Introduction
A little over 12 years ago, the scientific world was just learning of the emergence of a new disease, which at the outset, was far from being understood as the most serious pandemic that humanity has ever known.
The history of this disease is marked by great scientific feats, but, unfortunately, also by serious errors of judgement in the public health domain and in the protection of individual rights.
The day in June 1981 a little more than 12 years ago will remain long engraved in our memories as the day when, in the great auditorium of the Centres for Disease Control in Atlanta, the first publications had just been announced and commented on concerning what was then called "GRIDS" or Gay-Related Immunodeficieny Syndrome. This was the first error of judgement.
For a whole year, throughout 1982, publications were describing devastating clinical pictures among young adults, particularly homosexuals, drug-abusers and/or prostitute, and among children of what was beginning to be known as AIDS or Acquired Immuno-deficiency Syndrome.
HIV, or the Human Immunodeficiency Virus, was not discovered until 1983 a year later by the team at the Paris.
What is unique in regard to this epidemic is that it has manifested itself more than any other disease, because of its treatment by the media and its widespread nature, the interdepedence of health and development, of health and human rights, and of health and social inequalities.
It would have somewhat changed the relationships in the domain of knowledge between the usual repositories of knowledge and their potential disciples: as at the onset, everybody was at the same starting point.
It would have, above all, thorougly changed the relationships between the repositories of knowledge, the givers of care and those requiring care, the last group now requesting a right to have their say and participate in making decisions on the treatment. This is a completely new departure in the domain of health.
However, this disease has also revealed the weakness of our contemporaries, who thought themselves protected by science from any serious infection, and has resuscitated the old demons that feed on intolerance, ignorance and fear: proscription, culpabilization, and xenophobia. This was the second error of judgement.
Finally, again showing the lack of courage and the incredulity that surface when a new challenge upsets certainties and disturb comfort, individuals and interest groups take refuge in denying the danger: "The devil is the other person"; "It only happens to others"; "This disease does not concern us". From omniscient America to the most traditionalist countries in Africa or in Asia, this old reflex has , unfortunately often come into play, causing the massive infection of education and prevention to a disease long known to be sexually transmitted. This is the third error of judgement.
AIDS, THE PRINCIPAL PANDEMIC IN TODAY'S WORLD
Of course, humanity has known devastating pandemics long before AIDS, such as the pandemic that has finally been overcome (smallpox), and others that are under a certain degree of control (plague and cholera).
Because the onset of this pandemic was described for the first time and better known in the West and within social groups among whom it was likely to spread, the rest of the world thought itself safe. The greater visibility of the epidemic in the West is simply due to a better recording of cases (better technical and logistic means), and the fact of the decline in morbidity and mortality from the classic infectious diseases.
It is nevertheless unwise to believe that it is primarily a disease of the West. It is the world's pandemic!
Ten years ago, in 1983, after discovery of the causal agent and the proof of its sexual transmission, public health specialists had already suspected that it would spread to the whole of the planet unless a vaccine or a remedy, which it was thought would be easy to find, intervened to stop the disease. Alas, there is neither a vaccine nor an effective remedy yet in hand, at the present time, because of its extent and its inexorable medium term and long term progress, it is quite right to speak of it as the world's most important disease.
To meet the challenge of HIV infection and AIDS, WHO launched, in 1987, the Global Programme on AIDS, whose main objectives are:
Who has also worked in concert with the CSOs and above all with such international organizations as UNDP, UNESCO, UNICEF, the United Nations Fund for Population Activities and Bank for International Reconstruction and Development.
In the 1970s and 1980s the world experienced an epidemic of HIV infection which without yet having attained its peak is unfortunately being parallelled by an epidemic of AIDS cases. This means that for many countries the worst is yet to come.
In our modern times, because of its global nature and because of the inevitably unfavourable prognosis written in invisible ink on the forehead of every patient, AIDS has upset many certainties.
Among the responses that are required from the most humble of those involved up to the most illustrious we should acknowledge at least four, widely advocated by the Global Programme on AIDS and which could "make all the difference":
A little over 12 years ago, the scientific world was just learning of the emergence of a new disease, which at the outset, was far from being understood as the most serious pandemic that humanity has ever known.
The history of this disease is marked by great scientific feats, but, unfortunately, also by serious errors of judgement in the public health domain and in the protection of individual rights.
