradict nor resist each other.”80

The virgin cleansing myth

The myth that sex with a virgin can cure sexually transmitted diseases has a long history in Europe and elsewhere. Since the emergence of the AIDS epidemic, there has been much concern that this belief might encourage the rape of children, especially in Africa where HIV is widespread. A number of horrific reports in the popular press have fuelled such anxiety.
road sign

A road sign in Zambia confronting the "virgin AIDS cure myth"

Belief in the virgin cleansing myth has been reported from Africa, Asia, Europe and the Americas. There is no doubt that it has led to abuse of not only children but also the disabled (who are often assumed to be virgins).81 Nevertheless, the scale of the myth’s impact is disputed because it is not the only motivation behind child rape.82 83 In many cases the goal is more likely to be prevention than cure: men are seeking partners who are less likely to have HIV.

Thankfully efforts are being made to dispel the virgin cleansing myth around the world. But to effectively clamp down on child rape, such campaigns must be accompanied by changes to the cultural and legal environment that enables abuse to take place.
Spontaneous cures: Andrew Stimpson

Occasionally there are reports of HIV seeming to vanish for no obvious reason. One especially sensational story broke on 13th November 2005, when two British newspapers reported that a 25-year old Scot, Andrew Stimpson, had become the first person to be cured of HIV infection.84 85

In interviews with the two papers, Stimpson said he first suspected he might have HIV in 2002, after several weeks of feeling tired and feverish. Knowing his partner had been HIV positive for a number of years, Stimpson visited the Victoria Sexual Health Clinic in London for an HIV antibody test in May. The result was negative, but he was encouraged to return for further tests, as HIV antibodies often do not appear in the blood until several weeks or even months after initial infection.

In August 2002, Stimpson returned for three more HIV antibody tests. His first, taken on the 15th, was “indeterminate” (i.e. neither definitely positive nor negative), but the following two (taken on 20th and 23rd August) both found him to be HIV antibody positive. However, a viral load test showed the amount of virus in his blood was low, so he was not prescribed antiretroviral therapy. He made a personal choice to start taking multivitamin and mineral tablets and other dietary supplements.

For fourteen months Stimpson remained surprisingly healthy, so much so that, in October 2003, his doctor offered him a repeat test for HIV antibodies. Remarkably, the test came back negative. Two more, carried out in December 2003 and March 2004, also gave negative results.

Andrew Stimpson tried to launch a legal case against the Chelsea and Westminster NHS Trust (CWT) which had tested him, assuming his results had been mixed up with those of another client. The blood samples associated with his original positive diagnosis and his subsequent negative results were retested, and the DNA from the samples compared to his. All the samples were found to belong to Stimpson, and retesting produced the same “positive then negative” antibody results. According to Stimpson:

“After the repeat tests my doctor came into the room saying, ‘You’ve cured yourself! This is unbelievable.’”86

Andrew Stimpson’s story became an overnight media sensation. But a statement from the CWT cast doubt on the cure claims:

“It is probable that there was never any evidence of Mr Stimpson having the HIV virus but rather that there was transient evidence of an antibody response to the virus present in his bloodstream when he had the initial tests... The antibody testing is exquisitely sensitive and the smallest measure can be recorded which is probably what happened in this case.”87

A spokesperson for the CWT later said they had not categorically stated that Andrew Stimpson’s case was an example of a false positive test result, but that it was one of a number of scenarios that needed to be considered.88 The media quickly accepted the “false positive” explanation, and by the end of the month the story had ceased to be of interest to them.

The only news since then dates from June 2006, when the Guardian newspaper reported that Stimpson was still working with doctors, but that because of medical confidentiality, very little more was known about the case. However, Anna Maria Geretti, a clinical virologist at the Royal Free Hospital, was willing to speculate:

“These follow-up tests are very complicated. They could take over six months. But personally, I’m sceptical that they will find a cure from this case.”89

The most likely explanation remains the occurrence of a highly unusual false positive antibody test result. This may happen if the test detects a non-HIV antibody (i.e. a similar antibody produced against a different virus) or, theoretically, because there are somehow HIV antibodies present without an actual HIV infection. Occasionally a false positive may be the result of a faulty test, though a second backup test would normally eliminate this possibility.

Although receiving three false positive results would be exceedingly unusual, some scientists believe it is more plausible than a spontaneous cure. In any case it’s extremely unlikely that, as some newspapers suggested, the multivitamins and dietary supplements that Andrew Stimpson took would have had any effect on his “seroreversion” (the process of going from HIV antibody positive to HIV antibody negative). Millions of people living with HIV take multivitamins and minerals; while such supplements may help to maintain good general health, there is no evidence that they can eliminate HIV infection.

AIDS vaccine

An AIDS vaccine does not yet exist, but the idea is undergoing research and development.
Why do we need an AIDS vaccine?

Even a partially effective AIDS vaccine could save millions of lives. Experts have calculated that a vaccine that is 50% effective, given to just 30% of the population could reduce the number of HIV infections in the developing world by more than half over 15 years. More effective AIDS vaccines could cut the infection rate by more than 80%.1

Efforts to develop a vaccine against HIV and AIDS have been underway for many years. In 1996, Dr Anthony S. Fauci, Director of the National Institute of Allergy and Infectious Diseases said:

“Developing a safe and effective vaccine against HIV is critical to our efforts to control the devastating pandemic of HIV and AIDS” 2

This statement is still true today.
So what is a vaccine?

A vaccine is something that teaches the body to recognise and defend itself against viruses or bacteria that cause disease. Vaccines either help to prevent infection, or help to prevent or delay illness in people who are already infected. A vaccine is not the same thing as a cure for AIDS.

Effective vaccines have already been developed for some diseases, such as smallpox, polio and tetanus, and these have saved millions of lives. But there is still no vaccine against HIV, the virus that causes AIDS.
What would be the advantage of an AIDS vaccine?

An AIDS vaccine would have a number of key advantages over today’s HIV prevention options. In particular, the protection offered by a vaccine during sex would not depend on the consent of both partners (unlike condom use), and would not require behaviour change (unlike abstinence). A vaccine would also be invaluable for couples wishing to conceive a child while minimising the risk of HIV transmission.

Children could be given a vaccine before ever being exposed to the virus, and ideally this would protect them from all routes of HIV transmission. Vaccinating large numbers of people would probably require relatively little equipment and expertise, and would be much simpler and cheaper than providing antiretroviral treatment for those already infected.
How might an AIDS vaccine work?
an antibody in contact with an HIV protein

This image shows an antibody (green) in contact with an HIV protein (yellow & red), which is a possible target for AIDS vaccine developers.

An AIDS vaccine could be effective in either of two ways. A “preventive” vaccine would stop HIV infection occurring altogether, whereas a “therapeutic” vaccine would not stop infection, but would prevent or delay illness in people who do become infected, and might also reduce the risk of them transmitting the virus to other people. Although a preventive vaccine would be ideal, a therapeutic vaccine would also be highly beneficial.

The basic idea behind all AIDS vaccines is to encourage the human immune system to fight HIV. The immune system works using a combination of cells and chemicals called antibodies. Early vaccine research focused on teaching the immune system to produce antibodies that would block HIV entering human cells. However, products designed to work this way failed in clinical trials because the antibodies worked only against lab-cultured HIV, not against the wild strains of the virus.

Recent research has focused on encouraging the immune system to produce cells to fight HIV. Nevertheless, many scientists believe such “cell-mediated” approaches will not be very effective on their own, even as therapeutic vaccines. It seems likely that a really effective vaccine will have to take a two-pronged approach involving both cells and antibodies.
Why is it difficult to develop an AIDS vaccine?

Developing an AIDS vaccine is a very difficult challenge for scientists. There are many reasons for this, including:

* Nobody has ever recovered from HIV infection, so there is no natural mechanism to imitate
* HIV destroys the immune system cells that are meant to fight against it
* Soon after infection, HIV inserts its genetic material into human cells, where it remains hidden from the immune system
* HIV occurs in several subtypes, each of which is very different from the others
* Even within each subtype, HIV is highly variable and constantly changing
* There are no good animal models to use in experiments

Can these difficulties be overcome?

There are reasons to be optimistic about the search for an AIDS vaccine, despite the slow progress so far. Vaccines against other diseases took many decades to develop, whereas HIV was only discovered in the mid 1980s. It is therefore much too early to give up hope, especially given the current speed of scientific progress. In the past, some experts doubted the possibility of an effective polio vaccine, yet today polio is close to being eradicated thanks to successful vaccination programmes.

One particular reason for remaining hopeful is that most people remain healthy for several years after becoming infected with HIV, and a small minority have survived as long as 20 years without developing AIDS, even though they never entirely rid themselves of the virus. Also it appears that a few people have some kind of natural resistance to HIV infection, meaning they never become infected despite repeated exposure to the virus. These facts suggest that the immune system can be quite effective at controlling HIV.
Who is supporting research and development?

In 2008, the public, philanthropic and private sectors invested around $868 million in preventive AIDS vaccine research and development.3 The public sector provided around 84 percent, the philanthropic sector accounted for 12 percent, and the commercial sector accounted for the remaining 4 percent. Although funding for vaccine research has increased substantially since 2000, the 2008 contributions were a 10 percent decrease from 2007.4

The quest for an AIDS vaccine is aided by the not-for-profit International AIDS Vaccine Initiative (IAVI), which helps to support and coordinate vaccine research, development, policy and advocacy around the world. In addition an alliance of organisations called the Global HIV/AIDS Vaccine Enterprise exists to coordinate research and promote scientific cooperation and collaboration.
How are the possible AIDS vaccines tested?

Any potential AIDS vaccine must pass through three phases of clinical trials before being judged safe and effective. The first phase usually lasts from twelve to eighteen months, whereas the last phase can take three or four years to complete. In most cases volunteers taking part in the trial must be HIV-negative at the start of the trial, though it is important also to test safety in those who are already infected. Some therapeutic vaccine candidates may be tested on HIV-positive people to see if they can delay disease progression.

* Phase I involves a small number of volunteers to test the safety of various doses
* Phase II involves hundreds of volunteers to further assess safety and, in some cases, positive responses
* Phase III involves thousands of volunteers to test safety and effectiveness

A recent innovation is the Phase IIb trial, a larger form of the Phase II trial that provides some indication of effectiveness.

Trials of AIDS vaccines are made more difficult by the ethical obligation to provide condoms and prevention counselling to all those who take part. Providing such services lowers the overall rate of HIV transmission, which increases the number of volunteers required to produce a significant result.
What vaccine trials have already taken place?
AIDSVAX

The first AIDS vaccine candidate to undergo Phase III trials was called AIDSVAX. Two separate studies were conducted. One had around 5,400 participants - mostly gay American men - while the other involved around 2,500 injecting drug users in Thailand. The vaccine was made from a single HIV protein and was meant to stimulate a protective antibody response. The trials began in 1998 and 1999 respectively, and ended in 2003. No beneficial effect was found in either population group.5
STEP and Phambili

Two Phase IIb trials of a vaccine candidate created by the pharmaceutical company Merck were halted in September 2007. The studies - known as STEP and Phambili - had been expected to produce their first results by 2010. They were stopped when researchers found people receiving the vaccine were no less likely to become infected with HIV than those given the placebo - the version that had no medicinal properties. The STEP trial had started in 2004 in the USA, Canada, Australia, Peru and the Caribbean; the Phambili trial had begun in January 2007 in South Africa.6 7

There is some concern that slightly more HIV infections occurred among people who received the Merck vaccine than among those who took a placebo. The vaccine was delivered using adenovirus type 5, which causes the common cold. It has been suggested that the vaccine may have provoked a different immune response among people who already had some immunity to the adenovirus strain, and that this may have made them more susceptible to HIV infection. This hypothesis - which is supported by laboratory evidence8 - raises questions about the use of adenovirus in future vaccines.9 It has also been noticed that uncircumcised men were four times more likely to become infected with HIV if they received the vaccine than if they received the placebo.10

Following the failure of the trial several other trials were delayed to ensure the design of the trail took into account what had been learnt from the Merck vaccine study.

Leading vaccine researcher Dr. Gary Nabel described the results of the Merck vaccine trial as “a big blow to the field”.11 Nevertheless, Dr. Seth Berkley, President and CEO of the International AIDS Vaccine Initiative, has stressed that the outcomes are not all negative:

“Though the Merck candidate failed, the trial did not. The contribution of the volunteers was not in vain. As a result of their dedication, the field will have new data that will inform future vaccine design, help with the prioritization of candidates in the pipeline and guide decisions on how to best proceed with ongoing and upcoming trials.”12

ALVAC / AIDSVAX trial

In 2006 AIDSVAX was used in another Phase III trial in combination with ALVAC.13 It was hoped that a trial combining AIDSVAX, which promotes the production of antibodies to HIV, and ALVAC, which is designed to stimulate a cellular response to the virus, would prove more effective than the previous AIDSVAX trial.14 The trial recruited 16,402 young adults in Thailand.

The results, published in late 2009, showed that 74 trial candidates who received a placebo became infected with HIV, compared to 51 who had received the vaccine candidate.15 Although further examination produced mixed results, the analysis which the authors claimed was most relevant showed the vaccine prevented HIV infection by 31.2%. Drawing on this statistically significant result, the authors concluded that the trial showed a "modest protective effect of vaccine".16

Opinion differed over the significance of the study. Seth Berkley, of the International AIDS Vaccine Initiative was optimistic:

“The outcome is very exciting news and a significant scientific achievement. It’s the first demonstration that a candidate AIDS vaccine provides benefit in humans. Until now, we’ve had evidence of feasibility for an AIDS vaccine in animal models. Now, we’ve got a vaccine candidate that appears to show a protective effect in humans, albeit partially.” - 17

However, Dr. Otto Yang, an immunologist at University of California, LA, said:

"the results are weak enough that we need to be very careful about assigning too much optimism to them... It seems not so likely that the vaccine really did what it was intended to do". - 18

What vaccine trials are now underway?

By 2009, twenty-nine human trials of preventive HIV/AIDS vaccines were taking place worldwide.19 This number included one Phase II trial; three Phase I/II trials and twenty-five Phase I trials.
How soon could we have an effective vaccine?

“The path forward is not clear. I think there is agreement on that. Anybody who talks about a timeline for a vaccine is being silly and uninformed.”

- Professor John Mellors

In 1984, at the press conference arranged to announce the discovery of HIV, the US Health and Human Services Secretary Margaret Heckler said she hoped a vaccine against AIDS would be ready for testing in about two years.20

Unfortunately, the problem has turned out to be much more challenging than Secretary Heckler expected. Today’s researchers agree that the quest for an AIDS vaccine still has a long way to go. It is possible that the search could last decades.

“HIV infection has never provided scientists with a proof of concept of predictable protection, which historically has been the guiding principle for successful vaccine development.” – Dr Anthony S. Fauci, Director of NIAID21

The failure of the STEP trial in 2007 in particular has led some scientists to question whether the current approach to AIDS vaccine development has much chance of success, given that it favours products that work in a similar way to the failed Merck candidate.

“The path forward is not clear. I think there is agreement on that. Anybody who talks about a timeline for a vaccine is being silly and uninformed. It will require an incremental process of knowledge, and experimentation, and testing of ideas.” - Professor John Mellors22

The news media regularly announce a new “breakthrough” in AIDS vaccine research. However, most of these stories refer to products in Phase I or Phase II trials, where there has been no evidence of the product actually working in humans. Such stories are realistically talking only about potential breakthroughs.

Few if any vaccines are 100% effective. Most probably the first AIDS vaccines to succeed in trials will offer only partial protection, and these may need to be improved or combined with other products before being suitable for widespread use. Vaccine development is likely to proceed by small, incremental steps; we are unlikely to see an immediate “miracle breakthrough”.
Reaching people in need

If trials conclusively find a particular vaccine to be safe and effective then the next challenge is to distribute it and help people access it. In addition both governments and individuals will need to be convinced that the product is worth investing in. The process of getting a vaccine to all the hundreds of millions of people in need could take many years.

An important consideration is whether a vaccine could undermine the popularity of existing HIV prevention methods, such as condoms. If a product is only partially effective (as is almost inevitable) then experts will have to weigh up the potential risks and benefits very carefully before considering distribution. Upon release of any product, awareness-raising and prevention efforts will need to be redoubled to counter the risk of complacency.
Conclusion

It is very unlikely that HIV and AIDS will ever be eradicated without new scientific developments. Eventually, unless great progress is made in prevention, the number of people living with HIV will outstrip the resources available for treatment. The search for an effective vaccine must therefore be one of the very highest priorities for scientific research.

However, it is not realistic to expect such research to produce a major breakthrough for some time yet, and we should be wary of news stories suggesting otherwise. Any new discovery needs to undergo trials lasting years, and must then be distributed around the world before we will see its full benefits.

There is also a danger that focus will be diverted from existing successful initiatives that require continued funding, such as prevention and antiretroviral treatment programmes.

“The world is jumping into a flurry of excitement about a possible solution many years down the line – nobody seems to be in a similar flurry about the fact that, right now, two out of three people who need ART to stay alive aren’t receiving it.” – Paula Akugizibwe, AIDS and Rights Alliance for Southern Africa23

Millions of lives can be saved using the knowledge and tools already at our disposal, provided the world commits itself wholeheartedly to the cause.

Microbicides

A microbicide for HIV does not yet exist, but the idea is currently being researched and developed.
What is a microbicide?

A microbicide is something designed to destroy microbes (bacteria and viruses) or to reduce their ability to establish an infection. A microbicide for preventing HIV infection would be applied to the vagina or rectum to prevent the virus being passed on during sex.
What are the advantages of HIV microbicides?

A microbicide would share many of the advantages of an AIDS vaccine. It would be especially useful for women unable to insist on their partner using condoms, who might be able to use a microbicide without their partners knowing. However, a microbicide would not be able to prevent all forms of HIV transmission, and would require regular reapplication. Unlike vaccines, an effective microbicide must be made into a commodity that people will want to use regularly, such as a cream, gel or vaginal ring.
How might an HIV microbicide work?

A microbicide could work in at least four different ways:

* Kill or inactivate HIV
* Stop the virus entering human cells
* Enhance the body’s normal defence mechanisms against HIV
* Inhibit HIV replication

It is possible that a microbicide could work in much the same way as a vaccine, so research in one area could benefit the other. Alternatively, a microbicide could work in a similar way to today’s antiretroviral drugs, or it could act like a detergent by disrupting the outer coating of the virus.
What are the challenges in developing HIV microbicides?

There are many chemicals that kill HIV, including undiluted household bleach. But what is needed for a microbicide is something that works against HIV without causing discomfort or irritation. For example, when researchers investigated using the spermicide Nonoxynol-9 as an HIV microbicide they were surprised to find it actually increased the rate of transmission, probably because it caused vaginal lesions and inflammation, which made it easier for HIV to establish an infection, even though Nonoxynol-9 killed the virus in lab tests.1

For a microbicide to become popular, researchers must develop not only the active ingredient but also a microbicide that is socially acceptable, affordable and easy to apply. Ideally it would provide protection for several days or even weeks at a time.

Another major issue is how a microbicide affects sperm. To reach all those in need, scientists will have to develop both contraceptive and non-contraceptive microbicides.
Who is supporting research and development?

In 2008 around $244 million was invested in microbicide research and development - up by 8% on the previous year. About 85% of this money came from the public sector, 14% came from the philanthropic sector and 1% was accounted for by commercial companies (only $2.5 million).2

At present no major pharmaceutical firm is investing significant amounts of its own money in microbicide research because it is complex and the market is uncertain.3 As Professor Jonathon Weber has stated:

"[Microbicides] are perceived as drugs for Africa, and no one makes money from Africa" - 4

How are the possible microbicides tested?

There are three phases of clinical trials that a potential mircobicide must pass through before it is judged effective and safe. Phase I tends to last between twelve and eighteen months, whereas the final phase can take up to three or four years.

* Phase I involves a small number of volunteers to test the safety of various doses
* Phase II involves hundreds of volunteers to further assess safety and, in some cases, positive responses
* Phase III involves thousands of volunteers to test safety and effectiveness

The Phase IIb trial, a recent innovation, is a larger variant of the Phase II trial.

All microbicide trials provide condoms and prevention counselling to all participants, as an ethical obligation. As a result, the overall rate of HIV transmission is lowered, which means more volunteers are needed to produce a significant result. Most volunteers must be HIV-negative at the beginning of the trial, though it is also important to test safety in those who are already infected.
How many microbicides trials are under way?

By 2009, ten HIV microbicide candidates were undergoing trials.5 This included Phase III trials of PRO 2000 and Buffergel and a Phase IIb trial of Tenofovir gel.

* PRO 2000 is a type of entry inhibitor
* Buffergel maintains acidity in the vagina
* Tenofovir gel is based on an antiretroviral drug

There are more than 60 organisations involved in the development of microbicides. This includes sponsors, funders and research groups.6
Which microbicide trials have recently ended?

In August 2006, Family Health International decided to halt a Phase III trial of a surfactant called SAVVY after preliminary results showed no evidence of a protective effect. The organisation has no plans to further investigate this product.7
A computer-generated image of HIV exiting a cell

A computer-generated image of HIV exiting a cell

Two Phase III trials of an entry inhibitor called cellulose sulphate (also known as Ushercell) were halted in January 2007 after some sites recorded a higher HIV infection rate among women who used the gel, compared to those who were given a version that had no medicinal properties (a placebo). This result led to speculation that the gel may have increased the risk of HIV transmission. Later analysis indicated that the higher infection rate may have been due to chance.8

In February 2008, researchers announced the results of a Phase III trial of Carraguard, an entry inhibitor based on carrageenan, which is derived from seaweed. The product - the first ever to complete Phase III testing - was shown to be safe, but had no significant effect on HIV transmission.9

Also in February 2008, it was decided that the largest PRO 2000 trial should stop testing a higher strength version of the product because it was unlikely to be beneficial. A weaker version was investigated, but in 2009 the results did not reach a level of statistical significance.10 11 Results from a much larger study of PRO 2000, sponsored by the Medical Research Council and the Department for International Development in the United Kingdom, are expected in late 2009.
Conclusion

If one of the microbicide candidates were successful in preventing HIV infection, it would be a while before it would become widely available. Any successful product would have to undergo review and licensing by regulatory agencies before becoming available to the public. It would take time to work out the best formulation and dosage; find a suitable delivery method; and distribute the product. Also, if an effective product is produced it may be difficult finding investors, as the microbicide will have to be available to women in low- and middle- income countries and therefore profit margins will be low.12 In addition, any successful microbicide will only be partially protective and so would have to be complemented with other prevention methods.13

Whilst it is important to ensure continued funding and support for microbicide development, it would not be helpful to be overly optimistic about the effectiveness and potential availability of such a product. A microbicide will not be a ‘silver bullet’ for ending the epidemic, but rather another tool to add to existing prevention efforts.

History of AIDS

2009-12-03T04:40:00.003-08:00

These are some of the most important events that occurred in the history of AIDS over the period 1987-1992.
1987 History

At the beginning of January the UK Secretary of State for Social Services, Norman Fowler, visited San Francisco, and in a widely publicised visit shook hands with an AIDS patient. It was suggested that Princess Diana should follow his example, which she did later in the year.1 2

A leaflet about AIDS was delivered to every household in the UK, and the British Government also launched a major advertising campaign with the slogan "AIDS: Don't Die of Ignorance", and with the secondary advice:3 4

The ‘tombstone’ AIDS advert that was aired in 1987 in the UK. ©

"Anyone can get it, gay or straight, male or female. Already 30,000 people are infected." 5

In February there was a general media "AIDS week", when there were numerous TV and radio programs on AIDS in the UK.6 Many other countries also had education campaigns.

By this time, the World Health Organisation had been notified of 43,880 cases of AIDS in 91 countries.7

The first HIV case was officially recorded in the Soviet Union, and a massive HIV testing programme was conducted.8

Meanwhile in San Francisco, gay rights activist Cleve Jones made the first panel for the AIDS Memorial Quilt in memory of his friend Marvin Feldman.9

"The Names project is a campaign to provide memorials to those lives by creating a huge quilt made up of individual panels, each 3 by 6 feet, that have been made by families friends and co-workers of those who died. Each of the nearly 3000 panels, which have come from all over the country, bears the name of a victim of acquired immune deficiency."10

In March the U.S. Food and Drug Administration (FDA) approved AZT as the first antiretroviral drug to be used as a treatment for AIDS.11

Around the same time the organisation ACT UP (the AIDS Coalition to Unleash Power) was founded. ACT UP was committed to direct action to end the AIDS crisis, and their demands included better access to drugs as well as cheaper prices, public education about AIDS and the prohibition of AIDS-related discrimination. On 24th March they held their first mass demonstration on Wall Street.12
Silence=Death, gay protest

'Silence=mort' is the French language version of 'Silence=Death'.

Many of the placards used in ACT-UP's demonstrations carried the graphic emblem "SILENCE=DEATH". Created in 1987 by a group of gay men calling themselves the Silence=Death project, the emblem was leant to ACT-UP and for many Americans it became the symbol of AIDS activism.13

One ACT-UP committee used the emblem in a window display called "Let the Record Show" at the New Museum of Contemporary Art in New York; afterwards they regrouped as Gran Fury:14

"a band of individuals united in anger and dedicated to exploiting the power of art to end the AIDS crisis"15

Over the next few years Gran Fury produced many high profile public projects including the art banner announcing "Kissing doesn't kill: Greed and indifference do" and the poster "AIDS: 1 in 61" about babies born HIV positive in New York City.16

On the other side of the world, in Australia, the Grim Reaper education campaign was launched, with television images of death mowing down a range of victims in a bowling alley. Although widely criticised at the time, the advertisements did succeed in ensuring widespread discussion of AIDS.17

The Australian AIDS commercial from 1987.

"A bowling alley of death, haunted by decomposing grim reaper bowling over men, pregnant women, babies and crying children was featured on national television last night as the part of a $3 million AIDS education campaign, The 60-second commercial featuring the grim reaper, a macabre and dramatic rotten corpse with scythe in one hand and bowling ball in the other, is spearheading efforts by the National Advisory Committee on AIDS to educate Australians about the incurable disease."18

On 31st March, at a ceremony at the White House attended by President Reagan, it was announced that an agreement had been reached regarding ownership of the HIV antibody test patent. The Pasteur Institute agreed that it would end its legal challenge, and would share the profits from the test with the U.S. Department of Health and Human Services.19 Although the agreement officially resolved the question of who had invented the HIV antibody test, it did not address the question of who had discovered HIV and identified it as the cause of AIDS. It was generally agreed that:

"historians can decide who found the AIDS virus first."20

But to many people it appears clear that HIV was isolated in Paris a year before it was isolated in the USA.21

The following day President Reagan made his first major speech on AIDS, when he addressed the Philadelphia College of Physicians. Reagan advocated a modest federal role in AIDS education, having told reporters the previous day that he favoured teaching pupils about AIDS,
Kissing doesn't kill advert

Poster "Kissing doesn't Kill: Greed and indifference do" Gran Fury collection

"as long as they teach that one of the answers to it is abstinence - if you say it's not how you do it, but that you don't do it."22

In England the first specialist AIDS hospital ward was opened by Princess Diana. The fact that she did not wear gloves when shaking hands with people with AIDS was widely reported in the press.

