On the occasion of the thirtieth anniversary of AIDS
On the 5th of June 1981, I finished working an emergency room shift in Canada and prepared to board a plane to take me to my first job in Asia. On that day an American epidemiology report was published that described opportunistic infections in a group of gay men. These were the first case reports of AIDS.
As the thirtieth anniversary of AIDS is marked later this week, we will be bombarded with stories about the HIV pandemic in the mass media. Successes and failures will be noted. The propaganda machine will be running twenty-four hours. Perhaps this is a good time for me to look at some of my own failures and mistakes over the last three decades.
In the late eighties, as patients and people I knew were dying around me, I assumed that everyone who had HIV infection would die of AIDS. I was wrong. Most did, but not all. One of my first patients was a boy of two who lost everyone in his family to the disease. But he is alive today. And a relative was infected in the mid eighties but is still going strong. Both of them have antiretroviral treatment to thank for their survival.
The fifth International AIDS Conference began in Montreal a day after the Tiananmen Square uprising was crushed in Beijing. There I heard for the first time the theory that combination therapy with several antiretroviral medications might cure the disease. I believed this, but I was wrong again. There is still no cure for HIV infection. It was also at the Montreal conference that I heard first hand stories of HIV in Africa.
When the initial deaths of people who use drugs were reported in Vietnam a few years later and a heroin epidemic spread quickly throughout the country, I thought that the HIV epidemic among drug users would quickly burn itself out. I thought the old shooters would die and couldn't believe that young ones who knew about HIV would share needles. I was very wrong about this. HIV continues to spread among young people who inject drugs in Vietnam and around the world. Sharing injecting equipment is still a major mode of transmission in many Asian countries, Eastern Europe, Central Asia, and now eastern Africa. Most people who use drugs are treated as useless human beings by their families, communities, and governments. In Myanmar the number of new HIV infections among people who use drugs is still high and has been out of control for over ten years.
For a few years I bought the UNAIDS party line that large multisectoral multiministerial National AIDS Committees were needed by every country and that mass mobilisation would help to stem the epidemic. I was wrong. Large National AIDS Committees dilute responsibility, eat up financial and human resources, create tension with health authorities, and use top down methods that often do more harm than good. One or two leaders with small secretariats could do a better job. Will UNAIDS continue to advocate for big National AIDS Committees? The joint programme is in financial trouble and many expatriate jobs will be eliminated or downgraded soon. Activists can achieve much more than National AIDS Committees or the UN the joint programme.
I was also, for a while, filled with faith that health sector National AIDS Programmes might produce results. But they didn't. They only create the environment for change and leave it to other institutions to do the heavy lifting. In Myanmar the only programmes implemented by the National AIDS Programme are the ineffectual Prevention of Mother to Child Transmission programme, sometimes called the Test Fest, and the almost nonexistent 100% Condom Use Programme or whatever euphemism is currently used for it. I also discovered that new infections in Cambodia had begun to decrease five years before (!) their National AIDS Programme began to scale up activities.
Global incidence is decreasing. New infections are less common than they were a few years ago. So programmes today are "riding the epidemiological downslope to glory". Unless, of course, I am wrong about that, too.
The [him] moderator
June 2011