The day in June 1981 a little more than 12 years ago will remain long engraved in our memories as the day when, in the great auditorium of the Centres for Disease Control in Atlanta, the first publications had just been announced and commented on concerning what was then called "GRIDS" or Gay-Related Immunodeficieny Syndrome. This was the first error of judgement.
For a whole year, throughout 1982, publications were describing devastating clinical pictures among young adults, particularly homosexuals, drug-abusers and/or prostitute, and among children of what was beginning to be known as AIDS or Acquired Immuno-deficiency Syndrome.
HIV, or the Human Immunodeficiency Virus, was not discovered until 1983 a year later by the team at the Paris.
What is unique in regard to this epidemic is that it has manifested itself more than any other disease, because of its treatment by the media and its widespread nature, the interdepedence of health and development, of health and human rights, and of health and social inequalities.
It would have somewhat changed the relationships in the domain of knowledge between the usual repositories of knowledge and their potential disciples: as at the onset, everybody was at the same starting point.
It would have, above all, thorougly changed the relationships between the repositories of knowledge, the givers of care and those requiring care, the last group now requesting a right to have their say and participate in making decisions on the treatment. This is a completely new departure in the domain of health.
However, this disease has also revealed the weakness of our contemporaries, who thought themselves protected by science from any serious infection, and has resuscitated the old demons that feed on intolerance, ignorance and fear: proscription, culpabilization, and xenophobia. This was the second error of judgement.
Finally, again showing the lack of courage and the incredulity that surface when a new challenge upsets certainties and disturb comfort, individuals and interest groups take refuge in denying the danger: "The devil is the other person"; "It only happens to others"; "This disease does not concern us". From omniscient America to the most traditionalist countries in Africa or in Asia, this old reflex has , unfortunately often come into play, causing the massive infection of education and prevention to a disease long known to be sexually transmitted. This is the third error of judgement.
AIDS, THE PRINCIPAL PANDEMIC IN TODAY'S WORLD
Of course, humanity has known devastating pandemics long before AIDS, such as the pandemic that has finally been overcome (smallpox), and others that are under a certain degree of control (plague and cholera).
Because the onset of this pandemic was described for the first time and better known in the West and within social groups among whom it was likely to spread, the rest of the world thought itself safe. The greater visibility of the epidemic in the West is simply due to a better recording of cases (better technical and logistic means), and the fact of the decline in morbidity and mortality from the classic infectious diseases.
It is nevertheless unwise to believe that it is primarily a disease of the West. It is the world's pandemic!
Ten years ago, in 1983, after discovery of the causal agent and the proof of its sexual transmission, public health specialists had already suspected that it would spread to the whole of the planet unless a vaccine or a remedy, which it was thought would be easy to find, intervened to stop the disease. Alas, there is neither a vaccine nor an effective remedy yet in hand, at the present time, because of its extent and its inexorable medium term and long term progress, it is quite right to speak of it as the world's most important disease.
- 2.1. Onset and Rapid Spread of the Epidemic
1981: description of AIDS
1983: isolation of HIV, the causal agent
1983-1985: development of tests to detect the virus.
In the light of the history of humanity medical progress, it can be said that everything has gone very quickly, but it can also be said that the virus has also progressed very quickly. Thus, in the middle of the 80s, it was becoming clear that new virus, a retrovirus with the special faculty of preferentially attacking the body's immune cells had begun to spread insidiously in North America, in Europe and in sub-Saharan Africa. The disease has spread so rapidly that 10 years later no continent has been spared.
The rapid explosion of this epidemic occurred at the end of the 70s and the beginning of the 80s in the North America, Australia and Western Europe, among, first of all, the homosexuals and the bisexuals in the urban areas, and also in the Caribbean, and Southern and Central Africa among men and women whose common feature was the multiplicity of their sex partners.
During this present year of 1993, it is estimated that more than 14 million HIV infections have occurred cumulatively in the world since the beginning of the epidemic.
Two HIV serotypes are at present known: HIV-1, HIV-2. HIV-1 is predominant throughout the world, whereas it seems that HIV-2 is widespread in West Africa.
Their modes of transmission are identical and so are the clinical pictures of the disease once it manifested itself. However, it seems that HIV-1 is more easily transmissible, and that its clinical evolution is also more rapid.
