The cumulative world-wide statistics of HIV/AIDS is overwhelming. Altogether, more than 20 million people around the world have died of AIDS-related diseases since the epidemic began. Currently, double that number, 40 million people, are living with HIV and may be expected to die in the next decade. The World Health Organization estimates that alone in 2003, 4.8 million people were newly infected with HIV. In that same year, 2.9 million men, women and children died of the disease.

A horrifying 37.5 percent of all adults in Botswana, well over a third of the adult population – that is more than one in every three adults – is infected with HIV. The neighboring Republic of South Africa reports an infection rate of 20.1 percent – one in every five adults. That percentage translates into 5 million people infected with HIV, making South Africa the country with the largest number of people living with HIV/AIDS in the world.

The numbers can be extended. Sub-Saharan Africa, the area of Africa south of the Sahara desert, has, relative to its population, the most severe HIV epidemic anywhere in the world, and the rate of infection is still increasing in many countries. An estimated 3 million new infections occurred in 2003, which brings the number of people living with HIV/AIDS in the region up to an estimated 25 million.

There have been success stories. Uganda, which in the 1990s had an infection rate of 14 percent, has brought its infection rate down to 5 percent through a vigorous campaign of prevention that stressed the use of condoms and sexual abstinence. Zambia, whose infection rate was approaching 12 percent, has also managed to reduce the figures to the 5 percent range.

This is on the one hand encouraging news, but it cannot be taken as proof of a containment of HIV/AIDS. Eastern Africa once had the highest infection rates on the continent, but the epidemic has merely spread to the southernmost tip of Africa. Infection rates in Kenya and Ethiopia have reached the 10 percent range and continue to rise. West Africa has so far been spared the high prevalence rates of Southern and East Africa, but the numbers there are rising too. The Ivory Coast is among the top 15 nations in the world in its rate of infection, and Nigeria has a prevalence of over 5 percent. Taken as a whole, West Africa has a relatively low prevalence rate of less than 3 percent of the entire population, but the number is misleading.

As we saw in the United States, the HIV/AIDS epidemic is diverse in the beginning. It affects well-defined and limited groups, such as IV drug users, sex workers or homosexuals. It then spreads into the general population. A prevalence of less that 3 percent in West Africa merely means that – unless these nations take firm measures to curb the spread of the disease – they are standing at the beginning of their epidemics.

These numbers only convey a fraction of the story. More than 20 years into the epidemic, AIDS continues to decimate populations on a global scale. As the crisis grows, it evolves, presenting ever-new challenges, which remain to be solved. As the world commemorates World AIDS Day on Dec. 1, it is essential to deconstruct the latest challenges the world is facing combating one of the biggest killers of our time.

When discussing HIV/AIDS, it is easy to throw around numbers. They seem to define the extent of the epidemic so clearly, but we should constantly be aware of the qualifiers that always accompany any statistics on HIV/AIDS, namely “estimated” and “approximately”. Surely, if the epidemic is to be effectively combated, we must first have a clear idea of its extent. We must ask ourselves how accurate the statistics on HIV/AIDS are, and how they are derived. If the figures are estimates in the industrialized nations, with their sophisticated means of tracking and reporting disease, how accurate are the figures from the Second and Third World nations?

There are two very basic problems in tracking the numbers associated with HIV/AIDS. The first is determining the numbers of people infected with the HIV virus; the second is the different definitions of what constitutes AIDS. As most of our readers probably know, HIV is the virus that is widely recognized as causing a medical condition known as AIDS. Being infected with the HIV virus does not equate with having AIDS. To add to the difficulty, HIV is a retro-virus, which means that it may take several years to develop the symptoms of infection. Doctors generally assume that HIV has a five to 10-year latency period. The latency period is the number of years that a person can be infected without showing any symptoms. The victim may be apparently healthy in that time, but all the while the virus is replicating, spreading to different parts of the body, and the victim may infect other people in that period without even suspecting that he is infected himself. That is one of the reasons the AIDS epidemic was able to spread across the entire United States before it was recognized as a major health threat. By the time the first infections had developed into the medical condition called AIDS, many people were already infected with the HIV virus.

The only way to know if someone is infected during the latency period is to do a test for the presence of HIV in the bloodstream. Unfortunately, not many people bother taking this test because most people assume that if they are feeling fine, then they must be healthy. Most members of the general public would see no reason to go through the trouble and perhaps expense of taking the test, and so the numbers of people in the general public who are actually infected with HIV must be estimated, since hard numbers are not available. Furthermore, the tests for an HIV infection may not be easily available in Third World countries, so the international levels of infection are extremely difficult to determine certainly.