"she shook my hand without her gloves on. That proves you can't get AIDS from normal social contact."23

The WHO Global Programme on AIDS had developed a Global AIDS Strategy, which was approved by the World Health Assembly in May. The Global AIDS Strategy established the objectives and principles of local, national and international action to prevent and control HIV/AIDS, and it included the need for every country to have a "supportive and non-discriminatory social environment".24

But on 31st May President Reagan gave a speech about AIDS at a dinner of the American Foundation for AIDS Research and particularly focused on increasing routine and compulsory AIDS testing.25
Australian Grim Reaper advert

Grim Reaper (Australian AIDS campaign) circa 1987

The following day Vice President George Bush opened the 3rd International Conference on AIDS in Washington and was booed by the audience when he defended President Reagan's HIV testing proposals. Demonstrators against the administration's policies were arrested outside the White House by police wearing long yellow rubber gloves.26

"On the nightly news broadcasts, the world saw pictures of demonstrators being arrested by police wearing bright yellow, arm-length gloves. Although research had by now proved that the AIDS virus could not be passed through casual contact, the sight of the gloves served to reinforce the public's general overestimation of the risk of HIV transmission."27

In June the U.S. Public Health Service added AIDS to its list of diseases for which people on public health grounds could be excluded from the USA.28 Subsequently in July the "Helms amendment" created by Senator Jesse Helms added HIV infection to the exclusion list.29 Few foresaw the implications of the addition and it went virtually unnoticed.30

In July the WHO reviewed the evidence and confirmed that HIV could be passed from mother to child through breastfeeding. Nevertheless they recommended that HIV positive mothers in developing countries should be encouraged to breastfeed, as in many circumstances safe and effective use of alternatives was impossible.31

In light of more widespread HIV testing, the CDC revised their definition of AIDS to place a greater emphasis on HIV infection status.32

Prejudice against people with HIV continued in America. The Ray family lived in Arcadia, Florida, and they had three sons, each of whom was a haemophiliac and was HIV positive. During 1986 the family was told their sons could not attend school. In 1987 the family moved to Alabama, and once again they were refused entry to school. Threats against the family grew louder and more frequent, and on August 28th the Rays' small single-storey house was doused with gasoline and torched.33

In England, the UK Government expanded syringe exchange schemes to prevent transmission of HIV through drug use, and also launched an advertising campaign with the message 'Don't inject AIDS'.34

In the autumn, a book by Randy Shilts called 'And the Band Played On' was published, which chronicled the early years of the AIDS epidemic.35 Shilts' book made an important contribution to documenting the history of AIDS, but his view of "the facts about AIDS", as well as his opinions, differ greatly from others on a number of occasions.36

Shilts was the first to identify a French-Canadian flight attendant called Gaetan Dugas as 'Patient Zero'. Shilts claimed that Gaetan Dugas played a key role in the early spread of AIDS in America, and the story of 'Patient Zero' was widely publicised by the media.37 But there never was a Patient Zero.
1 in 61 advert

Poster "AIDS: 1 IN 61" Gran Fury collection

"There's no Patient Zero. It's lots and lots people moving around from New York to San Francisco, and the rest of the world. If there ever was an original Patient Zero, it would have been back in the mid-Seventies. But there isn't an original Patient Zero." - Andrew Moss38

In Africa, President Kaunda of Zambia announced that his son had died of AIDS, and appealed to the international community to treat AIDS as a worldwide problem.39 In Uganda, 16 volunteers who had been personally affected by HIV/AIDS came together to found the community organisation TASO.40

In October, AIDS became the first disease ever debated on the floor of the United Nations (UN) General Assembly. The General Assembly resolved to mobilize the entire UN system in the worldwide struggle against AIDS, under the leadership of the WHO.41

The American scientist Dr. Peter Duesberg published a scientific paper in a cancer journal that questioned the then dominant theory that viruses were involved in cancer causation, and also queried the link between HIV and AIDS.42 In November, Channel 4 broadcast the documentary 'AIDS: the Unheard Voices' to its British audience. In the documentary Duesberg and others argued that HIV could not be the cause of AIDS.43

By December, 71,751 cases of AIDS had been reported to the World Health Organisation, with the greatest number reported by the USA (47,022). Countries reporting over 2,000 cases included France (2,523), Uganda (2,369) and Brazil (2,102). Five other countries reported more than 1,000 cases: Tanzania (1,608), Germany (1,486), Canada (1,334), UK (1,170) and Italy (1,104).

The WHO also reported that an estimated 5 to 10 million people were infected with HIV worldwide, with 150,000 cases of AIDS expected to develop in the following 12 months and up to 3 million within the next 5 years.44
1988 History
1988 World AIDS day logo

As the global mobilisation against AIDS continued, a world summit of ministers of health was held in London to discuss a common AIDS strategy. The summit focused on programmes for AIDS prevention, and there were delegates from 148 countries.

One outcome of the meeting was the London Declaration on AIDS Prevention, which emphasised education, the free exchange of information and experience, and the need to protect human rights and dignity.45 The Director-General of the World Health Organization chose this occasion to announce that the WHO intended to promote an annual World AIDS Day, and the first such day would be on 1st December 1988.46

The meeting was opened by the UK's Princess Royal, who upset many people involved in AIDS education, as well as many people with AIDS, when she stated that:
All people with AIDS are innocent

Poster "All people with AIDS are innocent" Gran Fury collection

"the real tragedy concerns the innocent victims, people who have been infected unknowingly, perhaps as a result of a blood transfusion … but possibly, worst of all, those babies who are infected in the womb and are born with the virus."47

If there are "innocent victims", then by implication there are also "guilty victims". This was an unfortunate suggestion to be making at a world meeting on AIDS prevention.

In May the United States finally launched a coordinated HIV/AIDS education campaign.48 The distribution took place of 107 million copies of "Understanding AIDS", a booklet by Surgeon General C. Everett Koop.49 'Understanding AIDS' was the single most widely read publication in the United States in June 1988, with 86.9 million readers.50

The following month the American Medical Association urged doctors to break confidentiality in order to warn the sexual partners of people being treated for AIDS.51

"We are saying for the first time that, because of the danger to the public health and danger to unknowing partners who may be contaminated with this lethal disease, the physician may be required to violate patient confidentiality. The physician has a responsibility to inform the spouse or known partners. This is more than an option. This is an professional responsibility."

AIDS activists conveying the message that every half an hour someone dies from AIDS; Washington DC, 1988

AIDS Activists, Washington DC, 1988

In the USA frustration continued to grow over the slowness of progress in improving access to drugs. When the Presidential Commission on the HIV Epidemic issued its final report in June 1988, it declared that the FDA arrangements were "not meeting the needs of people with AIDS". On October 11th more than 1,000 ACT-UP demonstrators virtually shut down operations at the FDA headquarters.52

Eight days after the ACT-UP demonstration the FDA announced new regulations to speed drug approval.53

The first official needle exchange was started in the US to prevent transmission of HIV through drug use.54 A limited experiment started in November in New York City and, at about the same time, the Prevention Point opened in San Francisco.55 56 But Congress prohibited the use of federal funds to support needle exchange programs.57

On December 1st, the first World AIDS Day took place, with the WHO asking everyone to "Join the Worldwide Effort."58
1989 History

On February 7th, the FDA announced that it was going to approve an aerosol form of the drug Pentamidine for the treatment of PCP (a type of pneumonia) in people with AIDS.59 Much of the data that led to this approval was collected by CCC, the County Community Consortium of San Francisco, with further data collected by another community research organisation called CRI, the Community Research Initiative of New York.60

By March 1st, 145 countries had reported 142,000 cases of AIDS to the World Health Organisation (WHO). The WHO regarded this as under-reporting, and estimated the actual number of people with AIDS around the world to be over 400,000. It was predicted that this figure would rise to 1.1 million by 1991. It was also estimated that 5-10 million people were already infected with HIV.61

On April 2nd, Hans Verhoef, a Dutch man with AIDS, was jailed in Minnesota under the federal law banning travellers with HIV from entering the USA.62 In June a protest against the law took place at the opening ceremony of the Fifth International Conference on AIDS in Montreal, when 250 protestors with placards stormed the stage.63
AZT bottles

Zidovudine, better known as AZT

In August, there were more developments with respect to treatment, when the results were announced of a major drug trial known as ACTG019. ACTG019 was a trial of the drug AZT, and it showed that AZT could slow progression to AIDS in HIV positive individuals with no symptoms at all. The findings were considered extremely exciting, and on August 17th a press conference was held, at which the Health Secretary, Louis Sullivan said:

"Today we are witnessing a turning point in the battle to change AIDS from a fatal disease to a treatable one."

The result had enormous financial implications for the makers of the drug, Burroughs Wellcome. The day after the press conference, the value of the company's stock rose by 32 per cent.64 The high price of AZT angered many people; with a year's supply for one person costing about $7,000, Burroughs Welcome were accused of "price gouging and profiteering".65 66

In September, the cost of the drug was cut by 20%.67

In October the second drug for the treatment of AIDS, dideoxyinosine (ddI), started to be made available to people with AIDS, even though only preliminary tests had been completed.

"It become clear that ddl was not just another drug in terms of need: it was a life-and-death matter, said Richard L. Gelb, chairman of Bristol Myers."68

1990 History

At the beginning of the year, it was reported that a large number of children in Romanian hospitals and orphanages had become infected with HIV as a result of multiple blood transfusions and the reuse of needles. Jonathan Mann, the head of the WHO's Global programme on AIDS, noted that 'Eastern Europe is the new frontier for the AIDS epidemic'.69

In China, 146 people in Yunnan Province near the Burmese border were found to have HIV infection due to sharing needles. This shocked public health officials in China. It was not known whether this was the first sign of an epidemic or an isolated outbreak.70

"AIDS and drug addiction are still seen as consequences of contact with the West, AIDS being known as aizibing, the 'loving capitalism disease'."71

In New York city the needle exchange scheme was closed down.72
Jonathan Mann

Johnathan Mann

Jonathan Mann resigned as the head of the WHO AIDS programme, to protest against the failure of the UN and governments worldwide to respond adequately to the exploding pandemic, and to protest against the actions of the then WHO director-general Dr. Hiroshi Nakajima.73 During Jonathan Mann's leadership, the AIDS programme became the largest single programme in the organisation's history.74 But more importantly:

"Jonathan's persistence and passion helped wake up the world."75

and,

"Had it not been for Jonathan's unique contributions, the world's approach to AIDS might very well have gone towards mandatory testing and quarantine."76

Ryan White

Ryan White, 1971-1990

On April 8th Ryan White died in the United States. He was a haemophiliac infected with HIV through the use of infected blood products. He had become well known a few years earlier as a result of his fight to be allowed to attend public school.77 Just a few months later the Ryan White CARE Act was passed by Congress. The aim of the act was to provide grants to improve the quality and availability of care for individuals and families with HIV disease.78

In the UK and the US, there started to be more discussion about whether there would ever be a heterosexual epidemic because of the difficulty of female-to-male transmission of HIV.79 80 81

In June, a TV programme called 'The AIDS Catch' was screened in the UK, again questioning whether HIV caused AIDS and whether AIDS was infectious or not. The programme provoked a hostile response among the AIDS community and organisations.82 Some people felt that the programme was sensationalist and contained factual inaccuracies. It was also felt that the programme caused significant distress among people with HIV and undermined the efforts carried out in the field of HIV/AIDS prevention.83

Protests against the ban on HIV positive people entering America had continued. Although there had been minor changes to the law, at the time of the 6th International Conference on AIDS in San Francisco in June it was still considered by many to be "discriminatory and medically unsupportable".84 Consequently there was a widespread boycott of the conference, and many people who did speak at the conference took the opportunity to voice their views. One such person was June Osborn, the Chair of the National Commission on AIDS, who said:

"How sorry I am, and how embarrassed as an American, that our country whose tradition serves as a proud beacon for emerging democracies, should persist in such misguided and irrational current policy."85

Many demonstrations took place during the conference week, the most significant being the "United Call to Action", in which activists, scientists, and many others marched together to emphasise the importance of unified action to end AIDS.86
ACTUP protestors at the AIDS conference

ACT-UP protests at AIDS Conference, San Francisco

The International AIDS Society (IAS) announced that no further IAS sponsored conference would be held in a country that restricted the entry of HIV infected travellers.87 As a result of the US travel policy, no major international AIDS conference was to be held in the USA after 1990.

In July the CDC reported the possible transmission of HIV to a patient during a dental procedure. The dentist had been diagnosed with AIDS three months before performing the procedure. The CDC investigation did not identify any other risk factors or behaviours that could have put the patient at risk of HIV infection.88 A couple of months later the patient was named as 22-year old Kimberly Bergalis and the dentist was named as David Acer.89

"When she was diagnosed with AIDS we were in disbelief. All we could wonder was whether something went wrong at the dentists. Health officials said no way, it just can't happen. But Kimberly stuck by her guns and kept telling them to look at the dentist. Eventually the CDC supported her conclusion." - George Bergalis -90

In the UK, Prime Minister John Major announced that the Government would pay £42 million compensation to haemophiliacs infected with HIV and their dependants.91

By the end of the year, over 307,000 AIDS cases had been officially reported to the WHO, but the actual number was estimated to be closer to a million. It was estimated that 8-10 million people were living with HIV worldwide, of whom about 5 million were men and 3 million were women.92
Area Estimated HIV Reported AIDS Estimated AIDS
Africa >5,500,000 77,043 >650,000
N America 1,000,000 156,658 200,000
S America 1,000,000 28,937 90,000
Asia 500,000 843 2,000
Europe 500,000 41,564 50,000
Oceania 30,000 2,334 2,700
Total <9,000,000 307,379 <1,000,000

The 3 million HIV-infected women were estimated to have given birth to around 3 million infants, of whom over 700,000 were likely to have become infected with HIV.
1991 History

At the beginning of 1991 the CDC published a report confirming that, in addition to Kimberly Bergalis, two other patients had probably been infected by the same dentist.93 Such was the public concern about this that America's leading medical and dental associations announced that HIV positive doctors and dentists should warn their patients about their infection status or give up surgery.94 During the summer, in the midst of continuing public hysteria, the CDC also recommended that infected health care workers should be barred from certain procedures.95 96

The largest peak in requests for HIV testing in the UK was observed in January 1991 when the character Mark Fowler, in the BBC television series EastEnders, was diagnosed HIV-positive.97

In the autumn, in a dramatic move, Kimberly Bergalis testified to the US Congress. In what she called her "dying wish", she asked members of congress to enact legislation for mandatory HIV testing of health care workers, to ensure that:98

"others don't have to go through the hell that I have."

But, overwhelmed by opposition from the medical profession, the CDC chose not to recommend mandatory testing, and dropped its plans to list procedures that should not be carried out by HIV positive health workers. Kimberly Bergalis died a few days later.99 100

During the summer, a third antiretroviral drug dideoxycytidine (ddC) was authorised by the FDA for use by patients intolerant of AZT.101

Also during the summer, a study was published which showed that HIV was transmitted much more easily through breast milk than had previously been thought.102 But despite admitting that the news was discouraging, the WHO also said that women in developing countries should continue to breastfeed, as the threat to infant health from contaminated water was even greater than the threat from AIDS.103

The decision was taken to hold the 1992 international AIDS conference in Amsterdam, rather than its planned location in Boston, following the American administration's decision not to lift entry restrictions on HIV-infected travellers.104

A video of Magic Johnson announcing his retirement at a press conference on 7th November 1991

In the USA Earvin (Magic) Johnson announced that he had tested HIV positive and was therefore retiring from professional basketball, on the advice of his doctors. He said that he planned to use his celebrity status to help educate young people about the disease. He also said:

"I think sometimes we think, well, only gay people can get it - it is not going to happen to me. And here I am saying that it happen to anyone, even me Magic Johnson." - 105

A couple of weeks later in the UK, Freddie Mercury, lead singer of the rock group Queen, confirmed that he had AIDS. Just one day later it was announced that he had died.106

In France, haemophiliacs who became infected through infected blood products sued leading medical and government officials. They accused the blood transfusion centres of allowing the use of HIV-contaminated blood, even though tests to screen blood for HIV and techniques to destroy the virus in blood products were available.107 108
AIDS Ribbon

The red ribbon became an international symbol of AIDS awareness during 1991. The organisation Visual AIDS in New York, together with Broadway Cares, and Equity Fights AIDS, established the wearing of a red ribbon as a way of signifying support for people living with HIV/AIDS.109

As the end of 1991, about 450,000 AIDS cases had been reported to the Global Programme on AIDS (GPA) / World Health Organisation (WHO). It was estimated that 5-7 million men and 3-5 million women had been infected with HIV. Of these 9-11 million HIV-infected adults, nearly 1.5 million were estimated to have progressed to AIDS.110
1992 History

The WHO set as a priority target for prevention that, by the year 2000, the whole population at risk from HIV and AIDS in Africa and Asia should live in communities where condoms were both readily available and affordable.111

In the UK, the Department of Health made it an offence to sell, advertise or supply HIV antibody testing kits to the public.112

During 1992, a major UK newspaper ran a series of articles challenging the orthodox view that HIV alone causes AIDS.113

"But suppose the researchers are looking in the wrong place. Suppose HIV doesn't equal AIDS. Then we will have witnessed the biggest medical and scientific blunder this century." - The Sunday Times journalist Neville Hodgkinson114

Many other British newspapers joined the heated debate with journalists, researchers, activists and organisations expressing their opinions about the cause of AIDS.115

"'But what if HIV does cause AIDS? What effect will such articles have on attempts to inform the public on safe sex, or on the people who are suffering from AIDS and taking anti-HIV drugs?" - 116

Tennis star Arthur Ashe announced that he had been infected with HIV as a result of a blood transfusion in 1983.117

Fearful that it was discouraging tourists, a new government in Thailand threatened to scale down the country's extensive AIDS awareness campaign, which had begun in 1991 and won international acclaim. However, the government lost power within weeks and the campaign was restored.118

The FDA approved the use of ddC in combination with AZT for adult patients with advanced HIV infection who were continuing to show signs of clinical or immunological deterioration. This was the first successful use of combination drug therapy for the treatment of AIDS.119

"This new drug is not a cure, said James Mason, M.D., assistant secretary for health and head of the Public Health service, but it constitutes an important addition to the expanding group of antiviral drugs currently available, including AZT and DDI, for treating people with AIDS."

The CDC, under pressure from patients and doctors, decided to revise its definition of AIDS. The previous list of illnesses that defined AIDS had been criticised for some time because it did not include many of the conditions most often seen in HIV positive women and injecting drug users. The new definition would take effect from the start of 1993.120 121

The VIII International Conference was successfully held in Amsterdam rather than in its originally planned venue in Boston due to the U.S. travel policies on HIV positive people.122

In France four health care officials were brought to trial accused of allowing the distribution, between 1980 and 1985, of blood products known to be contaminated with HIV.123 124 The former director of the transfusion service, Michel Garretta, was sentenced to four years in prison, as was Jean-Pierre Allain, the former head of research at the transfusion centre. The third doctor, Jacques Roux, was given a four-year suspended sentence, whilst the fourth doctor was acquitted.125

In response to rising HIV prevalence, the Indian government decided to allocate $100 million to the National AIDS Control project over the next five years, which amounted to more than 15% of the national health budget. Most of this money would come from a World Bank loan.126 Experts predicted that within five years there might be more people affected by AIDS in India than in any other country

These are some of the most important events that have occurred in the history of AIDS over the period 1993-1997.
1993 History

In January it was reported that some people with AIDS already had resistance to the drug Zidovudine (AZT) even though they themselves had never taken the drug.

"Some of the patients may have gotten the virus from other patients who have been taking AZT and who are now transmitting the resistant virus."

Researchers said there was an urgent need to develop new drugs to combat the epidemic.1

On January 6th the Russian ballet star Rudolf Nureyev died. His doctor said that "he died from a cardiac complication following a cruel illness", but it was widely reported that he had died from AIDS.2 3 He was buried in his evening clothes with his medals and his favourite beret.4

During January, 116 new cases of AIDS were reported in the UK, bringing the cumulative total to 7,045. One in 6 of these new cases were acquired through heterosexual intercourse.5
HIV positive Romanian children

HIV-positive Romanian children

In Romania, despite the progress made since the overthrow of the Causescu regime, the number of children infected with HIV had increased. There were an estimated 98,000 infected orphans.6

China had reported one thousand cases of HIV infection, mostly in injecting drug users, but it was believed that this greatly understated the scale of the country's HIV epidemic.7 8 The Ministry of Health in China announced that soon only approved government blood donation centres would be able to collect and sell blood.9

In February the tennis player Arthur Ashe died, less than a year after announcing that he had been infected with HIV.10

In March, the House of Representatives in the USA voted overwhelmingly to retain the ban on the entry into the country of HIV positive people. 11

In South Africa, the National Health Department reported that the number of recorded HIV infections had grown by 60% in the previous two years and was expected to double in 1993. A survey of women attending health clinics indicated that nationally some 322,000 people were infected.12

A video of Princess Diana speaking at an AIDS conference in 1993.

Princess Diana continued her HIV/AIDS advocacy work and spoke at the opening address of the 2nd International Conference on HIV in Children and Mothers in Edinburgh.

"By the year two thousand, only seven years from now - even the most conservative estimates predict there will be more than thirty million people worldwide with HIV - equivalent to more than half the population of the United Kingdom". - Diana - Princess of Wales, 1993

In the UK in March, there were a large number of rather hysterical stories in the British press about the fact that a number of doctors in England had continued to practise medicine whilst knowing they were infected with HIV.13 The UK government responded by issuing new guidelines, according to which health care workers who believed that they had been exposed to HIV had to seek medical advice and testing. 14

Meanwhile scientists had found that HIV 'hides out' in lymph nodes and similar tissue early in the course of infection.15

“The virus lies concealed for a decade or so, quietly seeding the destruction of the immune system, the researchers found. The finding resoundingly solves a mystery of AIDS: where does the virus secrete itself during the decade or so after an initial infection when patients feel well and little virus can be detected in their blood?”16

In early April the ministers of health and finance from 39 countries met in Riga, Latvia, and launched an initiative to contain the spread of HIV in Central and Eastern European countries.17 During the Eighties, many countries of Central and Eastern Europe, the newly independent states, and the Russian Federation had introduced large-scale screening for HIV infection, with in excess of 20 million tests being carried out in the Russian Federation during 1993. One aspect of the Riga initiative was a refocusing of testing policies away from this mass screening and towards voluntary testing.18

A video of Dr R.P. Brettle talking in 1993 about AIDS treatment and the results of the Concorde trial.

The preliminary results were published of the large Anglo-French clinical trial of AZT known as Concorde.19 The results were interpreted as meaning that AZT was not after all a useful therapy for HIV positive people who had not developed symptoms.20

In the UK the radio DJ and comedian Kenny Everett announced that he was HIV positive, as did Holly Johnson, former lead singer with the group Frankie goes to Hollywood.21 22

The World Bank reviewed it activities against AIDS in Africa, and decided that AIDS should not dominate its agenda on population, health and nutrition issues. The World Bank believed that AIDS would have little demographic effect but recognised that it was a serious threat to health and economic development. With reference to blood screening, it was argued that this was costly and "might not be cost-effective under all circumstances".23

The ninth International AIDS meeting was held in Berlin, Germany. The general feeling of the meeting was one of disappointment. The message conveyed by the people who attended was once again to put more money and effort into effective prevention of HIV and AIDS.

“Dr. James W. Curran, who heads the AIDS Programme at the Centers for Disease Control and Prevention in Atlanta, said he left the meeting 'dispirited by the relentless assault of the virus'.”24

At the beginning of the year the CDC had expanded the US definition of AIDS to include people with other opportunistic infections, as well as HIV infected adults with a CD4 count of less than 200. The expert epidemiology group of the European Centre for the Epidemiological Monitoring of AIDS together with the WHO's Regional Office for Europe accepted the inclusion of the additional indicator diseases but not the CD4 cell count criteria. European data collection on this basis began on July 1st.25

In mid-1993 six United Nations organizations, including the WHO, began to seek agreement on forming a novel joint and cosponsored UN programme on HIV/AIDS.26

By this time it had been realised that HIV was also spreading rapidly in the Asia and Pacific regions, home to more than half the world's population, where more than 700,000 people were already believed to be infected.27

A video of Dr. Brettle talking in 1993 about combination therapy.

The drug 3TC was authorised by the FDA in the USA and the Federal Health Protection Branch in Canada, to be used in "compassionate" therapy in people who had not responded to other AIDS treatment or who are not eligible for clinical trials.28 Those patients who had developed a resistance to AZT were offered didanosine (ddI) and dideoxycytidine (ddC) - drugs that had been extensively studied. A number of trials were underway comparing the effectiveness of taking AZT on its own and in combination with ddI and ddC.29

Despite the years of litigation and number of newspaper accounts of the infection of haemophiliacs and transfusion recipients, no formal investigation of what had happened in Germany was undertaken until the 'scandal' of October 1993. In October, the failure of a small German blood supply company called UB Plasma to screen blood and plasma for HIV was made public. The company's misconduct was discovered by the Federal Health Office by chance, as a result of routine examination of positive HIV test results.30 The Federal Government also admitted that officials had covered up 373 cases of HIV-contaminated blood in the 1980s.31

On World AIDS Day, 1st December, Benetton in collaboration with ACT UP Paris placed a giant condom (22 metres high and 3.5 wide) on the obelisk in Place de la Concorde in Central Paris in an effort to waken the world to the reality of the disease. A symbolic monument to HIV prevention, it appeared on the covers of newspapers worldwide.32

At the end of 1993 the estimated number of AIDS cases worldwide was 2.5 million33
Region Estimated Adult HIV infection Estimated adult AIDS cases
Australasia >25000 5000
North America >1 million 400000
Western Europe 500000 125000
Latin America & Caribbean 1.7 million 300000
Sub-Saharan Africa >9 million 1.7 million
South and South-East Asia 2 million >75000
East Asia and Pacific >35000 >1000
Eastern Europe and Central Asia >50000 4500
North Africa & The Middle East 75000 12000
Total >14 million >2.5 million
1994 History

In the US the CDC launched a series of 13 bold and frank AIDS advertisements breaking away from their previous low-key approach. The advertisements focused on the use of condoms, which were rarely seen or even mentioned on American television.