2.2. Modes of HIV Transmission
Epidemiological and laboratory surveys have established the three main modes of transmission, viz. The sexual route, blood and transmission from mother to child (ef. table1).
Sexual transmission: heterosexual and bisexual modes of transmission are responsible for the largest number of infections. Aggravating factors are sexually-transmitted diseases (STD) multiple partners, sexual practices that cause injury and unprotected sexual intercourse. The sexual route is responsible for 70%-80% of infections throughout the world.
Transmission through blood: transfusion of blood derivatives, the exchange or use of non-sterile injection equipment and the donation of organs. The parts these play in the developed countries, is becoming continously smaller. The situation in the under -developed countries is all the more intolerable. This route is responsible for 3-5% of the total number of infections in the world.
Transmission from mother to child: there is a rate 30-40% in the African countries as against 20% in the developed countries. An advanced state of immunodeficiency, the conditions of delivery during childbirth, intrauterine infections and also breast-feeding are probably the most difficult to imagine on the part of the parents, but also the most difficult to tackle on the part of the public health decision-makers.
There are no other modes of transmission of any epidemiological significance.
2.3 Progress from infection to disease
One of the most alarming features of this epidemic for the public at large is the fact that there is quite a long and variable interval between HIV infection and the beginning of clinical symptoms. The experience so far acquired of this disease suggests that 50% of infected persons develop the disease at the end of 10 years. In the absence of other causes of death, almost all these persons will end up by dying of AIDS. Moreover, once the disease has manifested itself, the average survival time lies between one and three years (ef. Fig.2).
There is probably a difference in the natural evolution of the disease between the different serotypes HV-1 and HIV-2. There are also factors that have not all been completely elucidated that may interfere in the course of events:
- a variability in the strains of virus;
- individual genetic susceptibility;
- concomitant and intercurrent infections.
2.4. Interactions between HIV Infection and other diseases
The most obvious are between:
HIV infection and the sexually-transmitted diseases. The classical STDs, particularly gonorrhoea, syphilis and chancroid, occur under the same behavioural conditions as those that expose the individual to infection by HIV. STDs, whether suppurative or ulcerative, but particularly the latter, without any doubt facilitate the ingress and transmission of HIV. The risk from a single sexual act is then 10 to 100 times higher.
Hence, the value of developing services to control the cosmopolitan STDs by supplying appropriate diagnostic techniques, affordable medicaments, counselling and condoms.
Tuberculosis. Latent infection with Mycobacterium tuberculosis may reach proportions of the order of 30%-50% in many developing countries. The resurgence of endemic tuberculosis in some countries is creating something like a parallel epidemic where tuberculosis was almost under control. This is as true for the poor countries as for the rich.
The failure of immunity reactivates latent tuberculosis, making it aggressive, often miliary or multifocal, while the immune deficiency means that the person affected will carry more bacilli and be more sensitive to drug reactions, which often makes the tuberculosis bacillus resistant to antituberculosis drugs. HIV also contributes to the spread of tuberculosis among those close to the patient and renders it the most frequent opportunistic disease in the patient and renders it the most frequent opportunistic disease in the Third World countries.
2.5. World epidemiological situation and trends
As of June 1993, a total of 718.894 cases of AIDS have been cumulatively reported to the World Health Organization (WHO). Obviously, this represents only a small visible proportion of the real number of cases. In fact WHO estimates that the total number is a little over 2,500,000 AIDS cases in adults and children since the beginning of the epidemic to mid-1993; 80% of them occuring in the Third World.
Although the real and ultimate dimensions of the pandemic are unknown, it is estimated that by the year 2000, cumulatively a total of 30-40 millions HIV infections will have occurred and near 10 million AIDS cases occurred around the World. Pessimistic forecasts predict more than that.
Prevalence rates very greatly from one country to another and, within a particular country from one geopraphical area to another, or from the urban to the rural districts.
For certain urban areas of Central and Eastern Africa, rates of 30% have been reported, whereas in some rural zones of West Africa, the 1% mark has not been reached. Unfortunately, it is known that this situation is changing rapidly for the worse, in view of migratory movements, means of transport and the economic crisis.
Social groups whose sexual behaviour increases the risk of infection show, in places, alarming rates such as the 80% of prostitutes in Central and East Africa. Others are more and more threatened, for example:
- those who carry or have relapses of sexually-transmitted diseases:
- patients with tuberculosis:
- young needy people and women;
- military personnel.