Once the HIV infection has developed into the condition called AIDS, where the person’s immune system is collapsing and the victim is open to a number of opportunistic infections, the HIV infection becomes apparent; but here the problem of formal definition enters the picture. A diagnosis of AIDS is a medical term, based on formal criteria. A doctor looks at the number and types of opportunistic infections a patient may have; he orders a blood test to count the number of disease-fighting T-cells a patient has left, and to count how much of the virus is in the patient’s bloodstream to determine the viral load. It is on the basis of these numbers that a doctor will decide whether or not an HIV infection has developed into AIDS. However, the definition of what numbers define an AIDS diagnosis differs from country to country. One country’s department of health may require a T-cell count of below 600 before the doctor may call an HIV infection AIDS; another country may require a T-cell count of below 500. Internationally, doctors are beginning to agree on the technical definition of AIDS, but we should not assume that AIDS means the same thing from country to country.

The definition of AIDS was further complicated by the introduction of successful therapies for the condition. AIDS can now be treated with anti-retroviral drugs, which reduce the viral load – the number of virus in a patient’s blood – and increase the number of T-cells a patient has available to fight infection. When a patient has more than 500 T-cells and a viral load that has become undetectable due to anti-retroviral therapy, he may no longer fulfill his country’s formal definition for AIDS. However, he has not been cured. He still has the HIV infection. He can still become ill if the therapy is interrupted, but is he to be counted in the AIDS statistic or in the HIV-infection statistic?

The practice varies from country to country. In the United States, once a diagnosis of AIDS has been made, the patient remains in the AIDS statistic, even though he may become asymptomatic, which means he still has an HIV infection but shows no signs of the disease. However, not every country follows this practice. Some countries remove asymptomatic people from the AIDS statistics, which makes international comparisons more difficult.

Third World countries do not have as much money to spend on tracking particular diseases, so their estimates of the prevalence of HIV infections in their populations are based on broader assumptions. Third World countries will frequently use “marker diseases” to estimate the number of HIV infections in the general population. Tuberculosis frequently fills this role. Since tuberculosis no longer appears in the epidemic proportions it had during the 19th century, its appearance can be taken to indicate that the patient had a weakened immune system – the hallmark of an HIV infection. Therefore, some countries will count all deaths caused by tuberculosis as being among the HIV-related deaths. The use of marker diseases is not limited to Third World countries in the diagnosis of HIV. A case of thrush, a fungal infection of the mouth, is considered in the industrialized countries of Western Europe to be a primary indicator of an HIV infection. The difference is that in Western Europe, anyone with thrush would be given an HIV test to clarify the cause of the infection, whereas the relationship between the marker disease and the presence of HIV would remain ambiguous in a Third World country.

HIV figures from developing nations are therefore open to the danger of false positives. These would, for example, be cases where the patient dies of tuberculosis without an accompanying HIV infection. Recording the death as being from an HIV-related disease would wrongly inflate the estimates of the prevalence of HIV in general.

The statistics on women indicate one of the greatest shifts that is taking place in the HIV/AIDS epidemic: AIDS is becoming a female disease. This fact is still widely unknown in the United States, where we are used to thinking of AIDS as affecting mostly men, but even within the United States, 80 percent of new infections are among African-American and Hispanic women, although they only comprise a quarter of the population. The Center for Disease Control reports that in 2001 among teens, girls accounted for more than half of the new infections. Internationally, women account for 60 percent of the HIV-positive results in the 15 to 24-year-old age group. It should also be added that it is younger women who are more at risk for HIV. This reflects the position of women in most societies, where men are able to impose their sexual preferences. The majority of men prefer sex with younger women, whereas it is not approved of when women have sex with younger men.

There are several reasons for women’s increased vulnerability. One reason is that women are physically at greater risk of contracting HIV through sex than men are. According to Meg Newman, MD at the University of California San Francisco, heterosexual transmission from the male to the female partner is approximately eight times more efficient than female-to-male transmission. Most infections have occurred by the vaginal route, although participation in anal sex increases the risk. A more important reason is that women are not as in charge of their reproductive lives as men are. They are seldom able to decide the circumstances under which intercourse will take place. They are usually unable to insist on the use of condoms or other protective devices, and so far vaginal gels or creams have not been developed that are lethal to the HIV virus.

The greater vulnerability of women for HIV infection has considerable social implications. Men are the breadwinners in most societies, especially in poorer countries. A man’s removal through death or disease will reduce the family’s economic security.

It is the women who bear children and care for the family, especially for the sick. An HIV-infected woman in the Third World has a 40 percent chance of infecting her child during birth, and after birth there is the danger she may infect the child through breast-feeding. It is impossible to avoid breast-feeding in Africa, where doing so would be equivalent to an admission of HIV infection, as a woman will traditionally be blamed for her condition.