"One of the television ads, entitled Automatic, features a condom making its way from the top drawer of a dresser across the room and into bed with a couple about to make love. The voice-over says, 'it would be nice if latex condoms were automatics. But since they're not using them should be. Simply because a latex condom, used consistently and correctly, will prevent the spread of HIV.'"34

Your pocket guide to sex

'Your Pocket Guide to Sex' Book

In the UK, the Department of Health vetoed an AIDS campaign promoting safer sex and condoms, developed at a cost of £2 million, on the grounds that it was too explicit.35 The campaign was developed by the Health Education Authority (a government funded body), who later in the year were banned by the Department of Health from distributing the book, "Your Pocket Guide to Sex".36

In February the film maker Derek Jarman died of AIDS. He wrote in the preface of his autobiography:

"On 22nd of December 1986, finding I was body positive, I set myself a target: I would disclose my secret and survive Margaret Thatcher. I did. Now I have my sights on the millennium and a world where we are equal before the law."37

Randy Shilts

Randy Shilts

Randy Shilts, author of the book 'And the band played on' also died in February.38

In March, the actor Tom Hanks won an Oscar for playing a gay man with AIDS in the film Philadelphia.39

Official statistics for Brazil, with a population of about 154 million, indicated that some 46,000 cases of AIDS had been recorded, but estimates put the actual number at anywhere between 450,000 and 3 million cases. Two thirds of the known cases were in Sao Paulo state where AIDS was the leading cause of death of women aged 20-35.40

In France, on 7th April all the television networks, public and private, broadcast 'Tous contre le Sida' ('All against AIDS'), a special 4-hour AIDS programme. The aim was to heighten awareness about HIV/AIDS and to raise money.41 The estimated audience for the program was 33 million. Some 32,000 cases of AIDS had been recorded in France, with 15 deaths each day, and an estimated 150,000 people were thought to be infected. 42
European safe sex campaign

'The Flying Condom' AIDS prevention campaign, Europe

During the summer, the AIDS Prevention Agency in Brussels, in collaboration with the European Union, launched a campaign whose central image was 'the flying condom'. This was intended to serve as a visual reminder to young travellers of the risks of HIV infection. The logo was displayed in airports, railway stations, popular holiday destinations and other places young people visited during the summer.43

A large European study on mother-to-child transmission showed that Caesarean section halved the rate of HIV transmission.44

Research indicated that Thailand had reduced its rate of HIV transmission. This was largely due to action by the government, which had distributed condoms to brothels and insisted that they were used consistently; establishments that failed to comply were threatened with closure. Condom use in commercial sex had risen from 14% in 1989 to 94% in 1993.45

By July 1994 the number of AIDS cases reported to the WHO was 985,119. The WHO estimated that the total number of AIDS cases globally had risen by 60% in the past year from an estimated 2.5 million in July 1993 to 4 million in July 1994.46 It was estimated that worldwide there were three men infected for every two women, and that by the year 2000 the number of new infections among women would be equal to that among men.47

At the end of July, the UN Economic and Social Council approved the establishment of a new "joint and cosponsored UN programme on HIV/AIDS" to replace the WHO's Global Programme on AIDS. The separate AIDS programmes of the UNDP, World Bank, UN Population Fund, UNICEF and UNESCO would have headquarters with the WHO in Geneva, starting in 1996.48 Later in the year it was announced that Dr. Peter Piot, the head of the research and intervention programme within the Global Programme on AIDS, would be the head of the new UN program.49

A study, ACTG 076, showed that AZT reduced by two thirds the risk of HIV transmission from infected mothers to their babies.50 Somepeople believed that ACTG076 was:

“the most stunning and important result in clinical acquired immunodeficiency syndrome research to date.”51

And according to Dr Harold Jaffe of the CDC:

“It is the first indication that mother-to-child transmission of HIV can be at least decreased, if not prevented. And it will provide a real impetus for identifying more HIV-infected women during pregnancies so that they could consider the benefit of AZT treatment for themselves and their children.” - The New York Times -52

In early August 1994, the Tenth International Conference on AIDS was held in Yokohama, Japan. It was the first of the International Conferences to be held in Asia. No major breakthroughs emerged, and it was announced that in future the international conference would be held every two years.53
Pedro Zamora

Pedro Zamora

Meanwhile in the Russian Federation, deputies in the Russian Parliament, the Duma, voted at the end of October to adopt a law making HIV tests compulsory for all foreign residents, tourists, businessmen and even members of official delegations.54

India by this time had around 1.6 million people living with HIV, up by 60% since 1993. Local and state governments were accused of underusing and misusing HIV prevention funds.55

On 11th November AIDS killed the 22-year old Pedro Zamora. He had become famous when he appeared on MTV's 'Real World' documentary about the real lives of a group of young room mates.56

In December, President Clinton asked Joycelyn Elders to resign from the post of US Surgeon General, following her suggestion during a World AIDS Day conference that school children should, amongst other things, be taught about masturbation. Gay activists defended the Surgeon General and criticised the president's record on AIDS. Fears were expressed that the president's action would discourage other government leaders from speaking frankly about AIDS.57
1995 History

By 1st January 1995, a cumulative total of a million cases of AIDS had been reported to the World Health Organisation Global Programme on AIDS. Eighteen million adults and 1.5 million children were estimated to have been infected with HIV since the beginning of the epidemic.58

Later in the month the CDC announced that in the US, AIDS had become the leading cause of death amongst all Americans aged 25 to 44.

“The dramatic rise is due to the accumulating toll from AIDS and is almost certain to continue because of AIDS deaths reflect infections from HIV, the AIDS virus that were acquired several years earlier.” - Dr. Harold W. Jaffe of the CDC -59

Two research reports provided important new information about how HIV replicates in the body and how it affects the immune system.60 61

Meanwhile in the USA, two reports by government scientists recommended that the Clinton administration lift the ban on federal funding for needle exchange programs, because the programmes had been shown to be effective in reducing the spread of disease.62 63

In March the VII International Conference for People Living with HIV and AIDS was held in Cape Town, South Africa - the first time that the annual conference was held in Africa.64 The conference was opened by the deputy President, Thabo Mbeki, who spoke about how:

"the impact has begun to cut deep. Those affected are from the young and able-bodied work-force as well as young intellectuals."65

The South African Ministry of Health announced that some 850,000 people - 2.1% of the 40 million population - were believed to be HIV positive. Among pregnant women the figure had reached 8% and was rising.66
Peter Piot

Peter Piot Director of UNAIDS

The conference was also addressed by Dr Piot, the Director of the new Joint United Nations Programme on AIDS (UNAIDS). Dr Piot confirmed his commitment to involve people living with HIV/AIDS in the planning, shaping and guiding of the global response to the epidemic.67

In July, the US Senate voted to extend the Ryan White Care Act.68 As a result of the first five years of the Act:

"in the place of activists there were now thousands of AIDS organisations throughout the country - the AIDS "industry" made possible by the Ryan White Care Act".69

By the autumn of 1995, 7-8 million women of childbearing age were believed to have been infected with HIV. The WHO spoke out about the 'inadequate international response':

"The impact of the HIV/AIDS epidemic on women … is not yet receiving sufficient political awareness, commitment or enough action of programmes responding to the specific needs of women."70

Also in August, researchers announced the results of a study in Tanzania, which found that treating people for sexually transmitted diseases such as gonorrhoea substantially reduced their risk of becoming infected with HIV.71

In September two clinical trials, the Delta trial and the ACTG175 trial, showed that combinations of AZT with ddI or ddC were more effective than AZT alone in delaying disease progression and prolonging life.72

On 1st December, World AIDS Day, Nelson Mandela called on all South Africans to

"speak out against the stigma, blame, shame and denial that has thus far been associated with this epidemic."73

Protease Inhibitors

Protease Inhibitors

The FDA approved the first of a potent new family of anti-AIDS medications. The drug saquinavir belonged to a class of drugs called protease inhibitors. Its approval in record time was said to be:

"some of the most hopeful news in years for people living with AIDS."74

By December 15th, the World Health Organisation had received reports of 1,291,810 cumulative cases of AIDS in adults and children from 193 countries or areas. The WHO estimated that the actual number of cases that had occurred was around 6 million. Eight countries in Africa had reported more than 20,000 cases.75

Other organisations estimated that by the end of 1995, 9.2 million people worldwide had died from AIDS.76

Worldwide during 1995, it was estimated that 4.7 million new HIV infections occurred. Of these, 2.5 million occurred in Southeast Asia and 1.9 million in sub-Saharan Africa. Approximately 500,000 children were born with HIV infection.77

The WHO's Global programme on AIDS closed as planned on 31st December 1995.78 They estimated that by the end of the century, 30 to 40 million people would have been affected by HIV.79
1996 History
United Nations Logo

The new Joint United Nations Programme on AIDS (UNAIDS), bringing together six agencies belonging to or affiliated with the UN system (WHO, UNDP, UNICEF, UNFPA, UNESCO and the World Bank), became operational on January 1st.80

In February the heavyweight boxer Tommy Morrison was identified as HIV positive after being tested prior to a fight.81

"'I thought AIDS was something that happened to gays and drug addicts. A macho guy like me who loves ladies and is superfit - he doesn't get AIDS.' - These words were spoken not in 1986 but in 1996 by Tommy Morrison."82

In March, a government appointed panel issued a report sharply criticising the US government's domestic response to AIDS:

"The Government's $1.4 billion AIDS research program is uncoordinated, lacks focus and needs a major overhaul to attract new scientific talent and spur novel and imaginative ideas."83

Meanwhile the effect of AIDS was continuing to be felt at a community level. In the USA there had been a cumulative total of 81,500 AIDS cases in New York, and:

"despite two world wars, the Depression and epidemics, nothing in this century has affected the life expectancy for New Yorkers as greatly as AIDS."84

In May the US Food and Drug Administration (FDA) approved the first 'home sampling' system of HIV testing. Until then the FDA had insisted that all tests for HIV (whether blood or oral fluid) had to be done under the supervision of health professionals. Under the new system, someone would buy a sampling kit from a shop or by mail order, collect a sample of their blood, send it to a laboratory for testing, and receive their results by phone.

"'Too many American do not know their HIV status. Knowledge is power, and power leads to prevention', said HHS Secretary Donna E. Shalala. 'The availability of a home test should empower more people to learn their HIV status and protect themselves and their loved ones.'"85

Meanwhile in China it was estimated that the actual number of AIDS cases could be as high as 100,000. Two thirds of the reported AIDS cases had occurred in the southern province of Yunnan, where the use of heroin and the sharing of dirty needles had helped the spread of HIV.86
Nevirapine

Nevirapine (Viramune)

In June the FDA approved the drug Viramune (nevirapine), the first in a new class of drugs known as non-nucleoside reverse transcriptase inhibitors.87 Another treatment development that took place was the introduction of the viral load test, which provided information about the risk of disease progression.88

Throughout 1996 there was excitement and optimism about the treatment of HIV infected people.89 The health of many improved enormously when they started taking combination therapy. For some people, particularly those had been ill in hospital and were then able to go home, the improvement in health was so dramatic that it was referred to as the "Lazarus Syndrome".90

At the start of the 11th International Conference on AIDS in Vancouver in July:

"the air was electric with excitement and anticipation about the findings on combination therapies to be reported during the meeting."91

Some scientists even declared that:

"aggressive treatment with multiple drugs can convert deadly AIDS into a chronic, manageable disorder like diabetes."92

One doctor suggested that giving combination therapy to patients in the first few weeks of infection might mean that the virus could be completely eliminated in two or three years.93

However, Nkosazana Zuma, the health minister of South Africa, reminded the conference delegates that:

"most people infected with HIV live in Africa, where therapies involving combinations of expensive antiviral drugs are out of the question."94

It was also reported that there were limitations on the use of the drugs, such as severe side effects and the difficulty of taking large numbers of pills each day.95

"If you think the cure is here, think again. The cure is not here. We are a long way from a cure, even for the rich who can afford the treatments." - Eric Sawyer96

The government of Brazil pledged to begin providing free combination antiretroviral treatment by the end of the year. It said it would spend up to $45 million on protease inhibitors over the following twelve months.97

In October, in Washington D.C., the AIDS Memorial Quilt was displayed in its entirety for the last time, but it was also the first time that a display of the quilt had been visited by an American president.98 99

"What it has done always in the past, and will continue to do, is to put a face on this epidemic. It makes this epidemic human." - Anthony Turney100

In December, the White House announced its first ever AIDS strategy. This called, amongst other things, for sustained research to find a cure and a vaccine; a reduction in new infections; guaranteed access to high quality care for AIDS patients; and fighting AIDS-related discrimination.

"None of us can afford to sit by and watch this epidemic continue to take our neighbors, friends and loved ones from us" - President Clinton in a letter accompanying the AIDS plan101

AIDS advocates said that much would depend on how the stategy was implemented.

"It doesn't require rocket science to figure out what to do, what it requires is the political will to back it up." - Paul Donato102

New outbreaks of HIV infection were erupting in Eastern Europe, the former Soviet Union, India, Vietnam, Cambodia, China and elsewhere.

"The epidemic is starting to skyrocket in Russia and the Ukraine where transmission is from everything - injecting drugs, poor hygiene, and heterosexual and homosexual intercourse."- Dr Peter Piot103

At the end of the year UNAIDS estimated that during 1996 some three million people, mostly under the age of 25, had become newly infected with HIV, bringing to nearly 23 million the total number of infected people. In addition an estimated 6.4 million people - 5 million adults and 1.4 million children - had already died.
1997 History

Early in 1997 it was reported that, for the first time since the AIDS epidemic became visible in 1981, the number of deaths from AIDS had dropped substantially across the USA.104 This was excellent news but:

"The decline in deaths leaves more people living with AIDS and HIV infection. We do not want to be a wet blanket here, but we still need programs that assure good access to treatment and care for infected people." - Dr John Ward105

In New York City the decline was even more dramatic, with the number of people dying from AIDS falling by about 50 per cent compared to the previous year.106 The number of babies being born HIV positive had also declined dramatically.107

By the spring it was clear that although excellent for many people, the antiretroviral drugs did have unpleasant and in some cases serious side effects. Resistance could also occur, even when three drugs were being taken, and adherence was an important issue with many pills needing to be taken each day.108

A number of treatment guidelines were published, and some doctors, particularly in the UK, disagreed with the more aggressive approach taken by the US guidelines.109 110 Some doctors were particularly concerned about the recommendations concerning the beginning of treatment when patients did not have symptoms.111 The US approach was sometimes referred to as the "hit early, hit hard"112 approach to treatment.

Later in the year a number of studies were published which showed that HIV could not after all be eradicated by two or three years of treatment, even if three drugs were taken and the treatment was strictly followed.113

In May 1997 President Clinton set a target for the USA to find an AIDS vaccine within ten years, so it could be the "first great triumph" of the 21st century. To help attain this goal Clinton announced that a dedicated HIV vaccine research and development centre would be established at the National Institutes of Health.

"With the strides of recent years, it is no longer a question of whether we can develop an AIDS vaccine - it is simply a question of when. And it cannot come a day too soon." - President Clinton114

In July the CDC reported that it was likely that there had been a case of transmission of HIV as a result of "deep kissing", although other routes of transmission could not definitely be excluded. The HIV positive man had sores in his mouth and gums that regularly bled, and his female partner also had gum disease with inflamed and sore areas in her mouth.115

In August, at a UNAIDS-organised meeting in Nepal, an appeal was made for urgent joint action by South Asian regional governments to check the spread of the pandemic. Estimates of HIV/AIDS cases in India, Myanmar (Burma), Bangladesh and Nepal were put at 3 million, 350,000, 20,000, and 15,000 respectively.116

At the end of the year, UNAIDS reported that worldwide the HIV epidemic was far worse than had previously been thought. More accurate estimates suggested that 30 million people were infected with HIV. The previous year's estimate had been 22 million infected people.117

"The older estimates were based on data that came from a small number of countries. It was assumed that one could extrapolate similar rates of transmission for all countries in a particular regional factors would be pretty much the same. It turns out that the assumption was wrong." - The New York Times118

South African Kids

South African Children

It was also estimated that 2.3 million people died of AIDS in 1997 - a 50% increase over 1996. Nearly half of those deaths were of women, and 460,000 were children under 15. UNAIDS said it was likely that, in terms of AIDS mortality, the full impact of the epidemic was only just beginning.

Worldwide, 1 in 100 adults in the 15-49 age group were thought to be infected with HIV, and only 1 in 10 infected people were aware of their infection. It was estimated that by the year 2000 the number of people living with HIV/AIDS would have grown to 40 million.119

In Latin America and the Caribbean the disease was already having a major impact. Earlier in the year a doctor in San Pedro Sula, Honduras had said:

"We will go from a city that is predominantly young to a city of old people and children. We are in over our heads with AIDS cases. It is devastating us. And all we can do here is watch people die, nothing more."120

The United States Agency for International Development (USAID) said it believed that 40 million children in developing nations would lose one or both parents to AIDS by the year 2010.

"It is a crisis of staggering proportion, that is going to affect not only the future of these countries, it is going to affect the entire global network of trade, diplomacy and development. What we are talking about here is something that has never been seen before, which is countries with one-sixth to one-quarter of all children without one or both parents."121

These are some of the most important events that occurred in the history of AIDS over the period 1998-2002.
1998 History

In Canada there was an outbreak of HIV infection amongst injecting drug users in Vancouver.1

Glaxo Wellcome cut the price of AZT by 75% after a trial in Thailand showed it was safe and effective at preventing mother-to-child transmission of HIV in developing countries.2 However, even with this price cut it was expected that the drug would still be far too expensive for use in many developing countries.3

The Clinton Administration refused to lift a ten-year ban on using federal funds for needle exchange programmes

In some countries HIV positive people were returning to work, having recovered their health as a result of combination antiretroviral drug treatment. However, some people began to be affected by quite severe side effects of the drugs. The emergence of negative reactions - which included a kind of fat redistribution called lipodystrophy - cast doubt on the long term safety of combination therapy. The reasons why lipodystrophy appeared in some people taking anti-HIV drugs were unknown. Some reports linked the syndrome to drug regimens that contained protease inhibitors.4

"While fat disappears from some areas, for unknown reasons it redistributes to build up in others. The back of the neck resembles a buffalo hump. Breasts enlarge. A woman may have to buy a bra that is two sizes larger that the last one. The abdomen swells producing a sometimes painful pot belly that is dubbed 'a protease paunch'. A woman may look pregnant when she is not. Exercise may not work it off."5

In April, the Clinton Administration refused to lift a ten-year ban on using federal funds for needle exchange programmes, despite concluding for the first time that such exchanges prevent the spread of HIV and do not encourage drug use. Leaders in the fight against AIDS condemned the unexpected decision, which was announced by Health and Human Services Secretary Donna Shalala. During her speech Shalala quoted NIH director Varmus as saying:

"An exhaustive review of the science indicates that needle exchange programmes can be an effective component of the global effort to end the AIDS epidemic. Recent findings have strengthened the scientific evidence that needle exchange programmes do not encourage the use of illegal drugs."

But, without explanation, Shalala said the administration had "decided that the best course at this time is to have local communities use their own dollars to fund needle exchange programmes".6

In the UK the London Lighthouse charity closed its residential unit.7

In June, the company AIDSvax started the first human trial of an AIDS vaccine using 5,000 volunteers from across the USA.

"It opened a new era in AIDS research, and led us toward the human trials. It was like being in a room that was partially lit and getting darker and darker, and suddenly the lights went on and you could see the pathway out."8

San Francisco started a pioneering Post Exposure Prophylaxis (PEP) program giving HIV drugs to people that might have been exposed to HIV through sexual contact or needle sharing during injecting drug use. The HIV drugs were given to people at the earliest possible time after the risk exposure.

"The treatment really is to try, in case they've been exposed to HIV, to stop the replication before it infects the cells and like a brush fire gets out of control."9

The company AIDSvax started the first human trial of an AIDS vaccine using 5,000 volunteers

A study found that the combination of caesarean delivery and AZT reduced the risk of HIV transmission from a mother to her baby to less than 1%. The study also found that women who took AZT but delivered their babies by natural childbirth had a higher risk (6.6%) of transmitting HIV to their babies.10

In July, the 12th International AIDS conference was held in Geneva. The challenge of this conference was not only to discuss the advantages available for the treatment of HIV, but also to conquer overwhelming pessimism. The mood of the meeting was in sharp contrast to the euphoria at the previous AIDS meeting in Vancouver two years before.

"A series of reports about new problems with anti-HIV drugs and setbacks in vaccine trials left many participants thinking that their best hope against the epidemic was the strategy they had since it began: prevention."11

A French court ordered the former French prime minister Laurent Fabius to stand trial on charges of involuntary homicide for allowing HIV-tainted blood to be used in transfusions.12

The first case of a patient being infected with a strain of HIV resistant to the most powerful new antiretroviral drugs was reported in San Francisco in July. The mutated strain of HIV, seemingly impervious to protease inhibitors and older drugs, was found in a newly infected patient at San Francisco General Hospital.

"We may be seeing an emerging and dangerous edge to the epidemic."Dr. Frederick Hecht of the University of California at San Francisco13

The United Nations issued new recommendations advising that HIV positive women in developing countries should be counselled to make their own decisions about how to feed their babies. This was interpreted as a major policy shift towards endorsing the use of infant formula. At the same time the United Nations decided to conduct pilot projects in eleven developing countries to expand access to services to prevent mother-to-child transmission of HIV.14

Jonathan Mann, the first director of the Global Program on AIDS, died in the crash of Swissair flight 111, along with his wife the AIDS researcher Mary-Lou Clements-Mann.

"It was always safe for scientists and institutions to think of AIDS as a virus, a transmissible infection… but Dr. Mann structured it as a human rights issue, and a global rights issue. He really was a spiritual leader as well as scientific leader."Dr. James Curran15

Red ribbon in South Africa dedicated to Gugu Dlamini

Red ribbon in South Africa dedicated to Gugu Dlamini

The FDA gave approval for various new drugs including Sustiva (efavirenz), another drug in the NNRTI group.16

In South Africa, Gugu Dlamini, an AIDS activist, was beaten to death by her neighbours after revealing her HIV positive status on Zulu television. This happened just a month after Deputy President Thabo Mbeki had called for people to "break the silence about AIDS" in order to defeat the epidemic.17

"It is a terrible story. We have to treat people who have HIV with care and support, and not as if they have an illness that is evil."- Thabo Mbeki18

The 1998 World AIDS Campaign 'Young People: Force for Change' was prompted in part by the epidemic's threat to those under 25 years old, for as HIV rates rose in the general population, new infections were increasingly concentrated in the younger age groups. The campaign also had a special representative, Brazilian footballer Ronaldo.19

UNAIDS estimated that during the year a further 5.8 million people became infected with HIV, half of them being under 25.20
Country Estimated new HIV infections 1998
North America 44,000
Caribbean 45,000
Latin America 160,000
Western Europe 30,000
North Africa/Middle East 19,000
Sub-Saharan Africa 4 million
Eastern Europe/Central Asia 80,000
East Asia/Pacific 200,000
South Asia/South-East Asia 1.2 million
Australia & New Zealand 600
Global total 5.8 million

Sub-Saharan Africa was home to 70% of people who became infected with HIV during the year. South Africa, which trailed behind some of its neighbouring countries in HIV infection levels at the start of the 1990s was catching up fast. It was estimated that one in seven new HIV infections in Africa were believed to be occurring in South Africa. In Botswana, Namibia, Swaziland and Zimbabwe, the estimates showed that between 20% and 26% of people were living with HIV or AIDS.21
1999 History

In the United States a doctor who injected his former lover with HIV infected blood was sentenced to 50 years in prison.22

A group of researchers at the University of Alabama claimed to have discovered that a particular type of chimpanzee, once common in West Central Africa, was the source of HIV. The researchers suggested that HIV-1 was introduced into the human population when hunters became exposed to infected blood.23

Reports started to emerge from South Africa of rape cases involving young girls. It was suggested that a popular myth that sex with a virgin could cure AIDS was the root cause of this increase in child rapes.24 Later on in the year, the South African President Thabo Mbeki claimed that the anti-HIV drug AZT was toxic and could be a danger to health.25

According to the annual World Health Report, AIDS had become the fourth biggest killer worldwide, only twenty years after the epidemic began.26

The Ugandan ministry of Health started a voluntary door-to-door HIV screening programme using rapid tests in an effort to reduce the spread of HIV. This effort was intended to make HIV screening services accessible to more people, especially in rural areas where there were neither modern laboratories nor electricity to run standard HIV tests.27 Since 1986 the Ugandan government had implemented a number of successful initiatives, and whereas in 1992 it was estimated that 30% of adults in Kampala were living with HIV, by 1999 the figure had fallen to 12%.28 However, HIV/AIDS was still a considerable health problem in Uganda. It was estimated that 820,000 adults and children were living with HIV/AIDS as at the end of 1999.29

In the UK a judge ordered that a five-month-old baby girl should be tested for HIV against her parents' wishes. The baby's parents refused to have their daughter tested, contending that she was perfectly healthy and that they should have the right to decide what was best for her.

"This case is not about the rights of the parents, and if, as the father has suggested, he regards the rights of a tiny baby to be subsumed within the rights of the parents, he is wrong, the judge said."30

South Africa won the first round in its battle with the United States and multinational pharmaceutical companies to force a cut in drugs prices. The dispute concentrated on South African legislation that enabled local companies to manufacture HIV/AIDS drugs that could be sold at a fraction of the price of similar imported products. The US argued that the South African laws undermined the patent rights of drug manufacturers.31

Initial findings from a joint Uganda-US study identified a new drug regimen, a single oral dose of the antiretroviral drug nevirapine, as being both affordable and effective in reducing mother to baby transmission of HIV. This research provided real hope that mother to child transmission could be effectively reduced in developing countries.32

"This extraordinary finding is the most recent in our efforts to bring an end to AIDS, not only in the United States but in countries around the world."Donna E. Karala, the Health and Human Services Secretary

The UK Government announced that all pregnant women in Britain would be offered an HIV test in an attempt to reduce the number of babies infected with HIV. The Labour Government set a target of reducing the number of infant infections by 80% by 2002.33

Health officials rejected attempts to reopen the bath houses in San Francisco, which were closed 15 years previously at the height of the epidemic in 1984.34 A survey published in August found that growing numbers of gay men in San Francisco were having unprotected sex.35 The survey results provoked concern and disappointment among public health authorities because, instead of declining, the rate of new HIV infections had remained at about 500 per year.36

Needle sharing among injecting drug users set off an explosive increase in HIV infections in Russia. In Moscow, three times as many cases were reported in the first nine months of 1999 as in all previous years combined.37
Injecting drug use in Russia

Drug use in Russia

"Russia is broke, and AIDS prevention programs are taking a back seat to problems that appear more pressing, such as mass poverty, crime and Russia's huge foreign debts."38

In November, China broadcast its first ever television advertisement for condoms in an effort to stop the spread of sexually transmitted diseases and HIV/AIDS.39 Shortly after the advertisement was seen by hundreds of millions of people, it was banned by the State Administration of Industry and Commerce.40

'The River', a book by Edward Hooper, was published. There was a lot of debate about the role of polio vaccines in the origin of the AIDS epidemic.41

T-20, a member of a new class of AIDS drugs called fusion inhibitors, went into clinical trials.42

The Kenyan President Daniel arap Moi declared AIDS a national disaster and ordered a National AIDS Control Council to be set up immediately.

"AIDS is not just a serious threat to our social and economic development, it is a real threat to our very existence, and every effort must be made to bring the problem under control."President Moi43

However the president also said that his government and Kenya's churches would not advocate the use of condoms as a method of prevention because this would encourage young people to have sex.

A research study published in November argued that male circumcision could help to reduce HIV infection rates in Africa and Asia.44

At the request of countries around the world eager to reach the age group at highest risk, the 1999 World AIDS Day campaign, "Listen, Learn and Live!", continued to focus on people under 25.45

By the end of 1999, UNAIDS estimated that 33 million people around the world were living with HIV/AIDS and that 2.6 million people worldwide had died of the disease in 1999, more than in any other year since the epidemic began.46 It was also reported that for the first time more women than men were infected with HIV in Africa.47

"In 1992, a team headed by the late Dr. Jonathan Mann at the Harvard School of Public Health, published estimates of HIV infections in sub-Saharan Africa ranging from 20.8 million to 33.6 million by 2000. The World Health Organisation criticized Dr. Mann's estimates as excessive. Now academic scientists are criticizing the figures of Dr. Piot's Team. 'When we look at the figures today, they are worse than the scenarios Jonathan had published,'Dr. Piot"48

The World Bank warned that the effect of AIDS in Asia could be to erase the region's economic gains over the last two decades unless governments maintained funding for social programs. The United Nations estimated that 7 million people in Asia were living with HIV/AIDS.49
2000 History
Jesse Jackson publicly taking an oral HIV test

Jesse Jackson publicly taking an oral HIV test

In January, the Centers for Disease Control and Prevention (CDC) reported that, for the first time, the rate of AIDS diagnoses among black and Hispanic gay men had overtaken that among white gay men in the U.S. Statistics showed that African Americans comprised 57% of all new HIV infections, even though they made up just 13% of the U.S. population.50 In order to publicise the importance of HIV testing for African Americans, reverend Jesse Jackson publicly took an oral HIV test.51

UK national statistics revealed that 1999 had been the first year in which the number of newly diagnosed HIV infections probably acquired through heterosexual sex was higher than the number probably acquired through sex between men.52

Preliminary studies presented at the 7th Conference on Retroviruses and Opportunistic Infections showed that, in some cases, temporarily stopping HIV drug therapy might not lead to increased levels of virus or the development of drug resistance.53 This later became known as the structured treatment interruption or drug holiday.