- AFRICA 246.127
AMERICAS 371.086
EUROPE 92.822
WESTERN PACIFIC 5.058
SOUTH-EAST ASIA 2.002
EASTERN MEDITERTNEAN 1.799
TOTAL (as of 30 June 1993) 718.894
- Has Islamic morality protected and is it continuing to protect the populations? Some people think so.
- Is it a question of a time lag, due to the act that the epidemic was late in affecting these countries? Others think so.
In any case, it is sub-Saharan Africa which has the highest prevalence, reaching a total of about 7-8 million out of the 13-14 million estimated infected person worldwide.
Figures coming from South-East Asia bode ill. According to officials in certain countries in that region the number of infected persons has now reached several millions. The coexistence of highclass and mass prostitution with intravenous drug intake based on international traffic constitutes, without exaggeration, a real time bomb. Very alarming percentages of seropositivity among prostitutes and young military recruits are now being put forward by the authorities in India and Thailand.
Uncertainties subsist as to what is happening in eastern Europe and the former Soviet Union, but all the ingredients are there, i.e., prostitution, intravenous drug abuse, economic stagnation and failure to find a model of society that will integrate the young people and ethnic minorities.
It will therefore be easily understood that these ingredients, which are also found in Latin America and perhaps to a lesser degree in the Near East, should not be considered as a "specific cultural feature" of Africa or the Caribbean. That would be the fourth error of judgement.
People must accept that it is by behaving responsibly that and women can protect themselves effectively against AIDS but that no country in the world can claim to find refuge behind legislative and isolationist barriers that are proof against HIV.
In view of the initial explosion of AIDS among homosexuals or intravenous drug abusers in the developed countries, these is still a sex ratio "favourable" to men, whereas in the countries of the Third World, particularly in Africa, the sex ratio is 1/1. This is due to the preponderance of heterosexual transmission.
In the European countries and in the "Golden Triangle" in South-East Asia the spread of the epidemic seems to be maintained by infection due to the exchange of needles and syringes by drug abusers.
There are 14 million infections in the world: 13 million among adults and 1 million among children.
Meanwhile, only 600,000 cases of AIDS have been reported to WHO: failure to diagnose, delay in notification or perhaps refusal to notify. In reality one must expect more than 2.5 million cumulative cases of AIDS throughout the world since the beginning of the epidemic, of whom half have since died. Among these cases 0.5 million are children.
While in the Third World countries certain endemic disease and devastating disasters can still divert, elsewhere, in the developed countries, AIDS is already the principal cause of death among young adults.
In the United States of America and in Australia AIDS is the first cause of death among men in the 25-44 age group. In the United States of America it is the fourth cause of death for women in the same age group.
In Switzerland AIDS is the second cause of death among men in the 25-44 age group, after suicide, and the second cause of death among women in the same age group, after cancer.
It is also the case in certain Third World countries that are seriously affected: over 50% of deaths among young adults are due to AIDS in some countries of southern Africa. WHO estimates that by the year 2000 infant mortality in these countries will reach 200-250 per 1000 live births.
There are therefore several reasons for saying that HIV/AIDS infection is a major problem in the Third World:
- the wide extent of HIV infection and of AIDS in all the Third World countries, a feature paralleled in only by the lack of means;
- the unchanging nature of the circumstances favouring the infection;
- the immediate impact on individuals and the family unit;
- the impact on health indicators and health systems;
- the medium and long term negative impact on development.
- 3.1. Factors influencing the spread of the epidemic in the Third World
Behavioural factors
It is certain that sexual behaviour is the most important determining factor in the spread of the epidemic of HIV infection and AIDS. This sexual behaviour comprises:
- the early age of sexual initiation;
- sexual promiscuity, or in other words, multiple sexual partners;
- the frequency of casual or commercial acts.
Sexual risk practices such as sodomy, which, according to recent studies, is a current practice in Latin America and in the paedophile tourism now in fashion, are the "vectors" that are the most "effective" in transmitting HIV. Certainly these practices have been somewhat amplified by modern commercialism and the copying of models from elsewhere but they have also existed in certain areas long before sexual tourism and television features.