In countries where women are the population primarily affected by HIV, the first line of caregivers for other family members living with HIV is essentially removed. Finally, there is the probability that an HIV-infected woman will die. UNAIDS estimates that there are 15 million AIDS orphans around the world today. Many of these children are themselves at greater risk for infection because of the lack of a protective home life, and the possibility that they may be forced to turn to some form of prostitution to survive.

Until recently, help for low-income countries from the developed world has focused on the provision of food and water supplies. Charities and NGOs have concentrated their efforts on fighting famine and drought in Africa, and some lesser attempts have been made at combating diseases such as TB and measles. It is only recently that people have become aware that HIV/AIDS is a problem of equal or greater gravity. It was almost accepted that people in developing countries who were infected with HIV would die, and that the issues of food and water supplies were so pressing that disease wasn’t a consideration. This was especially true in areas such as sub-Saharan Africa, where both HIV and food/water supplies were vital issues. Eventually, when discussion started about the HIV issues in the late 1990s, people started to question the expanding death toll due to AIDS when drugs existed that could prevent HIV-related deaths, and further, why these drugs could not be manufactured at affordable rates. People in resource-poor countries where medical services failed to provide needed medications began demanding these medications.

Since 1995, the agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) was created, which protected companies’ patent rights. When countries sign up to the World Trade Organization (WTO), they also sign up to protect the patent rights of companies who sell products within their country. With respect to drugs, the major difference between TRIPS and previous agreements is that TRIPS requires countries to grant patent protection to pharmaceutical products for a minimum period of 20 years. Companies who have patents over their products see this as an essential element in international trade, as it guarantees them income in return for the investment made during the development of the drugs. However, in the case of the pharmaceutical companies, many people perceive it as putting profits before patients.

With hundreds of thousands of people dying for want of drugs, pressure began to grow on the pharmaceutical companies. In November 2001, the WTO met and agreed that TRIPS does not and should not prevent member countries from taking measures to protect public health. This means that poor countries can manufacture, buy and import cheaper generic drugs if there is a threat to public health.

In August 2003, the WTO announced a new agreement, intended to allow poor countries access to and import cheap generic antiretroviral drugs. This agreement was applauded by the pharmaceutical multinationals and the United States as being very balanced, although in practice it makes AIDS drugs even more inaccessible to the countries who need it most.

The process by which a poor country can declare the need for a suspension of a particular drug patent as a matter of emergency is wrapped in even more red tape and restrictions than previously, making the agreement no more than cosmetic. This means that poor countries can theoretically manufacture, buy and import cheap generic drugs if there is a threat to public health, although in reality it has proved difficult to do so. And, once begun, treatment must continue for a person’s lifetime, meaning a supply of drugs must not only be established, but an uninterrupted supply must be guaranteed.

Globally, less than 8 percent of the estimated 5.5 million people who need treatment were receiving it, as of June 2004. As we have seen, Africa has been hit hardest so far by the HIV epidemic. Sub-Saharan Africa has suffered particularly badly. There, HIV prevalence has remained steadily at high levels for the past few years. This does not mean that new infections are decreasing and drugs are keeping people alive longer – it means that there is a very high infection rate and a similarly high mortality rate. In Africa, where 70 percent of people with HIV/AIDS live, ARV treatment is available to less than 4 percent of those in need.

Asia has been hit by the main force of the epidemic more recently than Africa, causing some Asian countries to reacted rapidly – Thailand, for example, although their prevalence rates are still high. The epidemic in Asia is very diverse, and in some areas the severity is not measurable due to lack of testing and reporting facilities. In many Asian countries, the healthcare facilities are not in place to support a rollout of testing or medication.

South America, Latin America and the Caribbean have very poor medical facilities in some countries, whereas others have responded well to the impact of HIV. Brazil, for example, reacted early to the threat in the 1980s, engaging in an aggressive media campaign to educate the public. They have further reduced the impact of the virus by producing and providing free, generic medication and promoting condom usage.

Countries such as Argentina, Brazil, Chile, Costa Rica, Cuba and Uruguay now guarantee free and universal access to generic antiretroviral drugs through the public sector, and drugs have become much cheaper in Honduras and Panama. Drug prices do still vary, however, in this region, and access to education remains unequal.

In the Caribbean area, however, poor healthcare infrastructure and political instability means that the spread of HIV in many countries cannot even be effectively monitored, and this area may be the second worst affected in the world.

The Clinton Presidential Foundation has achieved some success by acting as a go-between for various low-income countries and the pharmaceutical multinationals. It has persuaded various drug manufacturing companies to reduce the prices of their drugs, or to hand over patents and allow cheap generic versions of the drugs to be made. The price for the most common antiretroviral medicine treatment will be as low as $140 per person per year. In April 2004 this deal was extended to offer cut-price medication to the 122 countries covered by the Global Fund. Even at these reduced prices, however, the cost of ARV treatment remains too high for many of the poorest countries in the world.

