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Editorial Comments

AIDS — past and future challenges

Susman, Ed

To the AIDS readership

Starting virtually from scratch – with only a sketchy report from the Centers for Disease Control and Prevention in June 1981 [1] – we have mobilized academia, government research, industry and public action to the point where we know more about HIV / AIDS than about any other viral disease on earth. In the space of just 20 years:

  •  we figured out that the disease was caused by an infectious agent
  •  we discovered what that agent was: a virus.
  •  we learnt how the virus infects
  •  we learnt how it survives in the body and how rapidly it replicates
  •  we learnt how the virus can suppress and destroy the immune system
  •  we took pictures of the virus, and how it spreads through the body
  •  we discovered how it hides in hidden reservoirs throughout the body
  •  we developed drugs that can hold the disease at bay for years
  •  we have ascertained the structure of the virus to make it possible to develop new sites of attack
  •  we know how to prevent infection from being passed vertically to newborns
  •  we learnt how the immune system could fight against the virus and have advanced to the threshold of developing a vaccine to protect people against HIV.

Tremendous achievements, all. But we still have failed in some critical aspects of fighting the pandemic: we have not learnt how to boost the immune response against HIV. Attention needs to be given to immune-based therapies as well as to antiviral drugs, and we do not yet have a vaccine against the virus. We have also been unable to design messages that effectively tell and remind our citizens constantly what they need to know to protect themselves and their children from this deadliest of biological killers.

The recent United Nations General Assembly report [2], produced through negotiations beset by political sensitivities, has been hailed as a blueprint for a worldwide attack on the virus. Certainly, it is a remarkable achievement. But the declaration failed to address the reasons AIDS thrives: those twins of destruction – ignorance and silence.

The pressure of organized morality, religion and politics continues to overcome science and logic in dealing with the disease that – in the next 20 years – will prove more deadly than the Black Death and will become the first disease since the Black Death to cause declines in the overall populations of several nations.

Bowing to pressure from various governments, the United Nations document failed to name explicitly the groups at greatest risk for contracting and spreading the disease. The scientific and the political communities know which groups are at risk, but our international politicians dared not allow them to be mentioned in the final United Nations declaration. For example,

  •  Commercial sex workers are never mentioned in the document; it sidesteps the issue by mentioning exploitation of women and girls.
  •  The document does not tell us that HIV/AIDS is rampant among the commercial sex workers of Grant Road in Mumbai, where row upon row of women attract customers in seedy, tiny cubicles that line the well-trafficked street. It does not tell us that the customers of these women, often workers from the countryside seeking some meager and ridiculously cheap sexual release far from home, may contract the disease through unprotected sex and then transmit HIV to their wives in distant villages. And since there is little discussion in India between a doctor and his female patient regarding sexual conduct (a situation similar in much of the rest of the world), the disease continues, now infecting thousands of babies who will be dead before they are 5 years old.
  •  Intravenous drug abuse is barely mentioned in the entire document, although the euphemism ‘drug using behaviour’ is used.
  •  The declaration does not tell us that the men and women who exchange needles in urban jungles, such as the inner cities in the United States and many other big cities in Europe and certain developing countries, produce HIV prevalence numbers that are scarily reminiscent of what was reported in the 1980s and early 1990s in sub-Saharan Africa.
  •  Any mention of men having sex with men is eliminated in the document.
  •  The document does not warn us that as many as one-third of men who have sex with men in the metropolitan areas of the United States, Europe and Australia are infected with HIV and that risk behaviour and sexually transmitted diseases among this group is rising, which will probably result in an increase in the number of new HIV infections in this group.

Apparently the message of the 13th International Conference on AIDS 2000 in Durban –Break the Silence– has yet to penetrate high levels in many of the world's kingdoms and democracies where political correctness outweighs the impact of HIV/AIDS.

The United Nations General Assembly established laudable goals, including timetables when nations should accomplish improvements in health care, in treatment of people living with AIDS, in caring for groups that are vulnerable to contracting AIDS such as women and girls, and in prevention programs. However, the disease will continue to resist meaningful control until nations and the leaders of these nations can discuss the utility of needle exchanges to prevent transmission of HIV, can accept that there are men who have sex with men, and can recognize that commercial sex work exists.

Before the leaders of the world spend too much time thinking that setting such goals achieves anything concrete, there are still some sobering facts to consider. Billions of virus particles are produced every day, resulting in new infections: 4 million people will become infected with HIV in the next 12 months, about 300 000 people in the next month, about 77 000 people in the next week, about 11 000 by this time tomorrow and about 500 in the next hour. In the time it took you to read this article, 50 more people in the world – young men, young women, newborn babies – became infected with HIV.

In terms of epidemiology that saves lives – not ideology that saves feelings – we ignore these facts to the peril of some of our most vulnerable sisters and brothers.


1. Centers for Disease Control. Pneumocystis pneumonia. MMWR 1981, 30: 250–252.
2. United Nation General Assembly. Declaration of Commitment on HIV/AIDS, Global Crisis–Global Action. 27 June 2001.

epidemiology; sexual behaviour; HIV transmission; United Nations

© 2001 Lippincott Williams & Wilkins, Inc.