Failure to use condoms must be classified as dangerous practices: because of a simple psychological block among those beginning their sexual life, the uncaring or very dangerous thoughtlessness of the person who knows what to do but does not do it, and the wait-and-see attitude of the defenders of sexual taboos.
Is it still necessary to demonstrate the effectiveness in vitro and in the field in several places in Africa and Asia of the use of condoms? Moreover, it will easily be seen from the figures on the marketing and distribution of condoms in the Third World countries that there is a demand for them. It is for the decision-makers to facilitate the use of condom and make it easy to obtain.
Finally, it is being confirmed that intravenous drug abuse is spreading rapidly in many parts of the Third World and that it is a potent ally of the sex industry in the propagation of HIV infection.
< DIV CLASS="HD3">Biological factors
Biological studies have shown a great difference in the variability of viral stains from Africa, Europe or America. Research is nevertheless necessary to confirm that this genetic variability of the Africa strains could increase their virulence because of their greater affinity to cells or their greater capacity to attain high levels of virus in the blood.
The prevalence of the facilitating STDs is generally in the developing countries, particularly in the urban zones among those that can be called the "hard kernels" i.e., prostitutes and their customers, long distance drivers, seasonal workers and military men in condition of prolonged celibacy. Sexual promiscuity allied to a lack of care provides a fertile breeding ground for clssical STDs and AIDs.
Certain traditional practices for erotic or preventive purposes may injure the vaginal wall and favour the penetration of HIV.
As an increasing number of women infected 5-10 years ago are reaching childbearing age, there will be a rapid increase in infections among children. The problem is all the more serious, in that, several independent studies have shown higher rates of mater-no-fetal transmission among Third World women (30-40%) than among European or North America women (15-20%).
Demographic factors
Of course, a high proportion of the population made up of young people between 15 and 40 years of age can be an important aspect for the Third World, but the incursion into this world of a sexually transmitted disease coinciding with underemployment and the smaller incomes of these young people is putting this unequalled potential in grave danger.
It is well-known how much seasonal or permanent migratory movements have contributed to enriching the big cities of the Third World with constantly renewed strata of young rural people facing increasing difficulties in finding lodging, work and medical care, while at the same time the ancestral values of good conduct and solidarity were becoming weaker. This phenomenon has favoured commercial sex, STDs and AIDS.
Socioeconomic and cultural factors
These factors are most frequently linked with economic underdevelopment, but the cultural environment here, as elsewhere, can sometimes have positive or negative effects on the progress of the epidemic.
One of the most glaring aspects is the status of women. The fact that women are disadvantaged educationally, legally and economically puts them in a position of total dependence, which may even include dependence in the choice and practice of their sexual life: there has been no action directed towards the sexual behaviour of the dangerous partner whether married or not; little has been done on the choice of prevention; women have been induced to take to prostitution through necessity or by force and here and there they have been forced to submit to the now suicidal practice of levirate.
In many developing societies taboos on sexuality inhibit thought and education and thereby prevent any effective policy for preventing sexually transmitted diseases. It is also taboos that limit the promotion and accessibility of the only means that is at present effective against HIV infection, i.e. the use of the condom.
Wars and the social disorders and poverty that they bring about lead to ruthlessness, and the adoption of risky sexual practices and banish any possibility of the most elementary care. It is this poverty that is causing the breakdown of families, forcing adults into incessant migrations and unhappily throwing millions of children on to the streets.
A community's organization and management influence the choices of strategies for protecting its health. Thus a lack of far sightedness or political courage, such as the refusal of a scientifically valid, easy and cheap preventive method, may have lasting repercussions on the health of all.
However, in many of these developing societies some forms of behaviour, practices and social rules may contribute to reducing to a minimum, the spread of HIV infection and its disastrous consequences:
- family cohesion in the wide sense;
- solidarity and mutual assistance;
- sexual abstinence outside marriage (with all its limitations);
- strict faithfulness in monogamic or polygamic relationships;
- the practice of circumcision for hygienic purposes.
3.2 Socioeconomic impact
In addition to the pain and physical disintegration due to repeated attacks of opportunistic infections, AIDS will cause very profound and long-lasting psychological disorders in the absence of treatment, the certainty of death, but above all, having to face rejection and stigmatization, both physically and psychologically. It will also end by having an adverse economic impact due to the increasing needs for medical care.
What can be said of the survivors?