In February, the trial started of Bulgarian health workers charged in Libya with deliberately infecting children with HIV. The Bulgarian medics - five nurses and an anaesthetist - were detained in 1998 after almost 400 children were given infected blood at a hospital in Benghazi, Libya's second largest city. Eight Libyans and a Palestinian were also charged.54

A more definitive study was published about the risk of transmitting HIV through oral sex. Although earlier studies had identified oral sex as a means of transmitting HIV, the new study was designed to find out the extent of HIV transmission through oral sex among men who have sex with men. The research suggested that oral sex accounted for about 7% of cases.55

"I think it reinforces what we've said already - which is that condoms should be used for whatever type of sex you have."Dr. Robert Janssen, Director of the Division of HIV/AIDS prevention at the CDC56

Thabo Mbeki

Thabo Mbeki

Early in the year the South African government made a decision to invite a panel of experts to pursue debate on questions relating to HIV/AIDS.57 In March it was reported that South African President Thabo Mbeki had consulted two American 'dissident' researchers to discuss their claim that HIV was not the cause of AIDS.58

Israel lost one of its most successful singers, Ofra Haza, from what was believed to be an AIDS-related complication. Following her death there was a considerable increase in demand for helplines and anonymous HIV testing.

"Nevertheless, her death has brought the whole issue of AIDS out into the open in Israel. This can only be a good thing for a country which has seven openly HIV positive people - including myself - out of an estimated 10,000."Aviram Germanovitch, Director of the Israeli AIDS Task Force59

In April, President Mbeki sent a letter to world leaders explaining his views on HIV/AIDS. In this letter Mbeki argued, amongst other things, that since HIV is spread mostly through heterosexual contact in Africa, the continent's problems are unique.

"Accordingly, as Africans, we have to deal with this uniquely African catastrophe... It is obvious that whatever lessons we have to and may draw from the West about the grave issue of HIV-AIDS, a simple superimposition of Western experience on African reality would be absurd and illogical."60

In Botswana, as many as one in four adults and four of every ten pregnant women were estimated to be infected with HIV.61 The president of Botswana, Festus Mogae, announced that new contributions from donors including $50 million donated by the Bill and Melinda Gates Foundation would allow his country to provide antiretroviral therapy to all HIV-infected pregnant women and children born with the virus.62

The Clinton Administration formally declared HIV/AIDS to be a threat to U.S national security. The United States government believed that the global spread of AIDS was reaching catastrophic dimensions that could topple foreign governments, spark ethnic wars and undo decades of work building free-market democracies abroad. It was the first time the National Security Council was involved in fighting an infectious disease.63

"We shouldn't pretend that we can give injections and work our way out of this. We have to change behaviour, attitudes, and it has to be done in an organized, disciplined, systematic way."Bill Clinton64

Later in the year, the U.S. Institute of Medicine released a report that sharply criticised the Clinton Administration for failure to develop a comprehensive and effective plan to combat the disease in the United States.65

In May, at the opening of the first meeting of the presidential advisory panel on AIDS in South Africa, President Mbeki offered his first detailed explanation of why he had consulted the two American 'dissident' AIDS researchers. He also explained why the 33-member presidential AIDS advisory panel contained people who believed that HIV caused AIDS and others who did not.

"We were looking for answers because all the information that has been communicated points to the reality that we are faced with a catastrophe, and you can't respond to a catastrophe merely by saying I will do what is routine."66

Five pharmaceutical companies offered to negotiate steep reductions in the prices of AIDS drugs for Africa and other poor regions.67 A couple of months later the United States offered sub-Saharan African nations loans to finance the purchase of AIDS drugs and medical services.68 The offer was not seen as very helpful and was rejected by many African nations.69

"Making drugs affordable is the solution rather than offering loans that have interest."70

According to the latest UNAIDS report, there were 34.3 million people infected with HIV worldwide, of whom 1.3 million were children under the age of 15. It was predicted that AIDS would cause early death in as many as half of the teenagers living in the hardest hit countries of southern Africa, causing population imbalances. In particular, it was predicted that two thirds of 15 year-old children in Botswana would die of AIDS before they reached 50.71

Almost four million people were estimated to be living with HIV in India. This meant that the country had the second largest HIV population in the world: only South Africa had more people living with HIV.72
HIV positive woman marching during the AIDS conference

HIV positive woman marching during the Durban AIDS conference

In July, the 13th International AIDS Conference was held in Durban, South Africa. This was the first time that such a conference was held in a developing country or in Africa.73 Nkosi Johnson, an eleven year old HIV-positive boy, gave a speech in the opening ceremony of the conference and called for the government to give AZT to pregnant HIV-positive women.74

Mbeki used his opening address at the conference to stress the role of poverty in explaining the problems faced by Africa and compared the campaign against AIDS with the struggle against apartheid.75

"As I listened and heard the whole story told about our own country, it seemed to me you could not blame everything on a single virus."76

To counter the comments made by president Mbeki, over 5,000 scientists around the world signed the 'Durban Declaration' affirming that HIV is the cause of AIDS.77

Nelson Mandela, South Africa's former president, closed the AIDS conference with a call for action to combine efforts and save people.78

"History will judge us harshly if we fail to do so now, and right now."

At the conference, preliminary findings were reported from nonoxynol-9 studies in Africa and Thailand. Scientists had hoped that nonxynol-9 would prove to be the first effective 'microbicide' that could reduce the risk of HIV transmission during sex, but the findings were quite the opposite. Women at high risk of HIV infection were warned not to use the spermicide nonoxynol-9 because the studies suggested it might increase the risk of transmission.79

"If you use nonoxynol-9, you are either wasting your money or possibly wasting your life."Dr. Joseph Perriens80

For some people these were not surprising findings, since the toxic effects of nonoxynol-9 had been reported since 1989.81

There were few other noteworthy scientific findings reported at the conference.

In September, the first phase of a new vaccine trial was launched in Oxford. The trials were sponsored by the International AIDS Vaccine Initiative.82 The research into an AIDS vaccine was criticised by the World Bank for focusing on a vaccine that could be marketed in western countries, despite the fact that more than 90% of HIV infections were in the developing world.83

It was reported that the number of people living with HIV in Brazil was less than half that once predicted by health experts, and the number of AIDS deaths had plummeted by as much as fifty per cent since the introduction of combination antiretroviral therapy in 1996. The country's HIV prevention and treatment programmes were seen as a model for other resource-poor countries to emulate.

"It makes a lot of sense to look at what Brazil is doing... Something they're doing is working."Mbulelo Rakwena, South Africa's ambassador to Brazil -84

Treatment provision remained non-existent in South Africa, and President Mbeki stated in an interview with the Time Magazine that he did not think that HIV alone caused AIDS.

"Clearly there is such a thing as acquired immune deficiency. The question you have to ask is what produces this deficiency. A whole variety of things can cause the immune system to collapse… But the notion that immune deficiency is only acquired from a single virus cannot be sustained. Once you say immune deficiency is acquired from that virus your response will be antiviral drugs. But if you accept that there can be a variety of reasons, including poverty and the many diseases that afflict Africans, then you can have a more comprehensive treatment response."85

In October, President Mbeki announced his withdrawal from the scientific and public debate on the causes of AIDS after admitting that he had created confusion in South Africa.86

There has been a lot of confusion about what Mbeki said and did not say during the year.87 It is clear that over a period of some months, particularly in April and in September, Mbeki led many people to think that either 1) he does not believe that HIV causes AIDS or 2) he does not believe that HIV causes AIDS on its own.

It would seem that Mbeki may have believed that immune deficiency is caused by a collection of factors such as poverty, nutrition and contaminated water as well as HIV, rather than just HIV on its own:

"You cannot attribute immune deficiency solely and exclusively to a virus."88

It is true that poverty related factors such as malnutrition will hasten the onset of AIDS in people who are HIV-positive. Therefore, it is also true that provision of food will slow down the progression of HIV. However improved nutrition is not enough in itself to permanently keep people healthy. History provides evidence of this.89
2001 History
Chinese campaign poster for World AIDS day

Chinese campaign poster for World AIDS day, 2001

After years of denial, China finally admitted that HIV/AIDS threatened its public health and economic security. China's most senior AIDS researcher stated that China could soon have one of the world's largest populations of people living with HIV. Infections were predicted to grow from about 600,000 to 6 million by 2005.90 It was believed that nearly 75% of people living with HIV in China had acquired the virus through injecting drug use or transfusion with contaminated blood.91

The Indian drug company Cipla offered to make AIDS drugs available at reduced prices to the international aid organisation Medecins Sans Frontieres (MSF). Cipla's offer to produce drugs at a price less than $1 per day put further pressure on multinational drug companies.92

The U.S. Government threatened Brazil with legal action over its production of generic HIV drugs.93 The complaint was dropped later in the year and Brazil promised to give the USA advance warning before changing its patent law for drugs.94

Thirty-nine pharmaceutical companies withdrew their case against the South African government's efforts to lower drug prices. This victory was, however, overshadowed by a statement by the health minister Manto Tshabalala-Msimang, who said that the government already offered adequate treatment to AIDS patients and that proposals to buy antiretroviral drugs were still being considered.95 The South African government released its annual HIV/AIDS figures estimating that 4.7 million people were infected with HIV/AIDS and that 24.5% of pregnant women were HIV-positive in 2000.96

According to a CDC study of six large U.S. cities, 30% of young gay black men were infected with HIV.97

"When people think 'gay', they think 'white'. But the people still at the greatest risk are sexually active gay men, and that cuts across all races."Helene Gayle of the CDC98

The CDC also reported that the rate of new HIV infections was increasing twice as fast among people aged over 50 as among younger age groups.

"Officials have speculated that a more open society, people entering the dating scene after the monogamy of marriage and the absence of a fear of pregnancy is causing the alarming rise in sexually transmitted infections."99

Zimbabwe's government announced that it would dissolve the board of the National AIDS Council, after allegations of inappropriate political support and mismanagement of funds. Zimbabwe had one of the highest HIV infection rates in Africa. It was estimated in 2001 that AIDS had orphaned 1 million children and 25% of Zimbabwe's 12 million population were HIV positive.100

In April 2001, it was reported that the year 2000 saw by the far the largest number of new HIV cases yet recorded in the UK. The Public Health Laboratory Service (PHLS) recorded 3,435 new diagnoses in 2000.101

"Many of those being diagnosed are people infected some years ago, but who are now coming forward for testing. This is good news because once people are diagnosed they can seek treatment."Barry Evans102

Kofi Annan

Kofi Annan

In April, at the African Summit in Nigeria, United Nations Secretary-General Kofi Annan called for spending on AIDS to be increased tenfold in developing countries.103 He suggested 'a war chest' of $7-10 billion to be spent annually on a global campaign against AIDS - a massive increase on the $1 billion per year that was then being spent.104 A few weeks after, it was announced that a new Global AIDS and Health Fund would not only target AIDS (as had at first been suggested) but would also address tuberculosis and malaria.105

"In this effort, there is no us and them, no developed and developing countries, no rich and poor - only a common enemy that knows no frontiers and threatens all people."Kofi Annan at the G8 summit in Genoa106

There were some concerns about how this new initiative was going to be governed and implemented, and the U.S. government was criticised for contributing only $200 million to the fund. Later on in the year, it was officially named as The Global Fund to Fight AIDS, Tuberculosis and Malaria.107 The amount of money donated to the Fund was a disappointingly low $1.6 billion108much less than the $10 billion that Kofi Annan had called for.

Newspapers all over the world marked the 20th anniversary of the first published report on the disease that came to be known as AIDS.

"At the time, I read the report with great interest, but I never imagined I was looking at the first sign of an epidemic, that in just 20 years would have infected 60 million people, killed 22 million and achieved the status of the most devastating epidemic in human history."Peter Piot recalling the first mention of AIDS109

Ugandan president Yoweri Museveni opened a regional centre for treatment of HIV-positive patients in Kampala. One of the main aims of the centre was to train health workers from all over Africa.

"Our hope is that the hundreds trained here will train thousands who will treat millions."110

Kofi Annan appointed the Canadian Stephen Lewis as his 'Special Envoy for AIDS in Africa'.111
Stephen Lewis

Stephen Lewis

Kofi Annan opened the UN General Assembly Special Session (UNGASS) on HIV/AIDS in New York. This was the first ever UN meeting devoted to a public health issue.112

During the UNGASS, representatives of all 189 members of the UN signed a Declaration of Commitment on HIV and AIDS. This document contained many significant pledges, including one to reduce HIV prevalence among young people (aged 15 to 24) by 25% in the most affected countries by 2005, and to reduce it by 25% globally by 2010.113

There was a sudden explosion in HIV cases among injecting drug users in Dublin, Ireland. It was reported that diagnoses jumped fivefold between January 1999 and June 2000. Diagnoses fell to a low of 12 in 1998, but in the next 18 months 96 people tested positive. Doctors blamed this on a sudden tightening of regulations around the supply of the heroin substitute methadone, which caused more people to start injecting street heroin.114

Stephen Kelly was found guilty at Glasgow High Court of 'culpable and reckless conduct' for having unprotected sex despite knowing that he had HIV. He infected his girlfriend in 1994. Kelly was the first person to be tried under Scottish law for this type of offence. It was feared that the threat of legal action would make people more reluctant to be tested for HIV.115

President George Bush appointed an openly gay man, Scott Evertz, as Director of the Office of National AIDS Policy, but did not find any extra money in his 2002 budget for AIDS prevention or treatment.116

The US Food and Drug Administration (FDA) issued a warning letter to manufacturers of HIV/AIDS drugs, cautioning them to tone down the optimistic tone of their antiretroviral drug advertisements.117

"Examples of such images range from robust individuals engaged in strenuous physical activity to healthy-looking individuals giving testimonials of a specific drug's benefit. However, not all individuals have a response to ARV therapy; in fact, some patients will still have disease progression despite ARV therapy."118

A former Japanese Health Ministry official was found guilty of negligence for failing to stop the sale of untreated blood products. Over 1,800 haemophiliacs had contracted HIV in Japan since the early 1980s from untreated blood and more than 500 had died.119
Publicty for the UN special sessions on HIV/AIDS 2001

Publicty for the UN special session on HIV/AIDS 2001

In August, AIDS activists took legal action against the South African health ministry over its continuing refusal to supply antiretrovirals to prevent mother-to-child transmission (MTCT) of HIV.120 In December, it was ruled that the South African government should give pregnant women free access to the drug nevirapine. The judge ordered the government to set up a nationwide MTCT programme with a deadline for an implementation report to be handed back to the court by March 2002.121

Ministers meeting at the World Trade Organisation conference in Doha, Qatar, agreed a new declaration on intellectual property rights. This made it easier for developing country governments to license the production of drugs against AIDS and other diseases without having to get permission from patent holders. It was hoped that the new rules would help improve access to antiretrovirals.122

It was reported that some Asian countries had reduced the transmission of HIV through widespread condom use. In Thailand, the rate of new infections had plummeted from 143,000 in 1991 to 20,000 in 2000.123 Meanwhile HIV was spreading fastest in Eastern Europe and Russia.124

A senior Iranian health official warned that the number of AIDS cases in the country had risen dramatically. In the past, Iranian officials estimated the number of HIV-positive people to be around 2,000, but the Deputy Health Minister said that the real figure was more than 15,000.125
2002 History

Ukraine became the first nation in Europe to have 1% of its adult population infected with HIV.126

Botswana became the first African country to begin providing antiretroviral treatment through the public sector. It was estimated the programme would cost $24.5 million in its first year and would reach 19,000 people.127

The US Secretary of State Colin Powell strongly advocated condom use to prevent the spread of AIDS and other sexually transmitted diseases, setting himself apart from President Bush's views on sex education in an MTV broadcast:

"In my own judgement, condoms are a way to prevent infection… Therefore, I not only support their use, I encourage their use among people who are sexually active and need to protect themselves."128

A new line of condoms carrying the logos of most important Brazilian football teams went on sale. The campaign was helped by a TV advertisement in which supporters wore caps with their team colours in the shape of a condom.

"The level of success was more than we had expected… We are selling the condoms in places not normally associated with this sort of product, such as news stands and bakeries."129

Later in the year, for the first time ever in Brazil, an HIV prevention campaign was being aimed at male homosexuals.130

A study showed that approximately 50% of Americans still believed they could acquire HIV through everyday contact, and most supported the mandatory testing of groups at highest risk of HIV infection.131

The Chinese Government announced a 17% jump in AIDS cases. The government estimated that the number of people with full-blown AIDS was as high as 200,000, of whom more than half were presumed already dead. It also estimated that up to 850,000 people were infected with HIV by the end of 2001. These figures were still far below the estimates by experts at the UN and the WHO, who said that as many as 1.5 million people could have been infected in China.132

The National Statistics Institute in Lisbon announced that there were 104.2 HIV cases per one million Portuguese residents in 2000, compared with 88.3 cases in 1999. This was the highest rate of HIV infection in the European Union. The European average was just under 25 cases per million residents. Injecting drug use was thought to be the main source of HIV infection in Portugal.133

The board of directors of the Global Fund to Fight AIDS, Tuberculosis and Malaria selected Richard Feachem to be its first leader.134 In the first funding round the Fund received applications for more than six times the amount they had anticipated. During the year the Global Fund announced their first round of payments of $600 million over a two-year period; the first $1 million was given out in December.135

The WHO published guidelines for providing antiretroviral drugs for treating HIV infection in resource poor countries. They also released a list of 12 essential AIDS drugs. These two moves were seen as "vital steps in the battle against the AIDS pandemic [that] should encourage both industrialised and developing country governments to make HIV treatment more widely available."136

In April, the South African government promised to start providing nevirapine to HIV-positive pregnant women and their babies to reduce the risk of HIV transmission. It was also going to be possible to offer AZT as post-exposure prophylaxis (PEP) to women who had been raped.137

A World Bank report said that HIV was spreading so rapidly in parts of Africa that it was killing teachers faster than the nations could train them. The report noted that for example in parts of Uganda and Malawi, nearly a third of all teachers were HIV-positive.138

"With more than 113 million children not in school in the poorest countries already presents a major challenge. However, HIV/AIDS makes this much greater in those countries where the education system is already struggling to grow, teachers are dying, or are too sick to teach. And every year more children are losing their parents and the support that allows them to go to school. Achieving education for all in a world of AIDS presents an unprecedented challenge to the world education community."World Bank President James D. Wolfensohn139

A report warned that Papua New Guinea was on the brink of an HIV/AIDS epidemic and the country could face losing 13-38% of its working population by 2020. It was estimated that Papua New Guinea had between 10,000 to 15,000 people infected with HIV. In comparison, Australia with a population almost 5 times that of Papua New Guinea had less than 12,000 HIV positive people. It was feared that HIV/AIDS could spread rapidly since 90% of infections were transmitted through heterosexual sex.140

A major Spanish study found that over 19,000 instances of unprotected oral sex did not lead to a single case of HIV transmission among 135 HIV-negative heterosexuals in a sexual relationship with a person with HIV.141

The WHO warned that HIV could spread rapidly throughout Afghanistan due to high levels of injecting drug use and unsafe blood transfusions. It also said that refugees were especially vulnerable to HIV infection because of sexual abuse, violence and lack of information and education. To learn more about this problem, the WHO was funding the first survey of HIV/AIDS in Afghanistan.142
Treatment activist protesting during the 2002 conference

Treatment activist protesting during the 2002 AIDS conference

In July, the 14th World AIDS Conference was held in Barcelona, Spain. Issues around providing HIV treatment for resource-poor countries dominated the mood and agendas of the conference.

"If we can get cold Coca Cola and beer to every remote corner of Africa, it should not be impossible to do the same with drugs."Joep Lange, the President of the International AIDS Society speaking at the closing ceremony143

At the Barcelona conference, there were encouraging results from trials of T-20, an injectable drug from a new class of treatments called fusion inhibitors. The results provided good news for people who had become resistant to existing drugs; the fusion inhibitors were called 'the most exciting advance since protease inhibitors were introduced'.144

The number of children orphaned by HIV/AIDS had risen three-fold in six years to reach an all time high of 13.4 million. It was estimated that India had the largest number of AIDS orphans of any country in the world, with an estimated at 1.2 million in 2001; this was predicted to rise to 2 million in five years and 2.7 million in ten years.145

"Children are taking the role of adults in many places affected by HIV because a generation has disappeared. They can't go through normal development. They have to work 40 hours a week. The very fabric of society is disappearing, with family structures crumbling."Peter Piot

Indonesia, the world's fourth most populous country, demonstrated how suddenly HIV/AIDS epidemics could emerge. After more than a decade of low HIV prevalence, the country was seeing rates increasing rapidly among injecting drug users and sex workers, with as many as 40% of people in drug treatment centres in Jakarta testing positive.146

Swiss researchers reported the first fully documented case of HIV-positive man who was additionally infected with a second strain of HIV through unprotected sex more than two years after he was first infected.147

Kami, a fluffy, mustard-coloured, HIV-positive character joined the cast of the South African version of Sesame Street. Kami's name was derived from the Tswana word for 'acceptance'.148

In the U.S., the Food and Drug Administration for the first time approved a rapid HIV test. It was hoped that this test, which could provide results in as little as 20 minutes, would counter the problem of people not returning to collect test results, and would also be useful for diagnosing pregnant women during labour.149

It emerged that several batches of cut priced drugs destined for Africa had been illegally sold at full European prices in the Netherlands and Germany. The drugs were supposed to be exported to Africa for 10% of the European price.150
HIV+ woman South Africa

For the first time, it was reported that women accounted for about half of all HIV-infected adults.

"The face of HIV/AIDS has become that of a young African woman - seven of 10 people living with the disease are in sub-Saharan Africa, and 58% of infected Africans are female. Of the 38.6 million adults living with the disease worldwide, 19.2 million are women."151

A study controversially suggested that more people in Africa may have been infected with HIV through medical injections and treatments than was previously thought.152

"Our observations raise the serious possibility that an important portion of HIV transmission in Africa may occur through unsafe injections and other unsterile medical procedures."153

In December the US Agency for International Development (USAID) announced it was adopting a new approach to preventing sexual transmission of HIV around the world, which would be known as "ABC" (Abstinence, Being faithful and Condom use). USAID said its ABC approach was based on the strategies adopted in Uganda, which it credited with reducing HIV prevalence in that country. The decision to adopt the ABC approach came three months after USAID hosted an experts technical meeting on behaviour change approaches to HIV prevention.154

The UN Secretary General, Kofi Annan, used World AIDS Day as a platform to speak out against HIV-related stigma and discrimination. He said that, 'the impact of stigma can be as detrimental as the virus itself,' and he urged people to replace 'fear with hope, silence with solidarity'. He went on to say that, 'the fear of stigma leads to silence and when it comes to fighting AIDS, silence is death'. The use of phrase 'silence is death' was interesting, as it had been used around the world for many years by AIDS activists, initially by the group ACT UP.155

These are some of the most important events that occurred in the history of AIDS from 2003 to 2006.
2003 History

Reports in January suggested that the rate of HIV in Swaziland was the world's highest with almost four out of ten adults infected. Prime Minister Sibusiso Dlamini said that prevalence had risen to 38.6% from 34.2% in January 2002. Although this figure was just under Botswana's rate of 38.8%, health officials said that Swaziland's figures were already out of date.1

Botswana was struggling to expand its antiretroviral treatment programme, largely because of a shortage of health workers. The government had hoped to provide drugs to 19,000 people by the end of 2002, but had enrolled only 3,200 by the end of January 2003.2

Jerry Thacker, a controversial Christian extremist chosen by the White House to sit on a presidential AIDS advisory panel and who once described the virus as the 'gay plague', was forced to withdraw his name after protests from gay rights groups.3

In his State of the Union address on 28th January, US president George Bush proposed spending $15 billion in combating AIDS in Africa and the Caribbean over the next 5 years. He called the scheme 'a great mission of rescue'.4

"This comprehensive plan will prevent 7 million new 'AIDS' infections, treat at least 2 million people with life-extending drugs, and provide humane care for millions of people suffering from AIDS, and for children orphaned by AIDS." President Bush5

Just two days later, US Health Secretary Tommy Thompson was elected as the new chairman of the Global Fund for HIV, TB and Malaria. It was hoped this move would prevent a conflict between the Bush administration and the international health community.6

In February, a rare case of female-to-female sexual transmission of HIV was reported. Doctors suggested the woman may have been infected through sharing sex toys after drug resistance tests found striking similarities between the HIV strains in her and her female partner.7

There had still been no dramatic increase in HIV transmission in Cuba since the beginning of the epidemic. The rate of infection was 0.03% and thought to be one of the lowest in the world. There had been virtually no transmission of HIV through injecting drug use, blood transfusion or from mother to child. The government had ensured that all HIV-positive mothers were treated with prophylactic AZT therapy and that their babies were delivered by caesarean section. The country had produced enough antiretrovirals to supply the country's patients.8

Globally the epidemic continued to expand, reducing world population estimates by 0.4 billion to 8.9 billion for 2050.

"The long-term impact of the epidemic remains dire… HIV/AIDS is a disease of mass destruction and we do not see a vaccine coming soon." - Joseph Chamie, director of the UNPD -9

An expert group reaffirmed that unsafe sexual practices were responsible for the majority of HIV infections in sub-Saharan Africa. This announcement was a response to claims made in 2002 that unsafe medical practises were to blame for an important portion of HIV transmission in Africa.10
AIDS vaccine development

AIDS vaccine development

Vaxgen announced that their AIDS vaccine had failed to reduce overall HIV infection rates among those who were vaccinated. The vaccine showed a reduction in certain ethnic groups, indicating that black and Asian volunteers may have produced higher levels of antibodies against HIV than white and Hispanic volunteers. However, many outside observers were sceptical of the ethnic group part of the study.11 In November, the AIDS vaccine also failed in a clinical trial in Thailand.

