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Ninety-five percent of these infections and deaths have occurred in developing countries. Sub-Saharan Africa is home to almost 64 percent of the estimated 38.6 million persons living with HIV infection (see Figure 1). In this region, women represent 60 percent of those infected and 77 percent of newly infected persons 15 to 24 years of age.2
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This crisis demanded a unique and truly global response to meld the resources, political power, and technical capacity of wealthy countries with the needs and capacities of developing countries. Such a response would have required policymakers to address taboos concerning sexual behavior, drug use, power relations between the sexes, poverty, and death. Instead, AIDS often engendered stigma, discrimination, and denial, because of its association with marginalized groups, sexual transmission, and lethality. The result was two decades of a slow, insufficient, inconsistent, and often inappropriate response.
In 1987, six years into the pandemic, the World Health Organization (WHO) established the Global Program on AIDS. This program, of which I was executive director from 1990 to 1995, raised awareness about the pandemic; formulated evidence-based policies; provided technical and financial support to countries; initiated relevant social, behavioral, and biomedical research; promoted participation by nongovernmental organizations; and championed the rights of those living with HIV. Among other efforts, the program provided assistance to two countries — Uganda and Thailand — that successfully reversed their epidemics.
Despite its achievements, the Global Program on AIDS was unable to muster the necessary political will in donor and affected countries, and its effectiveness was compromised by rivalries with other United Nations (U.N.) organizations, concern about the senior leadership of the WHO, and an increasing preference of wealthy governments for bilateral aid programs. So in 1996, the program was replaced by the Joint United Nations Programme on HIV/AIDS (UNAIDS), initially cosponsored by 6 U.N. agencies (now 10), with a mandate to lead an expanded, better-coordinated, multisectoral global response. UNAIDS found this task difficult. Its resources were limited, and resolving strategic conflicts among U.N. partners proved nearly impossible. Moreover, wealthy countries became disenchanted with the U.N. system and, as their own AIDS-related mortality declined, disengaged from the global response to the pandemic.
Then, around the turn of the millennium, four key developments inspired a new receptivity to the advocacy of UNAIDS. First, the World Bank became more active in AIDS-related lending, increasing its commitments from $500 million in 1998 to $2.7 billion today, much of it for sub-Saharan Africa. Second, in 2000, the XIII International AIDS Conference, in Durban, South Africa, raised global public consciousness about Africa's upward-spiraling AIDS-related mortality and the need for accessible, affordable antiretroviral drugs. Around the same time, Brazil reported that its use of antiretroviral drugs had dramatically reduced AIDS-related mortality and hospitalizations, providing hope for other developing countries. Emboldened nongovernmental organizations then agitated for the purchase of lower-cost, generic antiretroviral drugs and price reductions for brand-name products, while the Doha Declaration concerning the Agreement on the Trade-Related Aspects of Intellectual Property Rights and Public Health permitted broader access to antiretroviral drugs.
Third, politically powerful religious groups, particularly in the United States, that had long been reluctant to support condom distribution and other sex-related prevention programs embraced the need for global treatment, largely in order to reduce the numbers of children being orphaned by AIDS. And fourth, the spread of HIV into Russia, China, and India prompted concern that AIDS could destabilize global political and economic systems beyond sub-Saharan Africa, threatening global security.
These developments generated a long-needed enhanced response. Shortly after the Organization of African Unity declared the AIDS situation in Africa a state of emergency, U.N. Secretary-General Kofi Annan convened a U.N. Special Session on HIV/AIDS in June 2001. There, political leaders from 180 governments adopted a declaration of commitment that set program targets for affected countries and funding levels for donor governments.3 Soon thereafter, the multilateral Global Fund to Fight AIDS, Tuberculosis and Malaria was established to provide money rapidly for country-owned initiatives. As of March 2006, the fund had committed $5.2 billion to 131 countries, 57 percent of it for AIDS programs.
In January 2003, the U.S. government announced the President's Emergency Plan for AIDS Relief, through which it pledged $15 billion over a period of five years to prevention, treatment, and care, with a focus on 15 countries that are home to 80 percent of the people requiring treatment. Later that year, the WHO announced its intent to extend AIDS treatment to 3 million persons in the developing world by 2005. This "3 by 5" initiative fell short of its target but resulted in antiretroviral-drug treatment for 1.3 million patients (see Figure 2), preventing an estimated 250,000 to 350,000 deaths. In 2005 alone, $8.3 billion was spent on AIDS — about 30 times as much as at the creation of UNAIDS.2
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There is also a need for research on new approaches to prevention. Adult male circumcision, preexposure antiretroviral prophylaxis against sexual transmission in high-risk populations, acyclovir treatment for herpes simplex virus type 2, and microbicidal agents all hold promise. Although a preventive vaccine has been elusive, there is optimism that one will be developed within a decade.
Better international coordination remains imperative. Donors must align their assistance with and support robust, nationally led strategies, policies, and plans. UNAIDS should continue to enhance its coordination, technical support, monitoring, and leadership.
A quarter century into the pandemic, the global response stands at a crossroads. More new infections and deaths occurred in 2005 than ever before. A year ago, the Group of 8 (G8) countries and the U.N. World Summit embraced the goal of implementing "a package for HIV prevention, treatment and care, with the aim of as close as possible to universal access to treatment . . . by 2010."5 Such a package will require more resources — an estimated $18.1 billion in 2007 and $22.1 billion in 2008.2 As AIDS becomes a chronic disease, this funding must be used in part to strengthen fragile health care systems. The progress of the past five years provides a solid foundation on which to build the comprehensive and sustainable response vital to ultimate control of this pandemic. Without this response, many millions more will die of AIDS or be catastrophically affected by its consequences.
Source Information
Dr. Merson is a professor at the Yale School of Public Health, New Haven, Conn., and director of Yale's Center for Interdisciplinary Research on AIDS.
An interview with Dr. Merson is available at www.nejm.org.
An interactive AIDS timeline is available with the full text of this article at www.nejm.org.
References
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