- A fate often more difficult for a widow than a widower: a sudden loss of resources and land; loss of family ties; and the woman is often infected if not already at the stage of illness.
- As for orphans, there has never been talk before of orphans resulting from a particular disease, perhaps because the plague, smallpox or cholera had the "decency" not to leave orphans. But now AIDS orphans throughout the world, and particularly in Africa, are a major concern. Their number is outpacing the capacities for mutual assistance in the traditional extended family and even the capacity of certain countries that are most seriously affected. To feed, lodge, clothe and educate millions of children, some of which are infected, will need an unprecedented material commitment, but also an effort of education for those close to the patients but often hostile.
- In addition to widower, widows and orphans, account must also be taken of the elderly, who will also have to be looked after.
As in certain large American cities, AIDS is now the main cause of death among young adults in some great African town; elsewhere, in a country of South-East Asia, it is forecasted that by the year 2000 nearly 30% of all deaths will be due to AIDS. This is an unprecedented fact in the history of human medicine.
In the same way, there is an increase in infant mortality in places where spectacular progress had been recorded for the last 30 years (cf. Fig 7).
This will result, not surprisingly, in a shortage of human resources, particularly at the three key levels of society: agriculture, mining and industry and finally technical, educational and management staff, which is so much needed.
3.3 Impact on public health systems
At the moment it is easy to see that the health structures of the Third World will have difficulty in resisting the epidemic surge. Indeed AIDS does not come alone to knock at the doors of hospitals or dispensaries, it causes a resurgence and aggravation of other diseases that were more or less under control: tuberculosis, pneumococcosis, salmonellosis-all opportunistic infections that are now common and feared.
The increased cost is already difficult to bear for the meagre public health budgets of many countries, even those where investments in health had not been neglected.
The increased workload on health personnel and their fear of infection, whether justified or not together with the insignificant results of their efforts, are leading to a profound demoralisation that can be seen at every level: to the famous "burn-out" described in eastern and southern African hospitals.
However this impact does not affect the care givers alone, it also affects the patients and their families. Those who as doctors and carers have forged their experience in Third World countries, are well aware that if a minimum offer of care is not available in face of such a large demand, the populations will desert the referral clinics and the health professional will be deprived of any opportunity of delivering preventive messages either against AIDS or against curable diseases. The patients could take refuge in underground care practices that are sometimes as ineffective as they are dangerous.
To meet the challenge of HIV infection and AIDS, WHO launched, in 1987, the Global Programme on AIDS, whose main objectives are:
- To prevent HIV infection;
- To reduce the individual and social impact of the infection; and
- To unite national and international efforts against AIDS.
- the need to take patients into care through the supply of health care on an adequate and equitable basis of health;
- to counter any discrimination and stigmatization and to observe the rules of ethics in preventive strategies and research efforts;
- to put into speedy effect strategies to reduce to a minimum the negative socioeconomic impact of the pandemic.
Who has also worked in concert with the CSOs and above all with such international organizations as UNDP, UNESCO, UNICEF, the United Nations Fund for Population Activities and Bank for International Reconstruction and Development.
- 4.1. Preventing HIV infection
The main lines of prevention are:
4.1.1. Vaccine
Of course, the most elegant, the most reliable and doubtless the most repid method of preventing virus infection is vaccination. In this connection three types of vaccines are envisged for bringing the epidemic to a halt:
- a "preventive" vaccine: which protects uninfected persons from HIV infection;
- a "curative" vaccine: active immunotherapy halting the progress of the disease and thus reducing the viral burden and in the end possibly reducing transmission;
- a "perinatal" vaccine curative for the mother receiving it, and preventing transmission to the fetus and the baby.
In any case the trials to be carried out must follow irreproachable scientific and ethical guidelines and in particular not infringe individual rights; individuals will by definition have to be consenting volunteers. It is in this context that WHO will launch trials, Uganda, Rwanda, Brazil and Thailand.
But the popular saying: "The most beautiful girl in the world can only give what she has" applied to a vaccine. This means that the best of vaccines cannot totally replace preventive methods, since it cannot be 100% vaccine coverage of a population is difficult to achieve.
- The condom and again the condom!
Education and again education!
Information and again information!
Experience has shown that changing a risk behaviour is possible, even if it is some times slow to get off the ground: smoking and eating habits and taboos of mothers during the weaning period etc., are examples that should make us more patient but also more persevering on the road to success.
