Epidemiology, social, cultural and political
1School of Social Work, Bar-Ilan University, Ramt-Gan and Hadassah Medical Organization, Jerusalem, Israel
2The Thailand MOPH - US CDC Collaboration, DMS 6 Building, Ministry of Public Health, Nonthaburi, Thailand.
3Correspondence to Dr. Varda Soskolne, School of Social Work, Bar-Illan University, 52900 Ramat-Gan, Israel. Tel: ++972 3 5317806; fax:++972 3 5347228.
The course of HIV/AIDS in different parts of the world during the past year has intensified two main issues. First, how do political and economic forces shape the rapidly growing HIV epidemics in Asia and Eastern Europe and the response to the continued increase of HIV infection in the hardest-hit countries in Africa? Second, with the resurgence of sexually transmitted diseases (STD) and HIV incidence rates in major cities in Western countries , what are the longer term consequences of highly active anti retroviral therapy (HAART) on the incidence of HIV infection and on the clinical epidemiology of AIDS as a chronic disease?
The review papers in this section outline these issues from several perspectives. Gorbach, Ryan, Saphonn and Detels outline how societal factors — influence social and individual risk behaviors that shape the emerging epidemics in Russia, China and Vietnam. Withi the specific political context of each country, the task of prevention is enormous. Prevention programs cannot work unless the community makes them work. Yet these countries, even where there is a political will and national commitment to control the epidemic, have little experience in community mobilization, and need to adapt proven successful interventions to their cultural and social circumstances in order to aver the disastrous prospects of a large scale epidemic. Schneider and Fassin's review of the mother-to-child transmission (MTCT) prevention policy in South Africa provides another perspective of the impact of socio-political forces on the HIV epidemic. The global interest in the politics of AIDS in South Africa may arise from the desire to understand why one of the richest countries in Africa has such a severe HIV epidemic. Yet, the authors assert that the global criticism of South Africa's HIV policy, as stemming from denial, is often the result of insufficient understanding of the socio-political context in which decisions have been made. They review and analyze the recent developments around MTCT within the complex political changes that have occurred in South Africa to show how social activism and other internal pressures led to changes in policy.
While the debate over allocation of resources to prevention or to medical care in Africa  will probably continue, Opuni, Bertozzi, Izazola, Gutierrez and McGreevey review detailed information on resource allocation to HIV/AIDS in developing countries. Data from several studies in Latin America and the Caribbean using the National Health Accounts framework show the great variability between countries in this region, not only in total HIV/AIDS expenditures, but also in the proportion of expenditure on prevention. Additionally, data from two other major studies estimating resource needs in low- and middle-income countries for the years 2005 and 2007, show large discrepancies between estimates and current expenditures. Such gaps reflect the urgency in strengthening the quality of HIV/AIDS financing data in developing countries in order to provide policy makers with consistent data on the scale of resources required for prevention and care.
The accumulating information on the longer-term impact of HAART is presented from several perspectives. The changing clinical epidemiology of AIDS in Western countries reviewed by Sabin shows not only the changing patterns of AIDS defining events, the impact on mortality and on use of health services, but also the newer characteristics of persons with AIDS. Symptomatic HIV infection and AIDS now more often occurs at higher CD4 levels, and greater proportions of cases are women. The review raises the important question why people continue to develop AIDS despite the availability of HAART, and highlights the information and caveats in knowledge on medical and socio-demogrpahic factors associated with disease progression.
The growing proportion of long-term survivors requires better understanding of psychosocial implications of living with AIDS as a chronic disease. Siegel and Lekas review recent information within the chronic disease conceptual framework. The diverse general and AIDS-specific psychological reactions and social consequences of the disease in the post-HAART era have significant influence on patients' treatment decision making process. However, less is known about impact of HAART on maintenance of safe behaviors by people with HIV/AIDS. Together with inconclusive research on the impact of changing perceptions of AIDS and ‘HIV optimism’ [3,4] on risk behaviors of people at risk for HIV more research is inevitable.
The last review by Knodel and VanLandingham directs the attention to another population affected by HIV/AIDS, but which has been widely neglected in social science research: elderly parents of adult people living with HIV. The results of their study in Thailand and the scant information available from Africa demonstrate the major caregiving tasks carried out by aging parents and the emotional distress, economic, health and social consequences due to caregiving and death of the adult child with HIV. While AIDS orphans have received considerable attention, additional research and interventions are needed to enable AIDS parents to manage these major problems, particularly in developing countries.
The conclusions from these reviews highlight the pressing prevention challenges facing countries and communities around the world. The recent epidemics should be a warning sign for other countries undergoing similar political and social changes, like the republics of the former Soviet Union in Central Asia, or post-Taliban Afghanistan. More prospective research and rigorous prevention interventions are needed for communities in which HAART is available. Different psychosocial consequences specific to women or to serodiscordant couples, such as pregnancy and reproductive choices press for decisions about costs and policy. Along with the continuing debate on how to respond to the competing needs of those at risk for HIV infection AIDS and death, these are the challenges that lay ahead of us.
1. Katz MH, Schwarcz SK, Kellogg TA, Klausner JD, Dilley JW, Gibson S, McFarland W. Impact of highly active antiretroviral treatment on HIV seroincidence among men who have sex with men: San Francisco. Am J Public Health 2002, 92:388–394.
2. Marseille E, Hofmann PB, Kahn JG. HIV prevention before HAART in sub-Saharan Africa. Lancet 2002, 359:1851–1856.
3. Holmes WC, Pace JL. HIV-seropositive individuals' optimistic beliefs about prognosis and relation to medication and safe sex adherence. J Gen Intern Med 2002, 17:677–683.
4. Bolding G. HIV treatment optimism among gay men: an international comparison. Poster presented at the XIV International AIDS Conference, Barcelona, July 7–12, 2002.
© 2002 Lippincott Williams & Wilkins, Inc.