"The outcome of this trial is one more reminder of how difficult it is to combat HIV and how important it is for the international public health community to redouble the effort to develop an effective vaccine." - Donald P. Francis, Vaxgen President -12

Researchers warned that the number of women being diagnosed with HIV in Europe was rapidly catching up with men. The researchers also noted that initiatives supplying drug users with clean needles had been effective in Europe. HIV transmission through injecting drug use was said to have been almost eliminated in France, Germany and the UK, and significantly reduced in Spain and Italy.13

In March the Treatment Action Campaign (TAC) filed manslaughter charges against the health minister and the trade and industry minister in South Africa. The TAC held the ministers responsible for the deaths of 600 people a day whose lives could have been saved if they had had access to antiretroviral drugs.14

Russia received an approval for a long delayed loan from the World Bank to tackle HIV/AIDS and TB. For its part, the Russian Government promised to match the loan with $134 million in new money over 5 years for HIV/AIDS and TB. This contribution from the government signalled growing recognition that both HIV/AIDS and TB epidemics represented a threatening crisis for Russia's development.15
The antiretroviral Fuzeon (T-20)

The antiretroviral Fuzeon (T-20)

The first of a new type of anti-HIV drug gained approval in the USA. Unlike all previously approved drugs, Fuzeon (also known as enfuvirtide or T-20) was designed to prevent the entry of HIV into human cells. The drug was not available as a pill and had to be injected. It could be used as part of combination treatment only by patients who had already become resistant to other antiretroviral drugs.16

In April the US Centers for Disease Control and Prevention (CDC) announced a new initiative called Advancing HIV Prevention (AHP), designed to reduce the number of new HIV infections in the US. For two decades before AHP, the CDC mainly targeted its prevention efforts at persons at risk of becoming infected with HIV. In contrast, the new initiative would focus mainly on people already infected with the virus. AHP proposed making HIV testing a routine part of medical care and putting more resources into partner tracing. The recently-licensed rapid HIV test would play a key role in the new initiative.17

The US Senate approved President Bush's international AIDS bill in May, setting a timetable for spending $15 billion over five years.18

A team of Belgian researchers reported on the probable origins of HIV-2. They concluded that the virus had probably transferred from sooty mangabeys to humans in Guinea Bissau during the 1940s.19

South Korean Lee Jong-wook took office as the new Director-General of the World Health Organisation (WHO) and named HIV/AIDS as his top priority in his first speech.20

Meanwhile concerns were mounting over the Global Fund's sustainability as it faced a serious funding shortfall.21

New HIV/AIDS figures were released in India in July, and it was estimated that between 3.82 and 4.58 million Indians were HIV positive.22

In September the WHO declared that the failure to deliver treatment to nearly six million people with HIV/AIDS in developing countries was a global public health emergency. Only about 300,000 people in developing countries received the drugs at all, and in sub-Saharan Africa, where 4.1 million people were infected, just over 1% or about 50,000 people had access to antiretroviral treatment.23

Vatican cardinal Alfonso Lopez Trujillo stated that condoms were not safe and did not protect against the transmission of HIV.

"I simply wished to remind the public, seconding the opinion of a good number of experts, that when the condom is employed as a contraceptive, it is not totally dependable, and that the cases of pregnancy are not rare. In the case of the AIDS virus, which is around 450 times smaller than the sperm cell, the condom's latex material obviously gives much less security." - Cardinal Trujillo -24

In response the WHO said that it was "totally wrong" to claim that condoms did not protect against HIV and:

"It is quite dangerous to claim the contrary when you realize that today we are facing an epidemic which has already killed 20 million people and 42 million people are infected today."25

There was a sharp rise in trafficking of heroin through central Asia. This caused an increase in drug addiction and cases of HIV in many impoverished states including Tajikistan. Since the fall of the Taliban, who had banned the growing of opium poppies (the raw material for making heroin), production had skyrocketed in Afghanistan.26

In the US, estimates suggested there had been fewer than 100 AIDS diagnosses among children during 2002, compared to nearly 1,000 in 1992. The dramatic reduction was due to widespread use of antiretroviral drugs and avoidance of breastfeeding.27

South Africa approved the long-awaited provision of free antiretroviral drugs in public hospitals

In November the UN World Food Programme said it would shift its humanitarian aid effort in southern Africa from traditional emergency food supply to a greater response to HIV/AIDS including providing nutritional support, awareness campaigns, food baskets and other services to HIV-positive people.28

Many drug manufacturers lowered their prices of antiretroviral drugs in resource-poor countries during 2003. Although these price reductions were welcomed by many countries and organisations, it was understood that 'lower price medicines alone will not deliver treatment'. What was also needed was the ability of countries to deliver these drugs, building of stronger health systems and training of more health care workers in resource-poor countries.29

South Africa approved the long-awaited provision of free antiretroviral drugs in public hospitals in November. The cabinet instructed the Department of Health to proceed with implementation of the plan, which envisaged that within a year there would be at least one service point in every health district across the country, and within five years, one service point in every local municipality.30

UNAIDS warned that the efforts to stem the world's AIDS epidemic were 'entirely inadequate'. It was estimated that every day in 2003, around 14,000 people became infected with HIV. It was estimated that 40 million around the world including 2.5 million children were living with HIV/AIDS.31

Meanwhile India's health minister said that there would never be a widespread AIDS epidemic in the country.

"I will prove all experts wrong. We are taking on the disease from all fronts. We are tackling it very bravely." - Sushma Swaraj -32

On World AIDS Day the WHO announced a new plan called '3 by 5' to provide HIV/AIDS treatment for many resource-poor countries. The plan had many different elements, but the WHO were not planning to provide the drugs themselves. The WHO was hoping to have 3 million people in resource poor countries on AIDS drugs by the end of 2005.33

"Nothing close to this has ever been tried. It's not like finding babies with diarrohea and treating them for a week, or adults with tuberculosis and treating them for six months - both of which have been major efforts by the WHO in recent decades... HIV infection is a chronic disease. The 3 million - and the millions who will come after them - will have to take their medicine for years, until they die."34

Also on World AIDS Day, Wen Jiabao became the first Chinese premier to shake the hand of an AIDS patient. Mr Wen's handshake broadcast in close-up was the most dramatic of a series of government moves that demonstrate a new determination to fight AIDS.

"This was like breaking the ice… It's something that a lot of people working in the AIDS field inside China and outside have been hoping for and waiting for." - Joel Rehnstrom, the co-ordinator in China for UNAIDS -35

The Chinese government announced a policy of 'Four Frees and One Care', which promised free antiretrovirals to poor city dwellers and to everyone in the countryside; free voluntary counselling and testing; free drugs to prevent mother-to-child transmission; free schooling for AIDS orphans; and care and economic assistance to the households of people living with HIV/AIDS.36

According to new estimates, the number of people infected with HIV in the UK increased by almost 20% between 2001 and 2002, from 41,700 to 49,500, of whom 31% were undiagnosed.

"World AIDS Day reminds us that the problems we face with HIV are not going away, despite it being a disease that is largely preventable." - Kevin Fenton, a public health consultant -37

2004 History

In January Brazil's government reached a deal with pharmaceutical companies to reduce the price of HIV/AIDS drugs by around a third. It was believed that the deal saved the government about $100 million in 2004 and cut the average treatment cost per patient to a new low of $1,200.38 Also, 10 million free condoms were given out to people in Brazil during the carnival season as part of an AIDS-prevention campaign.39

In parts of Russia and Eastern Europe, HIV was spreading faster than anywhere else in the world.

In February, President Bakili Muluzi of Malawi announced that his brother had died from AIDS. This was intended to highlight issues of stigma and discrimination related to HIV/AIDS. President Muluzi made the announcement as he launched the first AIDS policy in a country where an estimated 15% of the 15 million population were HIV-positive.40

The Global Fund to Fight AIDS, Tuberculosis and Malaria suspended payments to three HIV/AIDS programmes in Ukraine, citing concerns over slow progress and management problems. It was the first time in its history that the Global Fund had stopped funding to a scheme that it had supported.41

In parts of Russia and Eastern Europe, HIV was spreading faster than anywhere else in the world. A survey by the United Nations Development Programme estimated that almost one in 100 Russians were HIV-positive and that AIDS could claim up to 20.7 million lives by 2045.42 The head of the UN Development Programme, Mark Malloch Brown, criticised Russia's efforts to combat the virus:

"President Putin mentioned it last May, but one speech is not enough and one reference in a speech is not enough." 43

Stephen Lewis, the UN special envoy for HIV/AIDS in Africa warned that the WHO's attempt to get three million people onto treatment by the end of 2005 was compromised by lack of financial support from the world's richest countries.

"There has never been a more determined plan of action… If 3 by 5 fails, as it surely will without the dollars, then there are no excuses left, no rationalizations to hide behind, no murky slanders to justify indifference. There will only be the mass graves of the betrayed." - Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa -44

In March, the US Food and Drug Administration approved the first oral fluid rapid HIV test.45

South Africa began a programme to give out free HIV/AIDS drugs after years of confusion and delays. The program started in South Africa's richest province, Gauteng, where five major hospitals, including Chris Hani Baragwanath, the largest in Africa, were selected to administer the drugs.46

"To me, it means a lot," said the frail man, whose girlfriend and 2-year-old daughter have also tested positive for HIV. "I have a child to raise... I want to take her to her first day of school, and I can only do that if I am healthy." - 27-year-old HIV-positive South African man -47

A study found that the HIV prevalence rate in Uganda had been reduced by 70% since the early 1990s. It was estimated that half a million Ugandans were HIV positive in 2004, compared with 1.5 million a decade before. It was believed that the reduction in HIV prevalence was due to people having fewer sexual partners as well as to effective prevention efforts in local communities.48

"In Uganda people became engaged with the epidemic at the community level. Local care groups, religious movements, non-governmental organisations and care networks all spread the message. Families, friends and neighbours began talking about HIV prevention and care, and sexually transmitted diseases stopped being a taboo subject."

A survey of US media coverage of the AIDS epidemic revealed that the number of AIDS-related stories peaked in 1987 and rapidly declined in the early 1990s, despite these being the peak years for AIDS deaths. The stories increased slightly in 1991, when Magic Johnson spoke publicly about his HIV status. The number of stories revived again in 1996-7 with the introduction of combination therapy.49

In May, five Bulgarian nurses and a Palestinian doctor accused of deliberately infecting children with HIV were sentenced to death by a Libyan court. The medical staff had been detained in 1998 and the trial had started in 2000.50

The US porn industry was hit by fears of HIV outbreak among its stars. By May, five porn actors had been found to be HIV-positive.51 52

President Bush's $15 billion initiative to combat the global AIDS pandemic, by now known as PEPFAR (President's Emergency Plan For AIDS Relief), began full implementation in June, having received its first funding in January. PEPFAR was to concentrate on fifteen focus countries, all of them in Africa except Guyana, Haiti and Vietnam (which was a late addition to the list). The initiative set a goal of providing AIDS treatment to 200,000 people living in the focus countries by June 2005.53

A new UNAIDS report estimated that 37.8 million people were living with HIV at the end of 2003, including 17 million women and 2.1 million children under 15 years old. It was estimated that there were nearly 8,000 AIDS deaths per day during 2003. These were slightly lower than previous estimates because improvements had been made to the estimation process, but without doubt the epidemic was still expanding. The number of AIDS orphans had risen to 15 million, of whom 12.1 million lived in sub-Saharan Africa.54

The WHO announced that, by the end of June, 440,000 people in developing and transitional countries were receiving antiretroviral treatment, an improvement of 40,000 since the end of 2003.55

The Bill and Melinda Gates Foundation announced that it would donate $50 million to the Global Fund, bringing its total Fund contributions so far to $150 million.56

The South African Treatment Action Campaign and its leader, Zackie Achmat, were jointly nominated for the 2004 Nobel Peace Prize, but were not chosen to win.57

In November the Global Fund said that it would delay launching its fifth round of grants for five months because of a funding shortfall. Some commentators said the US was not providing enough support for the Global Fund because it preferred its own PEPFAR initiative.58

Botswana's antiretroviral treatment programme, which had made dramatic progress during 2004, was providing medication to around 36,000 and 39,000 people by the end of the year - around half of the number who needed the drugs.59

Women, Girls, HIV and AIDS was chosen as the theme of World AIDS Day 2004. Events to mark the occasion took place around the world, including in China, where Premier Wen Jiabao called for "unremitting efforts" against the epidemic, and the Executive of the Global Fund warned of catastrophic consequences should such efforts fail.60 61 62

"Today the face of AIDS is increasingly young and female... We will not be able to stop this epidemic unless we put women at the heart of the response to AIDS." - Peter Piot, head of UNAIDS, on World AIDS Day63

2005 History

At the start of the year, UNAIDS published a report predicting the future of the global AIDS epidemic. Three very different scenarios highlighted how much would depend on the responses of governments, donors and civil society.64

Also in January, both the WHO and PEPFAR published figures detailing numbers of people receiving AIDS drugs. PEPFAR said it had helped to provide treatment to nearly 155,000 people in its fifteen focus countries by end of September.65 The WHO said that the total number receiving treatment in all developing and transitional countries had risen to 700,000 by the end of 2004, meaning that the 3 by 5 initiative had achieved its latest target.66

The US Food and Drug Administration (FDA) for the first time approved a generic AIDS drug made by a foreign company. PEPFAR had decided not to trust any drug that had not been approved by the FDA, which meant that all PEPFAR-funded programmes had had to stick to the more expensive brand-named products. However in January the FDA gave its approval to two drugs made by the South African company Aspen Pharmacare. This came just weeks after a product of the US company Barr Laboratories had become the first ever FDA-approved generic, and was predicted to mark a turning point in providing cheaper treatment in Africa.67

Nelson Mandela announced that his eldest son Makgatho had died of AIDS, aged 54.

"Let us give publicity to HIV/AIDS and not hide it, because [that is] the only way to make it appear like a normal illness."- Nelson Mandela68

Publication of death certificate data from South Africa revealed that the total number of reported deaths had increased by 57% between 1997 and 2002. Among those aged 25-49 years, the rise was 116% in the same six year period.69 Based on an analysis of a sample of death certificates, the South African Medical Research Council estimated that nearly two-thirds of deaths related to HIV had been misclassified (wrongly attributed to other causes) during 2000-2001.70

In April, the US Institute of Medicine published the results of an extensive review of data relating to the use of the drug nevirapine. It found that the drug was a safe and effective way to prevent mother-to-child transmission of HIV, and that news stories suggesting otherwise had distorted the facts.

"It is conceivable that thousands of babies will become infected with HIV and die if single-dose nevirapine for mother-to-infant HIV prevention is withheld because of misinformation." - National Institute of Allergy and Infectious Diseases -71

Brazil turned down $40 million offered by PEPFAR because it refused to agree to a declaration condemning prostitution. The director of Brazil's HIV/AIDS programme said the government had taken the decision "in order to preserve its autonomy on issues related to national policies on HIV/AIDS as well as ethical and human rights principles".72

A new set of international treatment figures were published by the WHO in June. They revealed that the 3 by 5 initiative was a long way off track, because only 970,000 people (15% of those in need) were receiving treatment, compared to a target of 1.6 million. The WHO admitted that it would be unlikely to achieve its goal of 3 million by the end of the year.73

PEPFAR said it had exceeded one of its own targets by helping to provide treatment to 235,000 people in its focus countries by the end of March.74 The figure given for Botswana was disputed by the country's health officials. They said the US was claiming credit for helping thousands of people whose treatment had in fact been funded overwhelmingly by the Botswanan government.75

Speaking at the 2005 National HIV Conference, the acting director of the CDC announced a new estimate of HIV prevalence in the USA. The CDC had calculated that between 1.039 million and 1.185 million Americans were living with HIV at the end of 2003, of whom 47% were black. One in four HIV-positive people did not know they were infected. Other studies presented at the conference showed that new infections among African Americans were rising, and the total number of new cases was remaining stable at around 40,000 per year.76
Make Poverty History rally

Over 225,000 people gather to form a human

white band around Edinburgh city centre,

as part of the Make Poverty History campaign.

In the UK at least, 2005 had been hailed as the ‘Year of Africa’ - the year in which real progress would be made towards relieving poverty and disease in that continent. The UK held the presidency of the European Union for the second half of the year, and in July the UK hosted the G8 (Group of Eight) summit of world leaders in Gleneagles, Scotland. Prime Minister Tony Blair promised that the main themes of the summit would be Africa and climate change. The meeting was preceded by massive "Live8" pop concerts around the world, and other events associated with the Make Poverty History campaign.

At the summit the leaders promised to double aid to Africa by 2010, and to cancel the debts of 18 poor countries, but no progress was made in improving trade justice, which many groups considered to be the most important issue. However, the leaders were praised for pledging to ensure as near as possible to universal access to antiretroviral treatment worldwide by 2010.77

South Africa's latest antenatal clinic survey showed that 29.5% of pregnant women were HIV positive at the end of 2004. According to the report, the total number of people living with the virus had risen to an estimated 6.29 million - far more than in any other country.78

The Global Fund to Fight AIDS, TB and Malaria in August suspended all grants to Uganda following concerns about possible corruption within the country's health ministry. Uganda's suspension was lifted in November, after an agreement was reached with the ministry over better financial management. Meanwhile the Fund announced its global AIDS programmes had exceeded targets for 2005.79 80 81

By August, nine generic antiretroviral drugs had been approved by the American Food and Drug Administration (FDA). However several African countries refused to allow the drugs to be imported until they had also been approved by the WHO.82 PEPFAR would not begin distributing generic drugs until near the end of the year.83

PEPFAR's approach to HIV prevention (described as "ABC") came under increasingly heavy fire from commentators who said it was motivated by ideology, and was focusing too much on abstinence until marriage while downplaying the role of condoms. Among the fiercest critics were Professor Duff Gillespie, a public health expert and former senior USAID official, who called PEPFAR's policies "outrageous and stupid", and Stephen Lewis, the UN Special Envoy for HIV/AIDS in Africa, who said the approach to HIV prevention would "cause a significant number of infections which should never have occurred". Two prominent US medical associations, the IDSA and the HIVMA, were also critical. However PEPFAR officials maintained that their approach to HIV prevention was balanced and based on evidence of effectiveness.84 85 86

At the UN World Summit in September, the General Assembly followed the example set by the G8 leaders, by committing themselves to:

"Developing and implementing a package for HIV prevention, treatment and care with the aim of coming as close as possible to the goal of universal access to treatment by 2010 for all those who need it"87

Russian President Vladimir Putin promised that his country would allocate at least 20 times more money to fight HIV and AIDS in 2006 than it did in 2005. The President said that AIDS in Russia was a "serious problem", and that current spending of $5 million per year was "practically nothing for Russia on the scale of things".88 89

In September the antiretroviral drug zidovudine (AZT) reached the end of its patent period in the US. This meant that any pharmaceutical company could now produce the drug legally and cheaply for the US market without having to pay royalties to the patent owner, GlaxoSmithKline. The FDA immediately approved four generic forms of AZT for sale within America.90

Zimbabwe, one of the countries worst affected by AIDS, was suffering from a severe economic crisis made worse by droughts and the government's controversial land redistribution programme. One consequence was a sharp rise in the price of AIDS drugs in the public sector, from $7.70 per month in July to $46 per month in October. At the same time the state-run treatment programme was handicapped by a lack of foreign assistance, due to Western opposition to land reform and reported violence and intimidation during elections.

"People are giving up [their] drugs - they have to choose between feeding and educating their kids or taking ARVs" 91

Zimbabwean President Robert Mugabe was accused of further worsening the AIDS crisis in his country through his slum clearance campaign, which left thousands of families homeless. But UNAIDS announced that Zimbabwe's HIV prevalence rate had fallen over the previous five years, from around one in four to around one in five infected.92 93

In 2005 skepticism about the cause of AIDS was still thriving in South Africa. The Democratic Alliance gave a list of the country's twelve most influential "AIDS dissidents" (people who question the theory that HIV causes AIDS), whom it said had an "ongoing and bizarrely powerful" influence on national HIV/AIDS policy. The list was headed by attorney Anthony Brink, the convenor and national chairperson of the Treatment Information Group and spokesperson for the Dr Rath Health Foundation, an organisation dedicated to promoting the use of vitamin supplements rather than antiretrovirals to treat AIDS. Also featured were President Thabo Mbeki and Health Minister Manto Tshabalala-Msimang.

"South Africa has become a safe haven for AIDS denialists and is the AIDS denialist capital of the world... Were it not for the influence of dissidents, South Africa would long ago have been able to take the steps that countries like Brazil and Thailand have taken to stop new AIDS infections, provide appropriate education and offer meaningful treatment to those already infected." - Democratic Alliance health spokeswoman, Dianne Kohler-Barnard -94

London bus appeals for universal access to AIDS treatment

A London bus covered with hundreds of hand-written messages from campaigners appealing for universal access to AIDS treatment, on World AIDS Day 2005.

By late 2005, it was clear that the World Health Organisation's 3 by 5 plan would fail to achieve its goal of 3 million people on treatment in resource-poor countries by end of the year. With refreshing honesty, the head of the WHO's HIV/AIDS programme admitted as much and said sorry.

"All we can do is apologise. I think we just have to admit we’ve not done enough and we started way too late." - Dr Jim Yong Kim

However, Dr Kim said the initiative should certainly not be deemed a failure:

"Before Three by Five, there was not an emphasis on saving lives... Many leaders in the world were saying we just have to forget about this generation of people who are infected, we're really thinking about the next generation... So something has happened that's extraordinary."95

The WHO estimated that expanded access to treatment had saved between 250,000 and 350,000 lives during 2005. However, their estimates also revealed there were more new HIV infections and more AIDS deaths in 2005 than in any previous year.

"2005 is likely to be remembered more for the 3 million deaths and almost 5 million new infections it heralded than for the 300 000 lives saved through treatment for HIV"- Front cover of The Lancet Volume 366 Number 950096

2006 History

In January, the rock star Bono announced the creation of a new commercial brand designed to help raise money to fight AIDS in Africa. “Product RED” originally involved four large companies (Armani, Gap, American Express and Converse), each of which would sell special red products and donate a portion of the profits to the Global Fund. The first merchandise would become available in the UK in March.97

The final results of the 3 by 5 initiative were revealed in March. By the end of 2005, only around 1.3 million people in low- and middle-income countries had been receiving antiretroviral treatment – less than half of the 3 million target. Though this result was highly disappointing, the WHO stressed that it still represented a more than three-fold increase within two years. Of the 152 countries involved in the initiative, only 18 met the target of 50% treatment coverage. Among the worst performers were Russia and India, and among the best was Botswana, where coverage had reached around 85%.

"Two years ago, political support and resources for the rapid scale-up of HIV treatment were very limited. Today ‘3 by 5’ has helped to mobilize political and financial commitment to achieving much broader access to treatment. This fundamental change in expectations is transforming our hopes of tackling not just HIV/AIDS, but other diseases as well." - WHO Director-General, Dr Lee Jong-wook98

PEPFAR announced that it was helping to provide treatment to 401,000 people in its fifteen focus countries,99 but this news was soon overshadowed by yet more criticism of the plan’s HIV prevention policies. A report by the Government Accountability Office revealed that, by allocating one third of its prevention budget to programmes promoting abstinence and fidelity, PEPFAR was forcing countries to cut funding for efforts to help high-risk groups and to prevent mother-to-child transmission.100

A new study suggested that the rate of new HIV infections in Southern India might have declined between 2000 and 2004, perhaps because of changes in sexual behaviour. One of the authors, Professor Prabhat Jha, said their results contradicted previous assumptions:

“There have been many predictions, mostly based on guesswork, that India's AIDS problem will explode – as it did in southern Africa – but we now have direct evidence of something positive.”101

Reports that an HIV-positive orphan, Isaiah Gakuyo, had been violently murdered by his uncle sparked protest marches in Kenya. Before his death, the teenager had been mistreated and isolated by his relatives because of his infection.

“The boy was facing violence on a daily basis. We don't want this to happen again.” - March organiser, Inviolata Mwali M'Mbwari -102

Dr Lee Jong-wook, Director General of the WHO, died after undergoing emergency surgery in May. Dr Lee had led the 3 by 5 initiative, and was especially passionate about achieving universal access to HIV/AIDS prevention, treatment and care.103

At the end of May, twenty-five years after doctors first became aware of AIDS, UNAIDS published an especially comprehensive report on the global epidemic. Although the number of people living with HIV was still rising, there was new evidence of HIV prevalence declines in Kenya, as well as urban areas of Burkina Faso and Haiti.104

The UNAIDS report also revealed that funding for the response to AIDS in low- and middle-income countries had risen from $300 million in 1996 to $8.3 billion in 2005, yet was still a long way short of what was required for meaningful action. Of the $18.1 billion that would be needed in 2007, only $10 billion was likely to be available.105

June also contained the fifth anniversary of the UNGASS declaration, in which UN member states had set ambitious targets for combating HIV and AIDS worldwide. Another High-level Meeting was therefore convened to agree a new “Declaration of Commitment on HIV/AIDS”, which would guide the global response over coming years. The final document was criticised by some campaigners for being vaguely worded, and for omitting any definite spending commitments.

“I wish we could have been a bit more frank in our declaration about telling the truth that some groups – like sex workers, drug users and men who have sex with men – are more at risk… This is not a time for embarrassment, this is about telling it straight because it is about saving people's lives. Openness, honesty, frankness, giving people enough information, not being squeamish and telling the truth is really, really, important.”- Hilary Benn, UK International Development Secretary106

The Vatican sparked excitement among AIDS campaigners when it suggested it was planning a review of its stance on condom use as a method of HIV prevention. However, it soon became clear that a major change in policy was unlikely, and that the Catholic Church would probably continue to oppose condom use in all circumstances.107
Bill Gates with President Bill Clinton at the International AIDS Conference in Toronto

Bill Gates with President Bill Clinton at the International AIDS Conference in Toronto

The Gates Foundation – the world’s largest private source of funding for HIV and AIDS – received a substantial boost to its finances in June, when the billionaire Warren Buffet promised to donate $31 billion over ten years. Bill Gates announced that he would step down as head of Microsoft to concentrate on the work of the Foundation.108

The first one-a-day pill for effectively treating HIV infection was approved for sale in the USA. A result of unprecedented cooperation between two major pharmaceutical companies, the pill, called Atripla, combined three types of drug widely used in first-line treatment. The advent of once-daily treatment represented great progress since the mid-1990s, when people with HIV usually had to take several pills every few hours.109

In August, attention turned to the XVI International AIDS Conference in Toronto. One major talking point was how to accelerate the expansion of antiretroviral therapy worldwide, and in particular how to alleviate dire shortages of healthcare workers in the most needy countries. Delegates also discussed the pros and cons of routine HIV testing, whereby everyone attending medical settings is offered an HIV test, regardless of symptoms. The WHOand others suggested that wider use of this approach would increase take-up of treatment and help to counter stigma.

The conference provided a platform for critics of the South African government’s response to AIDS. Activists protested at the country’s exhibition stand, which was dominated by unproven nutritional remedies, with almost no reference to effective medication. Conference co-chair Mark Wainberg said it was “unconscionable” that South Africa’s leaders would not talk openly about AIDS.110 Stephen Lewis (UN Special Envoy for HIV/AIDS in Africa) went further in his closing speech:

“South Africa is the unkindest cut of all. It is the only country in Africa … whose government is still obtuse, dilatory and negligent about rolling out treatment. It is the only country in Africa whose government continues to propound theories more worthy of a lunatic fringe than of a concerned and compassionate state... The government has a lot to atone for. I'm of the opinion that they can never achieve redemption.”111

Shortly after the conference, more than 80 prominent international scientists wrote an open letter to South African President Thabo Mbeki calling on him to sack health minister Manto Tshabalala-Msimang, whom they blamed for “disastrous, pseudo-scientific policies” on HIV/AIDS.112 Instead, the South African government set up a new inter-ministerial committee to take charge of the national AIDS response, to be headed by the deputy president, thus seeming to sideline the controversial health minister.113

To coincide with the Toronto conference, medical journal The Lancet produced a special issue with a red cover to help promote the Product RED brand. The 130-page journal was entirely devoted to AIDS-related articles, and included prominent adverts for Product RED merchandise.114 The Independent, a British newspaper, had been the first publication to produce a RED edition in May; it would repeat the stunt in September and December.115

In September, the WHO issued an emergency warning to health care professionals to be on the lookout for a new strain of tuberculosis, against which most existing drugs were ineffective. The WHO had been aware of XDR-TB (extreme drug-resistant tuberculosis) for several years, and it had been recorded in Asia, Eastern Europe and the United States. The alarm was raised when doctors reported 53 new patients in South Africa, 52 of whom died within 25 days. It was thought that most, if not all, of these people had been co-infected with HIV. Experts were concerned that they might be seeing the beginning of a devastating new epidemic.
The Lancet's RED edition

The Lancet's RED edition, August 2006

“There is no point in investing hugely in [AIDS treatment] programmes if patients are going to die a few weeks later from extreme drug-resistant tuberculosis… This is raising the spectre of something that we have been worried about for a decade – the possibility of virtually untreatable TB.” - Dr Paul Nunn of the WHO116

In the USA, the Centers for Disease Control and Prevention (CDC) issued new guidelines recommending routine HIV testing for all adults and adolescents attending healthcare services. Routine testing had already proved highly successful in identifying HIV among pregnant women; the CDC hoped that more general use of this approach would help to cut the rate of new infections, and would result in more people receiving treatment before becoming very ill.117

Product RED was launched in the USA in October, by which time Apple and Motorola were also supporting the brand.118

Kevin De Cock, director of the World Health Organisation's HIV/AIDS department, expressed growing concern about HIV in Papua New Guinea. Adult HIV prevalence in this Pacific nation was estimated to be 1.8% - a level not usually seen outside Africa. The country's health minister said that some isolated pockets could have rates as high as 30%.