To a certain extent, the pharmaceutical multinationals are themselves helping by allowing generics companies to produce patented medicines for a fraction of the price, and in some cases giving up the intellectual property rights to a drug. This, however, usually happens only with drugs which have now been replaced in Western countries by newer products.

In June 2004, there were only 440,000 people in developing countries accessing antiretroviral (ARV) therapy, and in just the year 2003 the epidemic has claimed the lives of an estimated 2.2 million people in sub-Saharan Africa alone.

Treatment for AIDS and opportunistic infections (OIs) has been promised to people in low-income, high HIV-prevalent countries. By 2003, commitments had been made to help the Global Fund to fight AIDS, TB and malaria, and U.S. President George W. Bush, Bill Gates and others had promised large sums of money to combat the spread of the epidemic.

In December 2003, the World Health Organization published a policy document outlining a plan to bring ARV treatment to 3 million people in developing countries by 2005. This document, the 3 by 5 Strategy, outlines how the WHO intends to work with other governments and groups to get treatment where it is most urgently needed. The WHO will not itself supply money or medicines, but will provide technical assistance, upgrade healthcare infrastructure and training, and help coordinate efforts to scale up treatment.

An additional $62 million is required to enable WHO to fulfill its plan for 2004-2005. Much of the funding pledged to the WHO 3 by 5 Project has yet to be received.

The United States has committed itself to reducing mother-to-child transmission of HIV by 20 percent by 2005 and by 50 percent by 2010. They also aim to provide anti-retroviral medication, with targets of treating 500,000 people by October 2005, 1 million people by October 2006, and 2 million people by the end of 2007. President Bush has increased funding for Global HIV/AIDS, tuberculosis and malaria from $840 million in 2001 to a request (to Congress) of $2.8 billion in the fiscal year of 2005. He aims to have 2 million people on antiretroviral treatment by 2008.

The World Bank has committed over $1.7 billion through grants, loans and other credits, which can be used to increase access to ARV treatment. The Global Fund to fight AIDS, tuberculosis and malaria has reported that its current grant disbursements will, over the next five years, pay for 1.6 million people to receive antiretroviral treatment.

The Accelerating Access Initiative, driven by the major pharmaceutical companies themselves, reports that it is currently covering over 150,000 people with ARV treatment, and could increase this figure. There have been, however, recent hitches with the Accelerating Access Initiative, which have led to medication prices actually increasing for NGOs and charities in some areas – South Africa, for example. At this stage it is impossible to say what the costs will be of tackling the HIV epidemic in developing countries, partly because the exact numbers of people infected can only be roughly estimated.

Clearly, there are major challenges involved in organizing provision of medication in resource-poor countries, but it is very positive that an attempt is finally being made. Over the next two years, a few hundred thousand lives should be saved, and although this is a fraction of those who might be helped, we are now in a situation where some progress could be made, given the political motivation. Unfortunately, by late 2004, the WHO 3 by 5 plan to bring ARV treatment to 3 million people in developing countries by 2005 appeared to have stalled due to insufficient political motivation to provide the necessary funding. While many promises have been made, not enough countries have shown willingness to provide financing. The U.K., Spain, Sweden, the United States and Canada are the only countries to have given the promised amount of funding to the WHO. An additional $62 million is required to enable WHO to fulfill its role as described in the WHO HIV/AIDS Plan for 2004–2005.

In his 2003 State of the Union Address, President Bush announced the Emergency Plan for AIDS Relief, a five-year, $15 billion initiative, $9 billion of which was to be new money. But, after one year, less than one percent of these 2 million people were receiving treatment via U.S. programs.

AIDS killed 2.9 million people during 2003, and this is not a figure that looks likely to be reduced during 2004, in spite of the good intentions of wealthier countries and the promises that have been made. If this shocking and preventable death rate is to be reduced, then promises must be turned into action, money must be released to the agencies that need it, and these agencies must work together to deliver the drugs, care and education to the people to whom they have been promised. Despite the progress the world has seen, such as treatment options and quality of life for those living with HIV, a small percentage of the world has been lucky enough to benefit from this progress.

Much more can be done. Western nations must recognize the urgency of this epidemic and further cooperate to tackle the growing death toll. In a reality where life-saving medicines are available, however, profitability still stands in the way of saving lives. Looking outside our own backyard, it’s easy to see the devastation wrought by this disease. World AIDS Day acts as a day to turn our eyes outward in order to see the big picture and experience the incalculable magnitude of this disease.