In this field, intervention aimed at women should be given preference since the social and economic conditions are known to be unfavourable to them particularly in the Third World countries:
- lower educational level;
- economic dependence;
- sociological pressure on sexuality;
- inability to influence the use of condoms.
Inducing a change in behaviour is also necessary in the case of young people towards whom strategies which are beginning to show their value must be generally aimed: institutionalised sexual education (school environment) or group interventions in which the young people direct operations and report on their observations, conclusions and recommendations.
4.1.3. Better control of sexually transmitted diseases
In view of the multiple role of classical STDs, their treatment is now priority.
Stress is going to be placed on the widespread and systematic application of case management using algorithms based on the syndrome approach that does not necessitate the laboratory tests that are not available in many countries. The same algorithms will must necessarily be from the list of essential drugs.
Of course, this approach presupposes establishing and maintaining functional health systems out to the most peripheral level as well as informing and referring to these systems the men and women who have most need of them.
In these services - rehabilitated and with improved morale-messages and educational sessions on sexuality will be given and condoms will be distributed by a "new look" personnel specially trained and retrained and retrained to eliminate the slightest hindrance to the attendance at the centres of women giving renewed confidence in them.
4.1.4 Prevention of transmission through blood
It is a question of systematically:
- making rational and effective use of blood stocks;
- examining blood and its derivatives for HIV;
- carrying out injections and surgery under sterile conditions;
- scrupulously observing universal measures of protection of care personnel;
- reducing transmission among drug abusers using injectable drugs.
- ensuring health care for pregnant women;
- providing appropriate counselling regarding breast feeding of a child born to a sero-positive mother.
Two components are essential in all countries, particularly in the poorest.
- counselling and psychological management of the HIV infected person or AIDS patient and his or her family;
- the provision of medicaments against the opportunistic diseases that predominate where antiretroviral products are not accessible.
4.3. Reducing the Socio-economic consequences
Adverse consequences whose beginning can already be seen in certain countries:
- excess infant mortality in places where real progress had been made during the last 50 years;
- excess mortality among young adults, in both poor and rich countries;
- AIDS orphans, who are now estimated to number more than two million throughout the world and who may number more than eight million by the year 2000;
- destabilization of the health system; since in certain countries about 60% of hospital beds for adults are occupied by AIDS patients, and the direct or indirect costs due to the disease are beyond the possibilities of the public health budgets.
A solution will call for what will sometimes be an excruciating review of the options for development which considered investments in human health as a dead loss and will put a severe strain on international solidarity. And yet solidarity is necessary!
4.4. Uniting efforts
First of all, this must be done in each country where strategies must be defined on a multidisciplinary basis and where it will be absolutely essential to find resources from the country itself.
This is strongly encouraged by the national decision-makers most committed to combating AIDS and also by all the cooperation organisms.
The same consensus in uniting efforts is now sought and defend by the main international organizations. Their strategies aim mainly at reducing transmission and finding a way of responding to the demand for care but they are also quite aware of the imperative need to fight against denial, stigmatization and failure to respect rights and freedom because of a disease.
In the 1970s and 1980s the world experienced an epidemic of HIV infection which without yet having attained its peak is unfortunately being parallelled by an epidemic of AIDS cases. This means that for many countries the worst is yet to come.
In our modern times, because of its global nature and because of the inevitably unfavourable prognosis written in invisible ink on the forehead of every patient, AIDS has upset many certainties.
Among the responses that are required from the most humble of those involved up to the most illustrious we should acknowledge at least four, widely advocated by the Global Programme on AIDS and which could "make all the difference":
- an unprecedented political and financial commitment by the countries of the world in the often neglected domain of public health;
- the recognition by every individual, by every community and by every leader of the possibility of risk behaviour and the need to adopt measures likely to reduce its consequences;
- the carrying-out and application of priority research on prevention comprising particularly research in socio-behavioural sciences, the improvement of services available in places where sexually transmitted diseases are treated and the provision of the best possible medical care;
- a punctilious acceptance by the community of these research priorities so long as they are "defined by both Third World researchers and those of the developed countries, by researchers in social sciences and researchers in bio-medical sciences, by men and by women, and by infected person", in every case in an athmosphere of real cooperation and in coformity with ethical standards recongnized by all.