“Papua New Guinea probably is somewhat in a class of its own in this region.” - Dr. Kevin De Cock119

In December, South Africa’s deputy health minister Nozizwe Madlala-Routledge decided to speak out against her own government, admitting there had been “denial at the very highest level” over the country’s AIDS crisis. She also acknowledged that leaders had created confusion about treatment by appearing to promote nutrition as a viable alternative. Activists greeted these statements as a “defining moment” in the country’s response to HIV and AIDS.120 121

The most important scientific announcement of the year was made in December, when the US National Institutes of Health revealed the results of two African trials of male circumcision as an HIV prevention method. The studies were halted early for ethical reasons because they had already provided clear evidence that the intervention reduced HIV transmission by around 50%. The WHO and other organisations suggested they would soon begin promoting male circumcision in areas with severe HIV epidemics. However, they also stressed that there were many difficulties associated with this intervention, including acceptability, demands on resources, and infections resulting from unsafe operations. Furthermore, it was clear that the benefit would be lost if circumcised men became over-confident, and began to engage in more risky sexual behaviour.122

At their second trial within two years, five Bulgarian medics and a Palestinian doctor were again found guilty of deliberately infecting 426 Libyan children with HIV, and were again sentenced to death. This verdict was condemned by the USA, the European Union and the UN human rights office. Leading experts in HIV and genetic testing had declared that the healthcare workers were almost certainly innocent, and that poor hygiene had led to the children becoming infected.123

These are some of the most important events that occurred in the history of AIDS from 2007 onwards.
2007 History

A large-scale international microbicide study was halted in January after preliminary results found that the product was not achieving its aims of preventing HIV infection in women. In fact, trials of the drug in some sites found that there was a higher infection rate amongst women who used the cellulose sulphate vaginal gel, compared to the placebo group.1 UNAIDS regarded the news as “a disappointing and unexpected setback” as “[t]he need to continue research to find a user-controlled means of preventing HIV infection in women is urgent.”2
President Yahya Jammeh sitting & dressed in white

President Jammeh of The Gambia claimed he could cure AIDS

Also in January came the dramatic announcement by President Jammeh of The Gambia that he had found a cure for AIDS.

“I can treat asthma and HIV/AIDS and the cure is a day’s treatment. Within three days the person should be tested again and I can tell you that he/she will be negative...”3

Jammeh’s claim was soon revealed to be unfounded. A scientist who conducted the tests rebutted the study’s findings, saying that none of the trial patients “could be described as cured.”4 Despite the negative outcomes of the trial, the president continued in his belief of his treatment plan, which was also endorsed by the Gambian health ministry and administered in state hospitals. The President of the International AIDS Society Dr. Pedro Cahn called the Gambian president’s claims “shocking and irresponsible”5, not only for providing false hope, but also for risking people’s lives by taking them off potent combination antiretroviral therapy.

Good news came to South Africa in March when the government finally developed an ambitious and comprehensive plan to try and tackle the epidemic after years of inaction. Headed up by the deputy president, Phumzile Mlambo-Ngcuka, and the deputy health minister Nozizwe Madlala-Routledge, the plan aimed to try and reduce the number of new infections by fifty percent, and bring treatment care and support to at least eighty percent of all HIV-positive people and their families.6 The new plan was welcomed by national and international health experts, although it was made clear that in order for the new goals to be realised there needed to be a fast track restructuring of the health care system.

Also that month came the first publication by the World Health Organisation (WHO) and the Joint UN Programme on HIV/AIDS (UNAIDS) regarding recommendations on circumcision and HIV. The guidance came three months after trials in Uganda and Kenya provided conclusive evidence that circumcision reduces the risk of transmission from women to men by around 50-60%. The publication stressed that men should be taught that circumcision provides only partial protection against HIV, to prevent them developing a false sense of security, and should only be provided as part of a comprehensive HIV prevention package. It also stressed that well-trained practitioners working in sanitary conditions should perform the procedure only after obtaining informed consent.7

In April, it was revealed by the WHO that at the end of 2006 two million HIV-positive people in low- and middle-income countries were accessing antiretroviral treatment. This means that around 28% of those in need of the life-saving drugs were receiving them. The speed of expansion remained too slow to meet the global AIDS treatment targets agreed by the G8 summit.8

By June the G8 had revised its universal treatment pledge to give every person in need of HIV treatment access by 2010. Instead, it proposed a new weaker target stating that the G8 would, “over the next few years” aim to ensure access for “approximately five million people”.9 The weakening of the original G8 pledge caused anger, as it was felt that a commitment had been broken which had been at the very heart of the fight against AIDS for the past two years.10 Although it was acknowledged that universal treatment by 2010 was more idealistic than feasible, many people believed that having such a demanding target put pressure on country governments to get as many people as possible into treatment programmes and highlighted the scale and urgency of the task.

In July, it was revealed that new methods of sampling led to a massive reduction in the estimated number of people living with HIV in India. Previous estimates had suggested that there were around 5.7 million people living with HIV in India, giving it the largest HIV caseload in the world. The new figures suggested that the actual total was somewhere between 2 and 3.1 million people - around 60% lower than the original estimate - and placed India third after South Africa and Nigeria for countries with the highest HIV infected populations. The previously inflated HIV numbers for India were due to figures being obtained in areas of particularly high HIV prevalence and taken from samples from surveillance sites visited mainly by pregnant women, injecting drug users and prostitutes.11

"“Today we have a far more reliable estimate of the burden of HIV in India,”" said the Indian Health Minister, Anbumani Ramadoss. He did however warn of complacency, as "“in terms of human lives affected, the numbers are still large, in fact very large.”"12

Later in July, there were reports of counterfeit antiretroviral drugs (ARVs) flooding the market in Zimbabwe, potentially putting many lives at risk. The adverse economic and political conditions in Zimbabwe meant that supplies of government-funded ARVs dried up in many parts of the country, leaving those with HIV at serious risk of developing AIDS. This left the door open for dealers to sell fake or illegally obtained pills to HIV positive people desperate to maintain their health. A spokesperson for the Medicines Control Authority of Zimbabwe (MCAZ) said “Such medicines may be counterfeited, adulterated and contaminated, thus rendering them ineffective and sometimes dangerous.”13
People wearing purple protesting

Protest at South African Deputy Health Minister's sacking

As July drew to a close so to did the eight-year ordeal of the six Bulgarian medics facing the death sentence in Libya for allegedly infecting hundreds of children with HIV. They had always denied the claim, saying their confessions were extracted under torture. Expert evidence from various scientists claimed that the infections began long before the medics had arrived in the country, and that they were due to poor hygiene and the reuse of equipment and needles.14 The Libyan authorities finally agreed to release the medics to spend the rest of their sentences in Bulgaria, but on arrival, they were pardoned by the Bulgarian President and returned home to their friends and families.15

Optimism regarding South Africa’s response to the AIDS crisis was short lived after it was announced in August that the Deputy Health Minister Nozizwe Madlala-Routledge had been fired. After years of denial and inaction in the country it was felt that Madlala-Routledge was a government member who finally recognised the seriousness of the epidemic and was determined to take effective action. The official reason for Madlala-Routledge’s dismissal was cited as her inappropriate labelling of infant deaths at Frere Hospital as ‘a national emergency’ and accusations of her attendance at an AIDS conference in Spain without the President’s permission. But it was felt that the underlying motive for her dismissal was her ongoing conflict with Tshabalala-Msimang, the Health Minister, and in particular their contrasting opinions on how to confront AIDS.16

It was revealed that the African nation of Botswana had managed to dramatically reduce rates of mother to child HIV transmission. Botswana, with one of the highest HIV prevalence rates in the world, set up a comprehensive treatment and care programme, to ensure that all women were being tested for HIV in pregnancy and offered appropriate drugs to prevent HIV being passed to their babies. Without intervention, around one in three babies born to HIV positive mothers will become infected with HIV themselves; but by implementing this programme, Botswana successfully cut the mother-to-child transmission rate to under 4%.17

In August, the U.S. Food and Drug Administration (FDA) granted accelerated approval to the new HIV drugs maraviroc (Selzentry) and raltegravir (Isentress). These two new drugs offered hope to patients infected with virus strains resistant to almost all other classes of drugs designed to fight AIDS.18

In October, it was revealed that hundreds of South Africans who had been involved in an AIDS vaccine trial might have an increased risk of HIV infection as a result. The trial, which was being conducted by the Merck pharmaceutical company, had been halted in the previous month after initial results showed the vaccine to be ineffective, an outcome that was described by leading vaccine researcher Dr. Gary Nabel as “a big blow to the field.”19 It was revealed that the infection rate was higher among people who received the vaccine than among those given a placebo. Experts said the vaccine itself could not have caused HIV infection, but it may have increased the risk of transmission by affecting immune responses.20

The biographer of Thabo Mbeki revealed in November that the South African President remained unconvinced that HIV caused AIDS. Mbeki had previously stepped back from the AIDS debate in South Africa in 2000 after causing much controversy.21
2008 History

At the beginning of 2008 the Swiss Federal Commission for HIV/AIDS published the findings of four studies, showing that people living with HIV who take effective antiretroviral therapy cannot pass on the virus through unprotected sex, as long as they adhere to the drugs, have an undetectable viral load for at least six months, and have no other sexually transmitted infections. It was not possible to prove conclusively that transmission is impossible, however the commission reported that scientific evidence showed the risk to be “negligibly small”. 22

The Swiss statement was met by immediate controversy, with questions over the reliability of its conclusions coming from HIV/AIDS advocacy groups as well as scientists. Concerns focused on the fact that the research was based solely on heterosexual couples and therefore neglected to include anal sex 23. UNAIDS and the WHO quickly issued a statement stressing that consistent use of condoms was still the safest protection against HIV. 24
Michel Sidibe, Executive Director of UNAIDS giving a speach.

Michel Sidibé, Executive Director of UNAIDS

In April, the Executive Director of UNAIDS, Peter Piot, announced that he would be stepping down at the end of the year. An editorial in The Lancet praised Piot for having “raised the profile of HIV/AIDS so successfully that the epidemic has remained a high priority on health, political and security agendas". 25 Later in the year it was announced that Michel Sidibé would be Piot’s successor. 26 27

In June, a team of scientists in South Africa were tried and found guilty by a South African court for conducting unauthorised medical trials and selling unregistered vitamin supplements as a treatment for AIDS. One of the supervisors of the illegal trials, Matthias Rath, was already widely criticised for his promotion of vitamins as a substitute for antiretroviral drugs. The South African court halted the medical trials and banned Rath from advertising his natural AIDS remedies. It also highlighted the responsibility of the South African government and its failure in not preventing Rath from distributing his products. 28

The American PEPFAR funding program was renewed on 30th July, committing $48 billion to HIV/AIDS, malaria and tuberculosis for fiscal years 2009-2013.29 This was triple the amount of money that the fund had distributed in its initial five years, and was commended by international HIV/AIDS activists and organisations. However, they stressed that the bill only authorised the expenditure and the money would still need to be appropriated each year. 30

The Reauthorization Act 31 also repealed a policy that had received substantial criticism: the requirement that one third of funding be spent exclusively on the promotion of sexual abstinence. However, it was replaced with a ‘reporting requirement’ for recipients who spend less than 50 percent of prevention funds on abstinence-only programmes. It was argued that this perpetuated bias in PEPFAR spending. 32

The political and economic climate in Zimbabwe worsened dramatically in 2008, exacerbating an already severe AIDS epidemic. A cholera outbreak that began in August was so critical that by December, UK Prime Minister Gordon Brown was describing the crisis as an “international emergency”. 33 The effect of the outbreak on people living with HIV and AIDS was compounded by the collapse of the health system, the government’s block on foreign aid, and widespread malnutrition, leading to an equally devastating AIDS crisis. 34 35

Medicines Sans Frontiers (MSF) estimated that in Bulawayo (the second largest city in Zimbabwe) there were 2,500 patients still waiting to receive antiretroviral drugs by the end of 2008. Even those who were able to access drugs were put at risk by the widespread lack of food, with 2008 producing the worst harvest Zimbabwe had experienced since the country gained independence in 1980. 36 The government’s decision to ban most international aid groups, which was imposed at the beginning of June and lasted throughout July and August, exacerbated food and drug shortages farther. MSF called for an urgent increase in the humanitarian response to the crisis, and stressed the importance of HIV and AIDS being a prominent part of this response 37

The seventeenth International AIDS Conference took place in Mexico City in August. For the first time in the history of the Conference, 2008 saw the use of ‘conference hubs’: a network of locations around the world where conference sessions were screened and accompanied by moderated discussion. The ‘hubs’ were considered very successful in widening the reach of the conference. 38

In the same month, UNAIDS published its 2008 report on the global AIDS epidemic. The report warned that with 2010 only two years away, the target of universal access by 2010 would be unattainable unless the global response to HIV was substantially strengthened and accelerated. However it also emphasised that signs of major progress in the HIV response were being seen for the first time in 2008.

“The 2008 Report on the global AIDS epidemic confirms that the world is, at last, making some real progress in its response to AIDS.” - Peter Piot, Executive Director of UNAIDS

Describing a "stabilization of the global epidemic", the report estimated that by the end of 2007 there were 33 million people living with HIV worldwide (down from the 39.5 million estimate made at the end of 2006). Although much of the reduction was attributed to better surveillance techniques in many countries, it also reflected the drop in HIV prevalence in certain areas, including sub-Saharan Africa. The report estimated that the annual number of AIDS deaths had declined from 2.2 million in 2005 to 2 million in 2007, reflecting an increase in the number of people receiving antiretroviral drugs. 39
Dr. Robert Gallo

Dr. Robert Gallo

In September, the resignation of president Thabo Mbeki was welcomed as a potential turning point in the controversial history of HIV and AIDS in South Africa. A Harvard study published shortly after asserted that more than 330,000 lives were lost between 2000 and 2005 as a direct result of the South African government’s failures in the provision of antiretroviral drugs. 40 The decision of interim president Kgalema Motlanthe to immediately appoint a new health minister, Barbara Hogan, was celebrated by AIDS activists as a sign of a new commitment to the AIDS response. 41 42

An old controversy was revived in October with the announcement of the winners of the Nobel Prize for medicine. The prize was split between Françoise Barré-Sinoussi and Luc Montagnier of the Pasteur Institute in Paris for their discovery of HIV, and a third scientist for his work on a separate disease. The decision not to credit American researcher Robert Gallo for his contribution to early work on AIDS resurrected a bitter dispute over who claimed rights to the discovery. In awarding the prize, the chair of the Nobel committee, Professor Bertil Fredholm, stated:

"I think it is really well established that the initial discovery of the virus was in the Institute Pasteur." 43

In November, German haematologist Gero Huetter announced that he had cured a man of HIV through a bone marrow transplant from a donor who had a genetic resistance to the virus. Huetter spoke at a press conference in Berlin stating that the patient, who was taken off antiretroviral drugs after the transplant two years before, continued to show no traces of the virus, leading doctors to declare him “functionally cured”. 44 However, it was generally accepted that the operation did not present a viable cure for AIDS. Researchers cautioned that further testing was needed to ensure that the virus had been completely eradicated and not just suppressed to very low levels or become latent. 45
100 days to fight AIDS March in washington D.C.

"100 days to fight AIDS" march in Washington D.C.

Also in November, Barack Obama was elected President of the United States of America. As part of his election campaign, Obama released a plan to combat global HIV and AIDS promising a move away from ideology and a greater focus on “best practice” in America’s HIV/AIDS strategy. 46 At home, Obama committed to implementing a comprehensive national strategy on HIV and AIDS in America in his first year, and to signing universal health care legislation by the end of his first term. In terms of America’s response to HIV and AIDS overseas, Obama pledged that he would substantially increase funding to both PEPFAR and the Global Fund. 47 However, commentators have questioned the likelihood of this pledge being followed through in the context of the unfolding international financial crisis.

Obama also openly supported lifting the ban on states using federal funding for needle exchange programmes 48 and pledged to overturn the controversial policy banning funding to international organisations that perform or promote abortion (known as the global gag rule). As the year drew to a close, HIV/AIDS advocacy groups and commentators expressed high expectations for the future of America's response to the AIDS epidemic under Obama. However there was emphasis on the need to maintain pressure to ensure that campaign promises are followed through. 49

History of AIDS up to 1986

2009-12-03T04:39:00.000-08:00

These are some of the most important events that occurred in the history of AIDS up to 1986.
Up to 1980

We do not know how many people developed AIDS in the 1970s, or indeed in the years before. We do now know that the origin of AIDS and the virus HIV was probably in Africa. What we also know is:

"The dominant feature of this first period was silence, for the human immunodeficiency virus (HIV) was unknown and transmission was not accompanied by signs or symptoms salient enough to be noticed. While rare, sporadic case reports of AIDS and sero-archaeological studies have documented human infections with HIV prior to 1970, available data suggest that the current pandemic started in the mid- to late 1970s. By 1980, HIV had spread to at least five continents (North America, South America, Europe, Africa and Australia). During this period of silence, spread was unchecked by awareness or any preventive action and approximately 100,000-300,000 persons may have been infected." - Jonathan Mann 1

1981 History

Kaposi's Sarcoma (KS) was a rare form of relatively benign cancer that tended to occur in older people. But by March 1981 at least eight cases of a more aggressive form of KS had occurred amongst young gay men in New York.2

At about the same time there was an increase, in both California and New York, in the number of cases of a rare lung infection Pneumocystis carinii pneumonia (PCP)3. In April this increase in PCP was noticed at the Centers for Disease Control (CDC) in Atlanta. A drug technician, Sandra Ford, noticed a high number of requests for the drug pentamine, used in the treatment of PCP:

"A doctor was treating a gay man in his 20s who had pneumonia. Two weeks later, he called to ask for a refill of a rare drug that I handled. This was unusual - nobody ever asked for a refill. Patients usually were cured in one 10-day treatment or they died" - Sandra Ford for Newsweek 4

In June, the CDC published a report about the occurrence, without identifiable cause, of PCP in five men in Los Angeles5. This report is sometimes referred to as the "beginning" of AIDS, but it might be more accurate to describe it as the beginning of the general awareness of AIDS in the USA.

A few days later, following these reports of PCP and other rare life-threatening opportunistic infections, the CDC formed a Task Force on Kaposi's Sarcoma and Opportunistic Infections (KSOI).6
Dr. Curran

Dr. Conant and Dr Volverg discussing

Kaposi's Sarcoma. Circa 1981

Around this time a number of theories were developed about the possible cause of these opportunistic infections and cancers. Early theories included infection with cytomegalovirus, the use of amyl nitrite or butyl nitrate "poppers", and "immune overload".7 8 9

Because there was so little known about the transmission of what seemed to be a new disease, there was concern about contagion, and whether the disease could by passed on by people who had no apparent signs or symptoms.10 Knowledge about the disease was changing so quickly that certain assumptions made at this time were shown to be unfounded just a few months later. For example, in July 1981 Dr Curran of the CDC was reported as follows:

"Dr. Curran said there was no apparent danger to non homosexuals from contagion. 'The best evidence against contagion', he said, 'is that no cases have been reported to date outside the homosexual community or in women'" - The New York Times 11

Just five months later, in December 1981, it was clear that the disease affected other population groups, when the first cases of PCP were reported in injecting drug users.12 At the same time the first case of AIDS was documented in the UK.13
1982 History

The disease still did not have a name, with different groups referring to it in different ways. The CDC generally referred to it by reference to the diseases that were occurring, for example lymphadenopathy (swollen glands), although on some occasions they referred to it as KSOI, the name already given to the CDC task force.14 15

In contrast some still linked the disease to its initial occurrence in gay men, with a letter in The Lancet calling it "gay compromise syndrome".16 Others called it GRID (gay-related immune deficiency), AID (acquired immunodeficiency disease), "gay cancer" or "community-acquired immune dysfunction".17 18

In June a report of a group of cases amongst gay men in Southern California suggested that the disease might be caused by an infectious agent that was sexually transmitted.19

By the beginning of July a total of 452 cases, from 23 states, had been reported to the CDC.20

Later that month the first reports appeared that the disease was occurring in Haitians, as well as haemophiliacs.21 22 This news soon led to speculation that the epidemic might have originated in Haiti, and caused some parents to withdraw their children from haemophiliac camps.23

The occurrence of the disease in non-homosexuals meant that names such as GRID were redundant. The acronym AIDS was suggested at a meeting in Washington, D.C., in July.24 By August this name was being used in newspapers and scientific journals.25 26 27 AIDS (Acquired Immune Deficiency Syndrome) was first properly defined by the CDC in September.28

By the beginning of July a total of 452 cases, from 23 states, had been reported to the CDC

An anagram of AIDS, SIDA, was created for use in French and Spanish.29 Doctors thought AIDS was an appropriate name because people acquired the condition rather than inherited it; because it resulted in a deficiency within the immune system; and because it was a syndrome, with a number of manifestations, rather than a single disease.30

Still very little was known about transmission and public anxiety continued to grow.

"It is frightening because no one knows what's causing it, said a 28-year old law student who went to the St. Mark's Clinic in Greenwich Village last week complaining of swollen glands, thought to be one early symptom of the disease. Every week a new theory comes out about how you're going to spread it." - The New York Times 31

By 1982 a number of AIDS specific voluntary organisations had been set up in the USA. They included the San Francisco AIDS Foundation (SFAF), AIDS Project Los Angeles (APLA), and Gay Men's health Crisis (GMHC).32 In November 1982 the first AIDS organisation, the "Terry Higgins Trust" (later known as the Terrence Higgins Trust), was formally established in the UK, and by this time a number of AIDS organisations were already producing safer sex advice for gay men.33 34

In December a 20-month old child who had received multiple transfusions of blood and blood products died from infections related to AIDS.35 This case provided clearer evidence that AIDS was caused by an infectious agent, and it also caused additional concerns about the safety of the blood supply. Also in December, the CDC reported the first cases of possible mother to child transmission of AIDS.36

By the end of 1982 many more people were taking notice of this new disease, as it was clearer that a much wider group of people was going to be affected.

"When it began turning up in children and transfusion recipients, that was a turning point in terms of public perception. Up until then it was entirely a gay epidemic, and it was easy for the average person to say 'So what?' Now everyone could relate." - Harold Jaffe of the CDC for newsweek 37

It was also becoming clear that AIDS was not a disease that just occurred in the USA. Throughout 1982 there were separate reports of the disease occurring in a number of European countries.38

Meanwhile in Uganda, doctors were seeing the first cases of a new, fatal wasting disease. This illness soon became known locally as 'slim'.39
1983 History

In January, reports of AIDS among women with no other risk factors suggested the disease might be passed on through heterosexual sex.40

At about the same time the CDC convened a meeting to consider how the transmission of AIDS could be prevented, and in particular to consider the newly emerged evidence that AIDS might be spread through blood clotting factor and through blood transfusions. As James Curran, the head of the CDC task force, said:

"The sense of urgency is greatest for haemophiliacs. The risk for others [who receive blood products] now appears small, but is unknown."41

The risk for haemophiliacs was so great because the blood concentrate that some haemophiliacs used exposed them to the blood of up to 5,000 individual blood donors.

In March, the CDC stated that,

"persons who may be considered at increased risk of AIDS include those with symptoms and signs suggestive of AIDS; sexual partners of AIDS patients; sexually active homosexual or bisexual men with multiple partners; Haitian entrants to the United States; present or past abusers of IV drugs; patients with haemophilia; and sexual partners of individuals at increased risk for AIDS."

The same report also said,

"each group contains many persons who probably have little risk of acquiring AIDS... Very little is known about risk factors for Haitians with AIDS."42

Nevertheless, the inclusion of Haitians as a risk group caused much controversy. Haitian Americans complained of stigmatisation, officials accused the CDC of racism, and Haiti suffered a serious blow to its tourism industry.43 44 Before long people were talking colloquially of a "4-H Club" at risk of AIDS: homosexuals, haemophiliacs, heroin addicts and Haitians.45 46 Some people substituted hookers for haemophiliacs.47

In May 1983, doctors at the Institute Pasteur in France reported that they had isolated a new virus, which they suggested might be the cause of AIDS

In the UK there were public concerns about the blood supply with references in newspapers to "killer blood".48 The media more generally started to take notice of AIDS, with the screening of a TV Horizon programme, "The Killer in the Village", and a number of newspaper articles on the subject of the "gay plague".49 50

In May 1983, doctors at the Institute Pasteur in France reported that they had isolated a new virus, which they suggested might be the cause of AIDS.51 Little notice was taken of this announcement at the time, but a sample of the virus was sent to the CDC.52 A few months later the virus was named lymphadenopathy-associated virus or LAV, patents were applied for, and a sample of LAV was sent to the National Cancer Institute.53

But whilst progress was being made by scientists there was at the same time increasing concern about transmission, and not just in relation to the blood supply. A report of AIDS occurring in children suggested quite incorrectly the possibility of casual household transmission.54

AIDS transmission became a major issue in San Francisco, where the Police Department equipped patrol officers with special masks and gloves for use when dealing with what the police called "a suspected AIDS patient".

"The officers were concerned that they could bring the bug home and their whole family could get AIDS." - The New York Times 55

And in New York:

"landlords have evicted individuals with AIDS" and "the Social Security Administration is interviewing patients by phone rather than face to face." - Dr David Spencer, Commisioner of Health, New York City 56

There was considerable fear about AIDS in many other countries as well:

"In many parts of the world there is anxiety, bafflement, a sense that something has to be done - although no one knows what." - The New York Times 57

As anxiety continued, the CDC tried to provide reassurance that children with AIDS had probably acquired it from their mothers and that casual transmission did not occur:

"The cause of AIDS is unknown, but it seems most likely to be caused by an agent transmitted by intimate sexual contact, through contaminated needles, or, less commonly, by percutaneous inoculation of infectious blood or blood products. No evidence suggests transmission of AIDS by airborne spread. The failure to identify cases among friends relatives, and co-workers of AIDS patients provides further evidence that casual contact offers little or no risk [...] the occurrence in young infants suggests transmission from an affected mother to a susceptible infant before, during, or shortly after birth."58

Reports from Europe suggested that two rather separate AIDS epidemics were occurring. In the UK, West Germany and Denmark, the majority of people with AIDS were homosexual, and many had a history of sex with American nationals. However in France and Belgium AIDS was occurring mainly in people from Central Africa or those with links to the area.59

Examples of this second epidemic included a number of previously healthy African patients who were hospitalised in Belgium with opportunistic infections (such as PCP and cryptosporidosis), Kaposi's sarcoma, or other AIDS-like illnesses. All of these Africans had immune deficiency similar to that of American AIDS patients. However they had no history of blood transfusion, homosexuality, or intravenous drug abuse.60 In light of such reports, European and American scientists set out to discover more about the occurrence of AIDS in Central Africa.

By this time, doctors working in parts of Zambia and Zaire had already noticed the emergence of a very aggressive form of Kaposi's sarcoma. This cancer was endemic in Central Africa, but previously it had progressed very slowly and responded well to treatment, whereas the new cases looked very different and were often fatal.61 62

In September the CDC published their first set of recommended precautions for health-care workers and allied professionals designed to prevent "AIDS transmission".63 In the UK, people who might be particularly susceptible to AIDS were asked not to donate blood.64

In October, the first European World Health Organisation (WHO) meeting was held in Denmark. At the meeting it was reported that there had been 2,803 AIDS cases in the USA.65

That meeting was followed in November by the first meeting to assess the global AIDS situation. This was the start of global surveillance by the WHO and it was reported that AIDS was present in the U.S.A., Canada, fifteen European countries, Haiti and Zaire as well as in seven Latin American countries. There were also cases reported from Australia and two suspected cases in Japan.66

By the end of the year the number of AIDS cases in the USA had risen to 3,064 and of these 1,292 had died.67
1984 History

At the CDC researchers had been continuing to investigate the cause of AIDS through a study of the sexual contacts of homosexual men in Los Angeles and New York. They identified a man as the link between a number of different cases and they named him "patient O" for "Out of California".68 The research appeared to confirm that AIDS was a transmittable disease, and the co-operation of "patient O" contributed to the study.69

However a problem arose when other people read the scientific paper.

"I called this guy Patient O... But my colleagues read it as Patient Zero." - Darrow for Newsweek 70

And so in March 1984 the myth of Patient Zero began.71 See 1987 for more information about Patient Zero.

Just one month later, on April 22nd, Dr Mason of the CDC was reported as saying:

"I believe we have the cause of AIDS."

He was referring to the French virus, LAV, and he was basing his opinion on the findings made in the preceding weeks by the researchers at the Pasteur Institute who had discovered the virus the previous year.72
Margaret Heckler

Margaret Heckler

Just one day later, on April 23rd, the United States Health and Human Services Secretary Margaret Heckler announced that Dr. Robert Gallo of the National Cancer Institute had isolated the virus which caused AIDS, that it was named HTLV-III, and that there would soon be a commercially available test able to detect the virus with "essentially 100 percent certainty". It was a dramatic and optimistic announcement that also included:

"We hope to have a vaccine [against AIDS] ready for testing in about two years."

And it concluded with:

"yet another terrible disease is about to yield to patience, persistence and outright genius".73 74

The same day patent applications were filed covering Gallo's work, but there was clearly a possibility that LAV and HTLV-III were the same virus.75 76 The scientific papers regarding Gallo's discovery of HTLV-III were published on 4th May.77 By 17th May, private companies were already applying to the Department of Health & Human Services for licences to develop a commercial test, which would detect evidence of the virus in blood, a test which it had already been said would be used to screen the entire supply of donated blood in the USA.78 79

Meanwhile there continued to be concern about the public health aspects of AIDS. This was particularly the case in San Francisco where all the gay bath houses and private sex clubs were closed. Some gay men regarded the closures as an attack on their civil rights. But Mervyn Silverman, Director of the San Francisco Department of Public Health stated the public health view as follows:
Dr Robert Gallo

Dr Robert Gallo

"There are certain places where things are allowed and certain places where they are not. You can't have sex at the McDonald's. You generally cannot have sex in the pews of a church or in a synagogue. People don't feel their civil liberties are being in any way abrogated because of that."80

Researchers who had visited Central Africa in late 1983 reported they had identified 26 patients with AIDS in Kigali, Rwanda, and 38 in Kinshasa, Zaire. The Rwandan study concluded that, "an association of an urban environment, a relatively high income, and heterosexual promiscuity could be a risk factor for AIDS in Africa".81 The Zairian study found there to be a "strong indication of heterosexual transmission".82

In light of these findings the Zairian Department of Public Health, in collaboration with American and European scientists, launched a national AIDS research programme called Project SIDA.83

By the end of 1984, there had been 7,699 AIDS cases and 3,665 AIDS deaths in the USA, and 762 cases had been reported in Europe.84 85 In the UK there had been 108 cases and 46 deaths.86
1985 History

In January 1985 a number of more detailed reports were published concerning LAV and HTLV-III, and by March it was clear that the viruses were the same.87 The same month the U.S Food and Drug Administration (FDA) licensed, for commercial production, the first blood test for AIDS. The test would reveal the presence of antibodies to HTLV-III/LAV, and it was announced that anyone who had antibodies in their blood would not in future be allowed to donate blood.88

There were a number of social and ethical issues, as well as certain medical matters, that had to be considered before the new test could be used even to ensure the safety of the blood supply. And even more aspects needed to be considered before the test could be more widely used. Concern particularly centred on issues of confidentiality and the meaning of a positive test result.89 90

"Richard Dunne, director of the Gay Men's Health Crisis, said that the group would not object to the wider availability of the procedure provided that certain safeguards were assured: informed consent, good counselling and confidentiality, 'which means anonymity,' he said. He stressed that the city must prevent insurance companies, employers, schools and others from gaining access to test results." - The New York Times 91

The first small-scale needle and syringe exchange project had been started in 1984 in Amsterdam, the Netherlands, but more projects were started in 1985 as a result of growing concerns about HTLV-III/LAV.92

In April more than 2000 people attended the first international Conference on AIDS held in Atlanta. Three major topics of discussion were the new HTLV-III/LAV test, the situation with regard to AIDS internationally, and the extent of heterosexual transmission.93
'AIDS is everyone's problem' campaign poster

"Some experts are sceptical that AIDS will spread as rapidly among heterosexuals as it has among homosexuals. Yet other experts, taking their cues from data emerging from preliminary studies from Africa showing equal sex distribution among males and females, are less sure." - The New York Times 94

Immediately after the conference, the World Health Organization (WHO) organized an international meeting to consider the AIDS pandemic and to initiate concerted worldwide action.95

Meanwhile in many countries there was a separate "epidemic of fear" and prejudice.96

In the UK tabloid press, AIDS gained many headlines and caused alarm among the public. In some newspapers, the prejudice was obvious. The haemophiliacs were seen as the "innocent victims" of AIDS whereas gays and drug-users were seen as having brought the disease upon themselves.97 The fear of AIDS caused firemen to ban the kiss of life, and caused holidaymakers to cut their holiday short for fear of contracting AIDS from an HTLV-III positive passenger on the Queen Elizabeth 2.98 99 A 9-year old HTLV-III positive haemophiliac was allowed to attend the local school, but some of the pupils where kept home by anxious parents.100
'This is not a setting for AIDS' campaign poster

In the US, it was feared that drinking communion wine from a common cup could transmit AIDS, and Ryan White, a 13-year old haemophiliac with AIDS, was barred from school.101 102

"In 1985, at 13, Ryan White became a symbol of the intolerance that is inflicted on AIDS victims. Once it became known that White, a haemophiliac, had contracted the disease from a tainted blood transfusion, school officials banned him from classes." - Time Magazine 103

The CDC removed Haitians from their list of AIDS risk groups, in light of information that suggested both heterosexual contact and exposure to contaminated needles played a role in transmission.104

On September 17th, President Reagan publicly mentioned AIDS for the first time, when he was asked about AIDS funding at a press conference. At the same press conference he was also asked a question whether he would send his children if they were younger to school with a child who has AIDS.

"It is true that some medical sources had said that this cannot be communicated in any way other than the ones we already know and which would not involve a child being in the school. And yet medicine has not come forth unequivocally and said, 'This we know for a fact, that it is safe.' And until they do, I think we just have to do the best we can with this problem. I can understand both sides of it." - Ronald W. Reagan 105

Drugs such as ribavirin, thought to be active against HTLV-III/LAV, were being smuggled from Mexico into the USA.106

The actor Rock Hudson died of AIDS on October 3rd 1985. He was the first major public figure known to have died of AIDS.107

All UK blood transfusion centres began routine testing of all blood donations for HTLV-III/LAV in October.108

For the Global Surveillance of AIDS, the WHO had initially used the definition of AIDS as developed in the USA in 1982. But this definition was difficult to use in developing countries where there was a lack of sophisticated laboratory tests. So in order to help with the surveillance of AIDS, particularly in Africa, a new WHO definition was adopted in October. This definition of AIDS became known as the Bangui definition.109

Towards the end of the year, Western scientists became much more aware of the "slim disease" that had become increasingly common in South West Uganda since 1982. Studies found that most cases were among promiscuous heterosexuals, the majority of whom tested positive for antibodies to HTLV-III/LAV. The site and timing of the first reported cases suggested that the disease arose in neighbouring Tanzania. Some scientists who studied slim concluded: " "Although slim disease resembles AIDS in many ways, it seems to be a new entity."110 ". However, others thought differently:

""[Evidence] suggests that slim disease cannot be distinguished from AIDS and ARC [AIDS related complex] by extreme weight loss and diarrhoea. Thus slim disease may not be a new syndrome but simply identical with AIDS as seen in Africa."111"

In December 1985, the Pasteur Institute filed a lawsuit against the National Cancer Institute to claim a share of the royalties from the NCI's patented AIDS test.112

During the year, knowledge of transmission routes was to change again, when the first report appeared of the transmission of the virus from mother to child through breast feeding.113 The first case of AIDS was also reported in China, and AIDS had as a result been reported in every region in the world.114

By the end of 1985, 20,303 cases of AIDS had been reported to the World Health Organisation.115 In the USA 15,948 cases of AIDS had been reported,116 and in the UK 275 cases.117
1986 History

In the UK the first needle exchange scheme started in Dundee 118 and the AIDS charity AVERT was also started.

In the UK, the government launched, in March, the first public information campaign on AIDS, with the slogan "Don't Aid AIDS". There were a series of advertisements in national newspapers.119

There was still at this time disagreement about the name of the virus.

"The name of the virus had itself become a political football as the French insisted on LAV (lymphadenopathy-associated virus), while Gallo's group used HTLV-3 (human T-cell lymphotropic virus, type 3)." - Time Magazine 120

In May 1986, the International Committee on the Taxonomy of Viruses ruled that both names should be dropped and the dispute solved by a new name, HIV (Human Immunodeficiency Virus).121

At the opening speech of the International Conference in Paris, held from 23rd to 25th June 1986, Dr H Mahler, the Director of WHO, announced that as many as 10 million people worldwide could already be infected with HIV.122

In August, the USA Federal Government accused an employer of illegal discrimination against a person with AIDS for the first time. A hospital had dismissed a nurse and refused to offer him an alternative job. This was seen as a violation of his civil rights.123

In September there was dramatic progress in the provision of medical treatment for AIDS, when early results of clinical tests showed that a drug called azidothymidine (AZT) slowed down the attack of HIV. AZT was first synthesised in 1964 as a possible anticancer drug but it proved ineffective.

The AZT clinical trial divided patients into two groups: one received AZT and the other received placebo, or dummy drugs. At the end of six months, only one patient in the AZT group was dead, whilst there were 19 deaths among the placebo group. The clinical trial was stopped early, because it was thought to be unethical to deny the patients of the placebo groups a better chance of survival.124
US surgeons general report on AIDS logo

"The announcement set off a flurry of excitement and controversy. AIDS hotlines and doctors' offices were flooded with calls, community leaders warned about undue optimism, and doctors debated the ethical and medical issues raised by the early cancellation of the AZT study." - Time Magazine 125

In the United States, the Surgeon General's Report on AIDS was published. The report was the Government's first major statement on what the nation should do to prevent the spread of AIDS. The "unusually explicit" report urged parents and schools to start "frank, open discussions" about AIDS.126

By this time, scientists had accumulated enough evidence to form an overview of AIDS in Africa. Studies of medical records showed there had been marked increases in a number of AIDS-related conditions during the late 1970s and early 1980s. In particular:

* Slim disease in Kinshasa, Zaire (late 1970s)
* Slim disease in Uganda and Tanzania (early 1980s)
* Esophagel candidiasis in Rwanda (from 1983)
* Aggressive Kaposi's sarcoma in Kinshasa, Zaire (early 1980s)
* Aggressive Kaposi's sarcoma in Zambia and Uganda (from 1982 and 1983)
* Crypotococcal meningitis in Kinshasa, Zaire (late 1970s to early 1980s).

In conclusion:

"These studies suggested that while isolated cases of AIDS may have occurred in Africa earlier, it was probably rare until the late 1970's and early 1980's, a pattern similar to that in the United States and Haiti."127

As in developed countries, AIDS in Africa was found to primarily affect young and middle-aged people, especially those who were unmarried. The sex and age distributions were seen to reflect other sexually transmitted diseases, and the major transmission routes had been identified:

"Available data suggest that heterosexual activity, blood transfusions, vertical transmission from mother to infant, and probably frequent exposure to unsterilized needles account for the spread of HIV infection and AIDS in Africa."128

HIV and AIDS had also been detected in India, among sex workers in the southern state of Tamil Nadu, igniting fears that the disease would soon spread across the subcontinent. In response, the Indian government decided to increase the number of HIV testing centres and improve the screening of blood donations.129

By the end of the year, 85 countries had reported 38,401 cases of AIDS to the World Health Organisation. By region these were: Africa 2,323, Americas 31,741, Asia 84, Europe 3,858, and Oceania 395.130History of AIDS up to 1986

The Origin of AIDS and HIV May Not Be What You Have Learned

2009-12-03T04:33:00.000-08:00

Most people believe that the origin of HIV, the AIDS virus, derives from some natural evolutionary event. Key among these HIV origin theories is the so called "cut hunter theory" in which a human, allegedly African native, received a bloody wound or infected splash while preparing a chimpanzee carrying a similar virus (i.e., SIVcpz). Most recent research, along with the scientific consensus, holds that the origin of HIV and AIDS could never have happened this way.

In 2001, The Royal Society of London's conference proceedings, which sought to determine the initial cause of AIDS and the origin of HIV, were published for the world to behold. The most highly respected scientists and academicians debated the possibility that HIV-1, the most widespread and deadly human AIDS virus, evolved from accidental vaccine contaminations and subsequent transmissions to mostly African villagers. The oral polio vaccine (OPV) received the focus of interest here since that vaccine was partially derived from growing live polio viruses in monkey kidney cells that have historically proven to be contaminated with cancer viruses such as SV40 -- the 40th monkey virus ever discovered. This virus, like HIV-1, is currently linked by medical scientists to widespread human cancers. By the end of the symposium, the esteemed delegates concluded HIV's origin, and AIDS, was not likely to have come from polio vaccine transmissions as chimpanzees were not proven to have been used during the manufacture of this vaccine

The hepatitis B vaccine was not considered by this esteemed gathering. Suspiciously neglected, this vaccine was produced in chimpanzees during pilot testing conducted in New York City, among gay men, and Central African villagers between 1972 and 1974. This was precisely timed for the emergence of AIDS in these exact, demographically distinct, communities by the late 1970s. The fact that this fact was neglected proves shoddy science or gross negligence at best.

Importantly, among the most respected of all HIV/AIDS origin theorists, the U.S. Government's chief DNA sequence analyst at the Los Alamos Laboratory in New Mexico , Dr. Gerald Myers, reported with his colleagues that the origin of HIV could not have begun with "cut hunters" or other single isolated cross species transmissions (called "zoonosis"). He reported that genetic sequencing studies prove some "punctuated origin of AIDS event" took place during the mid-1970s giving rise, virtually simultaneously, to at least ten different HIV "clades" (or genetic subtypes) associated with ten different distinguishable AIDS epidemics in Africa alone. The most likely cause of this widespread bizarre zoonosis was some man-made (i.e., iatrogenic) event involving chimpanzees.

Myers and his colleagues offered the following best explanation for the origin of HIV: "It is not far-fetched," they wrote, "to imagine the ten or so clades deriving from a single animal (perhaps immunosuppressed and possessing a swarm of variants) [as might have been the case with chimpanzees used in the process of hepatitis B vaccine manufacture] or from a few animals that might have belonged to a single troop or might have been gang-caged together. The number of animals required is secondary to the extent of variation in the source at the time of the zoonotic or iatrogenic event. The [vaccine] hypothesis makes a case for such a punctuated origin . . ." (See: Burr T, Hyman JM and Myers G. The origin of acquired immune deficiency syndrome: Darwinian or Lamarchkian? Phil. Trans. R. Soc. Lond. B (2001) 356:877-887.)

So if chimpanzees were not used to make the polio vaccine, and therefore the origin of HIV and AIDS did not come from this vaccine nor time period (1950s-early 1960s), then what other vaccine, given during the early to mid 1970s, might have used one or more SIVcpz-infected chimpanzees in the manufacturing process?

The answer to this question was singularly advanced by a Harvard-degreed independent investigator, Dr. Leonard Horowitz in the award winning book Emerging Viruses: AIDS & Ebola -- Nature, Accident or Intentional? (Tetrahedron Press, 1998; 1-888-508-4787; http:www.tetrahedron.org) Dr. Horowitz unearthed and reprinted stunning scientific documents and National Institutes of Health contracts proving that chimpanzees, contaminated with numerous viruses, were used to produce hundreds of hepatitis B vaccine doses administered to central African Blacks along with homosexual men in New York City at precisely the time Dr. Myers and colleagues claim the origin of HIV "punctuated event" occurred.

Unfortunately, as another Royal Society conference presenter, Dr. Julian Cribb, protested, too little attention is given by drug-industry-influenced medical journals, and the mainstream media, to controversial truths in science regarding the origin of HIV and AIDS. (See: Cribb J. The origin of acquired immune deficiency syndrome: can science afford to ignore it? Phil. Trans. R. Soc. Lond B (2001) 356:935-938.) As a result, documents such as those published by Dr. Horowitz, and others, showing AIDS apparently derives from contaminated hepatitis B vaccines, have never received adequate attention.

he origin of AIDS and HIV has puzzled scientists ever since the illness first came to light in the early 1980s. For over twenty years it has been the subject of fierce debate and the cause of countless arguments, with everything from a promiscuous flight attendant to a suspect vaccine programme being blamed. So what is the truth? Just where did AIDS come from?

The first recognised cases of AIDS occurred in the USA in the early 1980s (more about this period can be found on our history of aids page). A number of gay men in New York and California suddenly began to develop rare opportunistic infections and cancers that seemed stubbornly resistant to any treatment. At this time, AIDS did not yet have a name, but it quickly became obvious that all the men were suffering from a common syndrome.

The discovery of HIV, the Human Immunodeficiency Virus, was made soon after. While some were initially resistant to acknowledge the connection (and indeed some remain so today), there is now clear evidence to prove that HIV causes AIDS. So, in order to find the source of AIDS, it is necessary to look for the origin of HIV, and find out how, when and where HIV first began to cause disease in humans.
HOW?
What type of virus is HIV?

HIV is a lentivirus, and like all viruses of this type, it attacks the immune system. Lentiviruses are in turn part of a larger group of viruses known as retroviruses. The name 'lentivirus' literally means 'slow virus' because they take such a long time to produce any adverse effects in the body. They have been found in a number of different animals, including cats, sheep, horses and cattle. However, the most interesting lentivirus in terms of the investigation into the origins of HIV is the Simian Immunodeficiency Virus (SIV) that affects monkeys.
So did HIV come from an SIV?
It is now thought that HIV came from a similar virus found in chimpanzees.

It is now generally accepted that HIV is a descendant of a Simian Immunodeficiency Virus because certain strains of SIVs bear a very close resemblance to HIV-1 and HIV-2, the two types of HIV.

HIV-2 for example corresponds to SIVsm, a strain of the Simian Immunodeficiency Virus found in the sooty mangabey (also known as the White-collared monkey), which is indigenous to western Africa.

The more virulent, pandemic strain of HIV, namely HIV-1, was until recently more difficult to place. Until 1999, the closest counterpart that had been identified was SIVcpz, the SIV found in chimpanzees. However, this virus still had certain significant differences from HIV.
What happened in 1999?

In February 1999 a group of researchers from the University of Alabama1 announced that they had found a type of SIVcpz that was almost identical to HIV-1. This particular strain was identified in a frozen sample taken from a captive member of the sub-group of chimpanzees known as Pan troglodytes troglodytes (P. t. troglodytes), which were once common in west-central Africa.

The researchers (led by Paul Sharp of Nottingham University and Beatrice Hahn of the University of Alabama) made the discovery during the course of a 10-year long study into the origins of the virus. They claimed that this sample proved that chimpanzees were the source of HIV-1, and that the virus had at some point crossed species from chimps to humans.

Their final findings were published two years later in Nature magazine2. In this article, they concluded that wild chimps had been infected simultaneously with two different simian immunodeficiency viruses which had "viral sex" to form a third virus that could be passed on to other chimps and, more significantly, was capable of infecting humans and causing AIDS.

These two different viruses were traced back to a SIV that infected red-capped mangabeys and one found in greater spot-nosed monkeys. They believe that the hybridisation took place inside chimps that had become infected with both strains of SIV after they hunted and killed the two smaller species of monkey.

They also concluded that all three 'groups' of HIV-1 - namely Group M, N and O (see our strains and subtypes page for more information on these) - came from the SIV found in P. t. troglodytes, and that each group represented a separate crossover 'event' from chimps to humans.
How could HIV have crossed species?

It has been known for a long time that certain viruses can pass between species. Indeed, the very fact that chimpanzees obtained SIV from two other species of primate shows just how easily this crossover can occur. As animals ourselves, we are just as susceptible. When a viral transfer between animals and humans takes place, it is known as zoonosis.

Below are some of the most common theories about how this 'zoonosis' took place, and how SIV became HIV in humans:
The 'Hunter' Theory

The most commonly accepted theory is that of the 'hunter'. In this scenario, SIVcpz was transferred to humans as a result of chimps being killed and eaten or their blood getting into cuts or wounds on the hunter. Normally the hunter's body would have fought off SIV, but on a few occasions it adapted itself within its new human host and become HIV-1. The fact that there were several different early strains of HIV, each with a slightly different genetic make-up (the most common of which was HIV-1 group M), would support this theory: every time it passed from a chimpanzee to a man, it would have developed in a slightly different way within his body, and thus produced a slightly different strain.

An article published in The Lancet in 20043, also shows how retroviral transfer from primates to hunters is still occurring even today. In a sample of 1099 individuals in Cameroon , they discovered ten (1%) were infected with SFV (Simian Foamy Virus), an illness which, like SIV, was previously thought only to infect primates. All these infections were believed to have been acquired through the butchering and consumption of monkey and ape meat. Discoveries such as this have led to calls for an outright ban on bushmeat hunting to prevent simian viruses being passed to humans.
The Oral Polio Vaccine (OPV) theory
Could production of the oral polio vaccine have contributed to the spread of HIV?

Could production of the oral polio vaccine

have contributed to the spread of HIV?

Some other rather controversial theories have contended that HIV was transferred iatrogenically (i.e. via medical interventions). One particularly well-publicised idea is that polio vaccines played a role in the transfer.

In his book, The River, the journalist Edward Hooper suggests that HIV can be traced to the testing of an oral polio vaccine called Chat, given to about a million people in the Belgian Congo, Ruanda and Urundi in the late 1950s. To be reproduced, live polio vaccine needs to be cultivated in living tissue, and Hooper's belief is that Chat was grown in kidney cells taken from local chimps infected with SIVcmz. This, he claims, would have resulted in the contamination of the vaccine with chimp SIV, and a large number of people subsequently becoming infected with HIV-1.

Many people have contested Hooper's theories and insist that local chimps were not infected with a strain of SIVcmz that is closely linked to HIV. Furthermore, the oral administration of the vaccine would seem insufficient to cause infection in most people (SIV/HIV needs to get directly into the bloodstream to cause infection - the lining of the mouth and throat generally act as good barriers to the virus).4

In February 2000 the Wistar Institute in Philadelphia (one of the original manufacturers of the Chat vaccine) announced that it had discovered in its stores a phial of polio vaccine that had been used as part of the program. The vaccine was subsequently analysed and in April 2001 it was announced that no trace had been found of either HIV or chimpanzee SIV.5 A second analysis confirmed that only macaque monkey kidney cells, which cannot be infected with SIV or HIV, were used to make Chat.6 While this is just one phial of many, it means that the OPV theory remains unproven.

The fact that the OPV theory accounts for just one (group M) of several different groups of HIV also suggests that transferral must have happened in other ways too, as does the fact that HIV seems to have existed in humans before the vaccine trials were ever carried out. More about when HIV came into being can be found below.
The Contaminated Needle Theory

This is an extension of the original 'hunter' theory. In the 1950s, the use of disposable plastic syringes became commonplace around the world as a cheap, sterile way to administer medicines. However, to African healthcare professionals working on inoculation and other medical programmes, the huge quantities of syringes needed would have been very costly. It is therefore likely that one single syringe would have been used to inject multiple patients without any sterilisation in between. This would rapidly have transferred any viral particles (within a hunter's blood for example) from one person to another, creating huge potential for the virus to mutate and replicate in each new individual it entered, even if the SIV within the original person infected had not yet converted to HIV.
The Colonialism Theory

The colonialism or 'Heart of Darkness' theory, is one of the more recent theories to have entered into the debate. It is again based on the basic 'hunter' premise, but more thoroughly explains how this original infection could have led to an epidemic. It was first proposed in 2000 by Jim Moore, an American specialist in primate behaviour, who published his findings in the journal AIDS Research and Human Retroviruses.7

During the late 19th and early 20th century, much of Africa was ruled by colonial forces. In areas such as French Equatorial Africa and the Belgian Congo, colonial rule was particularly harsh and many Africans were forced into labour camps where sanitation was poor, food was scarce and physical demands were extreme. These factors alone would have been sufficient to create poor health in anyone, so SIV could easily have infiltrated the labour force and taken advantage of their weakened immune systems to become HIV. A stray and perhaps sick chimpanzee with SIV would have made a welcome extra source of food for the workers.

Moore also believes that many of the labourers would have been inoculated with unsterile needles against diseases such as smallpox (to keep them alive and working), and that many of the camps actively employed prostitutes to keep the workers happy, creating numerous possibilities for onward transmission. A large number of labourers would have died before they even developed the first symptoms of AIDS, and those that did get sick would not have stood out as any different in an already disease-ridden population. Even if they had been identified, all evidence (including medical records) that the camps existed was destroyed to cover up the fact that a staggering 50% of the local population were wiped out there.

One final factor Moore uses to support his theory, is the fact that the labour camps were set up around the time that HIV was first believed to have passed into humans - the early part of the 20th century.
The Conspiracy Theory

Some say that HIV is a 'conspiracy theory' or that it is 'man-made'. A recent survey carried out in the US for example, identified a significant number of African Americans who believe HIV was manufactured as part of a biological warfare programme, designed to wipe out large numbers of black and homosexual people.8 Many say this was done under the auspices of the US federal 'Special Cancer Virus Program' (SCVP), possibly with the help of the CIA. Linked in to this theory is the belief that the virus was spread (either deliberately or inadvertently) to thousands of people all over the world through the smallpox inoculation programme, or to gay men through Hepatitis B vaccine trials. While none of these theories can be definitively disproved, the evidence given to back them up is usually based upon supposition and speculation, and ignores the clear link between SIV and HIV or the fact that the virus has been identified in people as far back as 1959.
WHEN?

During the last few years it has become possible not only to determine whether HIV is present in a blood or plasma sample, but also to determine the particular subtype of the virus. Studying the subtype of virus of some of the earliest known instances of HIV infection can help to provide clues about the time it first appeared in humans and its subsequent evolution.

Four of the earliest known instances of HIV infection are as follows:

1. A plasma sample taken in 1959 from an adult male living in what is now the Democratic Republic of the Congo.9
2. A lymph node sample taken in 1960 from an adult female, also from the Democratic Republic of the Congo.10
3. HIV found in tissue samples from an American teenager who died in St. Louis in 1969.11
4. HIV found in tissue samples from a Norwegian sailor who died around 1976.12

A 1998 analysis of the plasma sample from 1959 suggested that HIV-1 was introduced into humans around the 1940s or the early 1950s.13

In January 2000, the results of a new study14 suggested that the first case of HIV-1 infection occurred around 1931 in West Africa. This estimate (which had a 15 year margin of error) was based on a complex computer model of HIV's evolution.

However, a study in 200815 dated the origin of HIV to between 1884 and 1924, much earlier than previous estimates. The researchers compared the viral sequence from 1959 (the oldest known HIV-1 specimen) to the newly discovered sequence from 1960. They found a significant genetic difference between them, demonstrating diversification of HIV-1 occurred long before the AIDS pandemic was recognised.

The authors suggest a long history of the virus in Africa and call Kinshasa the “epicentre of the HIV/AIDS pandemic” in West Africa. They propose the early spread of HIV was concurrent with the development of colonial cities, in which crowding of people increased opportunities for transmission. If accurate, these findings imply that HIV existed before many scenarios (such as the OPV and conspiracy theories) suggest.
What about HIV-2? When did that get passed to humans?

Until recently, the origins of the HIV-2 virus had remained relatively unexplored. HIV-2 is thought to come from the SIV in Sooty Mangabeys rather than chimpanzees, but the crossover to humans is believed to have happened in a similar way (i.e. through the butchering and consumption of monkey meat). It is far rarer, significantly less infectious and progresses more slowly to AIDS than HIV-1. As a result, it infects far fewer people, and is mainly confined to a few countries in West Africa.

In May 2003, a group of Belgian researchers led by Dr. Anne-Mieke Vandamme, published a report16 in Proceedings of the National Academy of Science. By analysing samples of the two different subtypes of HIV-2 (A and B) taken from infected individuals and SIV samples taken from sooty mangabeys, Dr Vandamme concluded that subtype A had passed into humans around 1940 and subtype B in 1945 (plus or minus 16 years or so). Her team of researchers also discovered that the virus had originated in Guinea-Bissau and that its spread was most likely precipitated by the independence war that took place in the country between 1963 and 1974 (Guinea-Bissau is a former Portuguese colony). Her theory was backed up by the fact that the first European cases of HIV-2 were discovered among Portuguese veterans of the war, many of whom had received blood transfusions or unsterile injections following injury, or had possibly had relationships with local women.
WHERE?

The question of exactly where the transfer of HIV to humans took place, and where the 'epidemic' officially first developed has always been controversial. Some have suggested that it is dangerous to even try to find out, as AIDS has frequently been blamed on an innocent person or group of individuals in the past. However, scientists remain keen to find the true origin of HIV, as most agree it is important to understand the virus and its epidemiology in order to fight it.
So did it definitely come from Africa?

Given the evidence we have already looked at, it seems highly likely that Africa was indeed the continent where the transfer of HIV to humans first occurred (monkeys from Asia and South America have never been found to have SIVs that could cause HIV in humans). In May 2006, the same group of researchers who first identified the Pan troglodytes troglodytes strain of SIVcpz, announced that they had narrowed down the location of this particular strain to wild chimpanzees found in the forests of Southern Cameroon17. By analysing 599 samples of chimp droppings (P. T. troglodytes are a highly endangered and thus protected species that cannot be killed or captured for testing), the researchers were able to obtain 34 specimens that reacted to a standard HIV DNA test, 12 of which gave results that were virtually indistinguishable from the reactions created by human HIV. The researchers therefore concluded that the chimpanzees found in this area were highly likely the origin of both the pandemic Group M of HIV-1 and of the far rarer Group N. The exact origins of Group O however remain unknown.

HIV Group N principally affects people living in South-central Cameroon, so it is not difficult to see how this outbreak started. Group M, the group that has caused the worldwide pandemic, was however first identified in Kinshasa, in the Democratic Republic of Congo. It is not entirely clear how it transferred from Cameroon to Kinshasa, but the most likely explanation is that an infected individual travelled south down the Sangha river that runs through Southern Cameroon to the River Congo and then on to Kinshasa, where the Group M epidemic probably began.

Just as we do not know exactly who spread the virus from Cameroon to Kinshasa, how the virus spread from Africa to America is also not entirely clear. However, recent evidence suggests that the virus may have arrived via the Caribbean island of Haiti.
Why is Haiti significant?

The AIDS epidemic in Haiti first came to light in the early 1980s, at around the same time that cases in the USA were being uncovered. Following the discovery of a number of Haitians with Kaposi's Sarcoma and other AIDS-related conditions, medical journals and books began to claim that AIDS had come from Haiti, and that Haitians were responsible for the AIDS epidemic in the United States.

These claims, which were often founded on dubious evidence, fuelled pre-existing racism in the US and many Haitians suffered severe discrimination and stigmatisation as a result. A large number of Haitian immigrants living in the US lost their jobs and were evicted from their homes as Haitians were added to homosexuals, haemophiliacs and heroin users to make the 'Four-H Club' of groups at high risk of AIDS.18

The emotionally-charged culture of blame and prejudice that surrounded HIV and AIDS in the early years meant that it soon became politically difficult to present epidemiological findings in a neutral and objective way. For many years the link between Haiti and the US epidemic was therefore dropped as a subject.

In March 2007 however, it returned to the public eye at the Fourteenth Conference on Retroviruses and Opportunistic Infections (CROI) in Los Angeles. A group of international scientists presented data based on complex genetic analysis of 122 early samples of HIV-1, group M, subtype B (the most common strain found in the USA and in Haiti) showing that the strain had probably been brought to Haiti from Africa by a single person in around 1966; a time when many Haitians would have been returning from working in the Congo.19

Genetic analysis then showed that subtype B spread slowly from person to person on the island, before being transferred to the US, again probably by a single individual, at some point between 1969 and 1972. A paper published in October 2007 by Worobey and colleagues gave a 99.7% certainty that HIV subtype B originated in Haiti before passing to the US.20

It is possible that HIV had entered the US several times before subtype B took a firm hold (which would explain the infection of the St. Louis teenager in the early to mid-1960s), but it was the late 1960s / early 1970s transfer that is believed to be responsible for the widespread epidemic seen in the US today. Once the virus had established itself in the gay community, in would have spread fairly rapidly (anal intercourse carries a very high transmission risk), with transmission occurring within and between the US and Haiti, and internationally, until the original route taken by the virus was largely obscured.

Dr Michael Worobey, lead researcher in the study, claimed that his data was not intended to place any blame on Haiti, or on Central Africans, and stressed that none of the people who first transmitted HIV would have been aware they were infected. His work still received strong protests from one Haitian delegate at the CROI conference however, demonstrating the extent to which tracing HIV’s origins remains a politically sensitive exercise.
What caused the epidemic to spread so suddenly?

There are a number of factors that may have contributed to the sudden spread of HIV, most of which occurred in the latter half of the twentieth century.
Travel
International travel has undoubtedly played a major role in the spread of HIV.

International travel has undoubtedly played

a major role in the spread of HIV.

Both national and international travel undoubtedly had a major role in the initial spread of HIV. In the US, international travel by young men making the most of the gay sexual revolution of the late 70s and early 80s would certainly have played a large part in taking the virus worldwide. In Africa, the virus would probably have been spread along truck routes and between towns and cities within the continent itself. However, it is quite conceivable that some of the early outbreaks in African nations were not started by Africans infected with the 'original' virus at all, but by people visiting from overseas where the epidemic had been growing too. The process of transmission in a global pandemic is simply too complex to blame on any one group or individual.

Much was made in the early years of the epidemic of a so-called 'Patient Zero' who was the basis of a complex "transmission scenario" compiled by Dr. William Darrow and colleagues at the Centre for Disease Control in the US. This epidemiological study showed how 'Patient O' (mistakenly identified in the press as 'Patient Zero') had given HIV to multiple partners, who then in turn transmitted it to others and rapidly spread the virus to locations all over the world. A journalist, Randy Shilts, subsequently wrote a book21 based on Darrow's findings, which named Patient Zero as a gay Canadian flight attendant called Gaetan Dugas. For several years, Dugas was vilified as a 'mass spreader' of HIV and the original source of the HIV epidemic among gay men. However, four years after the publication of Shilts' article, Dr. Darrow repudiated his study, admitting its methods were flawed and that Shilts' had misrepresented its conclusions.

While Gaetan Dugas was a real person who did eventually die of AIDS, the Patient Zero story was not much more than myth and scaremongering. HIV in the US was to a large degree initially spread by gay men, but this occurred on a huge scale over many years, probably a long time before Dugas even began to travel.
The Blood Industry

As blood transfusions became a routine part of medical practice, an industry to meet this increased demand for blood began to develop rapidly. In some countries such as the USA , donors were paid to give blood, a policy that often attracted those most desperate for cash; among them intravenous drug users. In the early stages of the epidemic, doctors were unaware of how easily HIV could be spread and blood donations remained unscreened. This blood was then sent worldwide, and unfortunately most people who received infected donations went on to become HIV positive themselves.

In the late 1960's haemophiliacs also began to benefit from the blood clotting properties of a product called Factor VIII. However, to produce this coagulant, blood from hundreds of individual donors had to be pooled. This meant that a single donation of HIV+ blood could contaminate a huge batch of Factor VIII. This put thousands of haemophiliacs all over the world at risk of HIV, and many subsequently became infected with the virus.
Drug Use

The 1970s saw an increase in the availability of heroin following the Vietnam War and other conflicts in the Middle East , which helped stimulate a growth in intravenous drug use. This increased availability and together with the development of disposable plastic syringes and the establishment of 'shooting galleries' where people could buy drugs and rent equipment, provided another route through which the virus could be passed on.
CONCLUSIONS

It is likely that we will never know who the first person was to be infected with HIV, or exactly how it spread from that initial person. Scientists investigating the possibilities often become very attached to their individual 'pet' theories and insist that theirs is the only true answer, but the spread of AIDS could quite conceivably have been induced by a combination of many different events. Whether through injections, travel, wars, colonial practices or genetic engineering, the realities of the 20th Century have undoubtedly had a major role to play. Nevertheless, perhaps a more pressing concern for scientists today should not be how the AIDS epidemic originated, but how those it affects can be treated, how the further spread of HIV can be prevented and how the world can change to ensure a similar pandemic never occurs again.

Risk factors for HIV/AIDS

2009-12-02T03:06:00.001-08:00

In HIV negative individuals

*
Education regarding HIV/AIDS- Regarding routes of transmission of HIV
*
To know the HIV status of any sexual partner
*
To use latex condoms every time you have sex if the HIV status of the partner is unknown
*
Male circumcision- a study conducted has showed 53 percent reduction of HIV infection in circumcised HIV-negative men compared with uncircumcised men
*
Use sterile disposable needles- not to share needles and syringes
*
Blood and blood products always need to be HIV screened
*
Regular screening tests- if you're a man or woman, who has had sex with one or more new partners, are tested annually.

In HIV positive individuals

*
Avoid sexual practices that expose them to blood, semen or vaginal secretions.
*
Using a new latex condom every time you have vaginal or anal sex and using a dental dam, condom or piece of plastic wrap during oral sex
*
Don’t share needles and syringes
*
Don’t donate blood or organs
*
Don’t share razor blades or tooth brushes
*
If your partner is pregnant, tell her you have HIV - She needs to receive treatment to protect her own health and that of her baby.

Safer sex

*
Safer sex is sex between 2 people who don't have HIV infection or any STDs
*
Only have sex with each other
*
Not using injectable drugs
*
Using male latex condoms if you have any doubts about whether your partner is infected or whether he or she is having sex with someone else.
*
If a man doesn't want to use a male condom, use a female condom. Female condoms may not be as effective as male condoms, but they offer some protection.
*

isk factors for HIV/AIDS

Unprotected sexual intercourse

*
Unprotected vaginal, anal or oral sex with multiple partners (heterosexual, homosexual or bisexual)
*
Unprotected sex with HIV-positive partner
*
During sex, HIV can be transmitted through cuts and tears on the penis, vagina, or anus.
*
Through these cuts and tears, infected blood, semen, vaginal fluids, and anal fluids may enter the uninfected person's body.
*
Cuts and scrapes are more likely during anal sex, forced sex, dry sex, or when women are very young (because their cervixes are not fully developed and therefore more likely to rip or tear during intercourse).

Role of STD’s in HIV/AIDS

Increased susceptibility

STDs probably increase susceptibility to HIV infection by two different mechanisms.

*
Genital ulcers (e.g., syphilis, herpes, or chancroid) result in breaks in the genital tract lining or skin. These breaks create a portal of entry for HIV.
*
Non-ulcerative STDs (e.g., chlamydia, syphilis, herpes, gonorrhea, and trichomoniasis) increase the concentration of cells in genital secretions that can serve as targets for HIV (e.g., CD4+ cells).

Increased infectiousness

When HIV-infected individuals are also infected with other STDs, they are more likely to have HIV in their genital secretions.

HIV in semen is as much as 10 times higher in men who are infected with both gonorrhea and HIV than in men infected only with HIV.
Unsafe drug abuse behaviors

*
Sharing or injecting drug use paraphernalia, such as needles and syringes, increases the risk of HIV transmission.
*
People who use illegal injectable drugs are also more likely to have STI/STD, which increase their risk for both contracting and transmitting HIV.
*
Mixing sex, drugs and alcohol interact in many ways to increase a person's risk of getting or giving HIV.
*
The use of these substances can increase sexual desire and enhance underlying personality characteristics, such as and sexual compulsivity.

Blood transfusion

Blood transfusion or received blood a blood clotting factors before 1985.
Mother- to- fetus/infant transmission (vertical transmission)

*
Infants are infected with HIV, either during pregnancy or delivery or through breast-feeding.
*
But if women receive treatment for HIV infection during pregnancy, the risk to their babies is significantly reduced.
*
Pregnant women who are HIV-infected and who are co-infected with genital herpes have a higher risk of transferring AIDS to their child.

Psychological risk factors

*
Psychological disorders such as hypersexuality, sexual obsession, and depression, are associated with high-risk sexual behaviors with multiple partners.
*
They are also associated with drug abuse and addiction, which can increase HIV risk through needle sharing and injection

HIV/AIDS is not transmitted by hugging, kissing, dancing or shaking hands — with someone who has HIV or AIDS.
Not to enter blood, semen, urine, vaginal fluid or feces get into anus, vagina or mouth, in HIV infected individuals

Prevention of AIDS

2009-12-02T03:06:00.000-08:00

HIV infection finally leads to the development of the AIDS. After the HIV infection it takes some years for the AIDS to set in. Once a patient starts getting opportunistic infections then the stage is termed as Acquired Immune Deficiency Syndrome (AIDS). It is a very dangerous disease and there is no vaccine and definitive treatment available for the effective protection and treatment of the disease. Therefore the prevention is only cure for the disease. The transmission of the disease will be by blood, semen, vaginal secretions and breast milk into the body. Measures to prevent HIV infection are -

* Education is the most important tool to improve the social awareness regarding the disease and is the effective mean to prevent the transmission.
* Before going for unprotected sex HIV status of the partner should be confirmed.
* New condom should be used every time the vaginal or anal sex is performed. Old condom should be thrown away and should not be repeated at all. One can chose from polyurethane or latex condoms. Females can also use female condoms. One should not use oil based lubricant along with the latex condoms as they tend to weaken the condom. Along with latex condoms only water based lubricants should be used. While doing oral sex, flavored condoms, dental dam or plastic wrap can be used.
* Male circumcision reduces a man's risk of acquiring HIV through heterosexual intercourse by more than 50%. Medically performed circumcision although carries a lot of other benefits also.
* Drug users should use new needle every time to inject the drug.
* Blood or blood products transfusion should be taken into account only after ensuring personally that the product is free from HIV. One should not only rely on the blood bank but he/she should check the certificate of the laboratory themselves.
* If someone has multiple sexual partners than he/she shall take the tests yearly to rule out any infection. Like women are advised Pap smear yearly.
* Although the number of deaths have decreased due to the AIDS by the newer drugs available in the market and due to the latest modalities of treatment but still one should keep in mind that AIDS is not curable and there is no vaccine available for the HIV yet.
* HIV infected persons should always follow the safe sex practices and should take effective protection so that they will not pass on infection to others.
* All the partners of HIV infected person need to be tested and if positive then they will need the proper medical care.
* Pregnant lady if infected with HIV should take appropriate treatment so that the transmission of the disease to the fetus is prevented.
* HIV infected person should not share needles or syringes, donate blood or organs, share razor blades or toothbrushes to prevent the effective transmission of the virus to others.

The ‘ART’ of managing HIV

2009-12-02T03:04:00.001-08:00

HIV is one of the greatest public health challenges the world is facing today. However, the response mankind mounted against this epidemic is historic. There is no other disease in the history which provoked such a comprehensive, prompt and effective response within a short span of time.

When HIV first struck in the world, the virtual absence of any hope regarding possible treatment or vaccine led to widespread scare, stigma and discrimination against the infected. The only measure we could take was spreading preventive messages.

But by 1996, we had an effective drug therapy which could bring back the lost immunity by suppressing the virus in the human body. From a death sentence, it changed to a chronic manageable disease. India started its Antiretroviral Programme with just eight ART centres in high prevalence States and the national capital in 2004 which grew to 224 full-fledged ART centres providing regular ART to more than 2,70,000 individuals today. It is worth mentioning that Kerala has achieved a unique distinction for starting its own ART programme in 2004 by providing free ART through all Government Medical Colleges which has been merged with the national programme now. Currently, the State has six ART centres and eight Link Art Centres. 4,018 People Living with HIV (PLHIV) are taking ART drugs from our centres, which are branded as Ushus Centres, for awareness purposes. 11,024 PLHIVs have registered themselves at the Ushus Centres for whom regular check-ups are provided. The availability of ART through the public healthcare system has changed the way world looked at HIV. It gradually became a chronic manageable disease. The mortality rate of HIV has suddenly reduced.

Earlier, the drug regime was complicated. Now it has been simplified, which helps the treatment adherence. Management of opportunistic infections for PLHIVs have helped them to gather confidence for a positive living. All these have increased the quality of living of PLHIVs. This led to large number of people who are at the risk of having this infection to come openly seeking HIV tests.

HIV is a developmental issue and several studies so far from various parts of the world have showed that HIV care has a role in the macro and micro economy of the society. For example, a study at the Thrissur Medical College showed that 74 percent of PLHIVs taking ART are employed at 10 months of ART and many of them got employed for the first time after the initiation of ART.

It is also possible that ART can reduce the transmission significantly, as the virus circulating in the blood reduces to undetectable level in few months of regular treatment. Also, ART can reduce the chance of a person - a healthcare provider getting infected during a surgery or a child getting infected from the mother. Proper care during pregnancy can reduce the transmission rate from mother to child to less than 2 percent from 30-40 percent without care. Even though we have many success stories, it is not the time to be complacent.

The recently published AIDS epidemic update by UNAIDS and WHO shows that even though there is a significant fall in new infections worldwide since 2006, the epidemic is still evolving and even the factors affecting the spread is not uniform.

Stigma and discrimination continue to be a big stumbling block in providing quality care and support services. Human rights violations in the name of HIV is also continuing. Hence, this World AIDS Day is the time for us to renew our pledge and promises we have made to the present and future generations.

The Impact of HIV/AIDS

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Over the past 27 years, nearly 25 million people have died from AIDS.1 HIV/AIDS causes debilitating illness and premature death in people during their prime years of life and has devastated families and communities. Further, HIV/AIDS has complicated efforts to fight poverty, improve health, and promote development by:2

* Diminishing a person’s ability to support, work and provide for his or her family. At the same time, treatment and health-care costs related to HIV/AIDS consume household incomes. The combined effect of reduced income and increased costs impoverishes individuals and households.

* Deepening socioeconomic and gender disparities. Women are at high risk of infection and have few options for providing for their families. Children affected by HIV/AIDS, due to their own infection or parental illness or death, are less likely to receive an education, as they leave school to care for ailing parents and younger siblings.

* Straining the resources of communities – hospitals, social services, schools and businesses. Health care workers, teachers, and business and government leaders have been lost to HIV/AIDS. The impact of diminished productivity is felt on a national scale.

Through unprecedented global attention and intervention efforts, the rate of new HIV infections has slowed and prevalence rates have leveled off globally and in many regions. Despite the progress seen in some countries and regions, the total number of people living with HIV continues to rise.

* In 2007, globally, about 2 million people died of AIDS, 33 million were living with HIV and 2.7 million people were newly infected with the virus.1

* HIV infections and AIDS deaths are unevenly distributed geographically and the nature of the epidemics vary by region. Epidemics are abating in some countries and burgeoning in others. More than 90 percent of people with HIV are living in the developing world.3

* There is growing recognition that the virus does not discriminate by age, race, gender, ethnicity, sexual orientation, or socioeconomic status – everyone is susceptible. However, certain groups are at particular risk of HIV, including men who have sex with men (MSM), injecting drug users (IDUs), and commercial sex workers (CSWs).

* The impact of HIV/AIDS on women and girls has been particularly devastating. Women and girls now comprise 50 percent of those aged 15 and older living with HIV.1

* The impact of HIV/AIDS on children and young people is a severe and growing problem. In 2007, 370,000 children under age 15 were infected with HIV and 270,000 died of AIDS.1, 4 In addition to the estimated 2 million children living with HIV/AIDS, about 15 million children have lost one or both parents due to the disease.1, 4

* There are effective prevention and treatment interventions, as well as research efforts to develop new approaches, medications and vaccines.

* The sixth Millennium Development Goal (MDG) focuses on stopping and reversing the spread of HIV/AIDS by 2015.

* Global funding is increasing, but global need is growing even faster – widening the funding gap. Services and funding are disproportionately available in developed countries.

Growing Up with HIV

2009-12-02T02:52:00.000-08:00

LUSAKA, Dec 1 (IPS) - Sixteen-year-old Andela Milambo* wants a husband. She is not looking for love, but for someone to share the burden of living with HIV. She wants to be able to take her medicine without having to hide, to discuss the recurring herpes with someone who understands.

Living with HIV since the age of six, she wants someone else to make the decisions, "while I read a magazine."

Milambo, says she got infected through a contaminated needle. She describes a life dominated by the fear of dying from AIDS but says the worst times are when she gets herpes flare-ups that make it hard to walk, talk or eat.

She skips school often due to "small illnesses" like colds which are usually accompanied by a bad cough that debilitate her body. Her grades are bad and she has little hope of obtaining a full certificate when she completes secondary school next year. "But that's alright, I was not intending to go to college anyway."

She has made no lasting friendships for fear that people will find out her HIV status. While her parents and a few close relatives who know her condition try to offer support, they actually make things worse, she says.

"I see them just age in front of me when I am sick, they get so stressed and sad, I prefer to suffer in silence."

She hears how young people talk about HIV and AIDS and the level of discrimination and ignorance frightens her. "I can never confide in a young person that I am positive, the stigma would kill me faster than AIDS."

Milambo envies other young girls going to movies, laughing, dancing. She has no time for that, she says, because she has to work to save her life. Instead she does "boring" things like peer education for her local clinic.

Rather wryly, she says, "Though I say it's boring, the clinic is the one place I feel comfortable at. As a peer educator I have the run of the place with no questions asked. So treatment and information for me is free and easy to get."

It is also the place Milambo is looking for a husband. "Men at the clinic are knowledgeable and because they work around HIV, they are compassionate. When I turn 18 I will choose one. As head of household, my husband will make the decisions regarding our welfare, while I watch television or read a fashion magazine… being married would make me a "proper person" because everyone aspires to be married, at least that's the one thing I can achieve."

James Banda also wants a normal life. The eighteen-year-old is openly living with HIV and confines himself to dating HIV positive girls because he hates having to explain to every new girl why he has to take pills on a regular basis. The girls usually run away from him after that, he says. "The ones that stick around see me as a charity challenge and I am their good Christian deed."

Infected with HIV on his first sexual encounter, his life's mission now is to find a girl with whom he can have a child.

Banda says after his diagnosis he did things "by the book."

"I went for rigorous counseling, came out in a big way, telling anyone that would listen about my status, I did the whole nine yards. I was celebrated by NGOs who made me the poster boy of an HIV positive youth. But after a while, the novelty wore off and I got tired of always talking about HIV as if that's what defines me."

He says there are times when he wishes he had not disclosed his status. Like when he goes to a disco and people come up to him to caution him not to drink, or whisper that he shouldn't be there, that he has not "learnt his lesson."

"The books on living positively with HIV says I should continue to live as much of a normal life as possible. The reality is different; there can never be anything normal about my life."

Bouts of opportunistic infections, always being on the lookout for a cure or better therapy, not being able to plan ahead ten or even twenty years are some of the things that make his life abnormal, Banda says.

Having passed his school leaving exams with distinction, he is going to college next year to study accounting. He says he has it all; the support of his family, a few good friends and good future prospects. But living with HIV "is still damn hard."

Living with HIV in secrecy is what is harder still for Adam Malik*.

Drinking himself "senseless once in a while" is how Malik copes with his situation. A Zambian of Indian extraction, he lives in the close knit community that refuses to acknowledge HIV in their midst and openly stigmatises people with HIV.

Eighteen-year-old Malik knows this only too well, that's why not even his parents know that he contracted HIV at the age of 14 from the house maid with whom he had a sexual relationship for over a year, and has recently started treatment.

Malik says because he has always been a quiet solitary kind of person, no one notices when he is depressed or feeling unwell. He has not suffered any of the major opportunistic infections.

But, he adds: "Keeping such a secret is a heavy burden. I suffer tension headaches and have developed a facial tick from the stress."

Malik says he is fortunate Zambia has an efficient roll out for ARVs. He was surprised how easy it was to get onto the programme. Of course he chose an out of the way clinic where no one was likely to recognise him.

He reads up on the latest treatments but does not go for counseling as he is scared of being recognised.

Malik is also frightened that he will be coerced into jumping onto the HIV conference circuit as a young HIV positive Indian male. "I will be a novelty that the AIDS activists will not be able to resist. They will show me around like a trophy. I have seen it happen to youth who have come out."

His life on the outside has not changed, he says. He is still the good son, taking his mother and sisters shopping, helping his father in the family store, hanging out with the boys on a Friday night.

Soon a wife will be chosen for him and he will be expected to have children, he says. He wonders what will happen then. "It will kill my mother to know that I have HIV. My father will kick me out of his home. My sisters' chances of a good marriage will be ruined. When I think of all this, I hit the bottle to forget."

He knows that this will interfere with the efficacy of his medication, but finds it's the only way he can cope. "I am frightened," Malik says