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© 2006 American Public Health Association
DOI: 10.2105/AJPH.2006.089086
EDITORIAL |
Ron Stall is with the Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pa. Thomas C. Mills is with the Western Psychiatric Institute and Clinic, University of Pittsburgh, Pittsburgh.
Correspondence: Requests for reprints should be sent to Ron Stall, PhD, MPH, Graduate School of Public Health, University of Pittsburgh, 111 Parran Hall, 130 DeSoto Street, Pittsburgh, PA 15261 (e-mail: rstall{at}pitt.edu).
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INTRODUCTION |
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 TOP INTRODUCTION AIDS EMERGES FIRST WITHIN...AIDS IS A DISEASE...AIDS PREVENTION WORKS, BUT...BIOMEDICAL RESPONSES MAY NOT...CAREFUL ANALYSIS OF INITIAL...HOW WILL HISTORY JUDGE...References |
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This summer marks the 25th anniversary of the first scientific description of the AIDS epidemic.1 Since the publication of the initial report describing 5 cases of an unknown disease, the epidemic has grown at an exponential rate. An estimated 40300000 people are living with HIV infection around the globe, of whom 4900000 were infected during the year 2005 alone.2 The explosive trends in the global epidemic have also occurred in the United States; an estimated 925000 to 1025000 HIV-seropositive persons resided within the United States in 2003.3 Unless we find ways to field effective AIDS prevention and treatment programs on a global basis, we will continue to stand witness as a dangerous epidemic spins out of control, with tragic repercussions for the rest of this new century. Here, we identify the most prominent attributes of AIDS—already evident at the quarter century milepost—that challenge the effective functioning of prevention and treatment efforts and identify some initial successes that may provide guidance for future advances in managing the epidemic.
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AIDS EMERGES FIRST WITHIN MARGINALIZED COMMUNITIES |
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TOPINTRODUCTIONAIDS EMERGES FIRST WITHIN...AIDS IS A DISEASE...AIDS PREVENTION WORKS, BUT...BIOMEDICAL RESPONSES MAY NOT...CAREFUL ANALYSIS OF INITIAL...HOW WILL HISTORY JUDGE...References |
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AIDS strikes first and most cruelly among those groups marginalized because of their drug use patterns, alternative sexualities, gender, racial minority status, or lower socioeconomic status. As such, its development is a classic example of how sociocultural processes operate to create health disparities. AIDS-related disparities can also assume impressive dimensions. Although population-based surveys find that the proportion of men who have had sex with men during the past year only account for about 3%4 of the adult male population, these men accounted for 50% of the cumulative AIDS caseload reported through 2004.5 Similarly, according to the last census, African Americans account for 12.3% of the US population, yet they accounted for 43% of the number of persons living with AIDS at the end of 2004.6 Even worse, these health disparities exist within an epidemic of enormous scale. Through 2004, a cumulative total of 462760 AIDS cases had been reported in the United States among men who have sex with men (MSM) to the Centers for Disease Control and Prevention,5 a figure roughly equivalent to the total number of American military deaths during World War II. And yet, the burden is borne by a very small subpopulation of American men. Understanding the specific mechanisms of how AIDS takes its greatest toll among culturally or economically marginalized populations—and finding ways to disrupt these processes—remains a scientific goal of the first order.
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AIDS IS A DISEASE OF DENIAL |
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TOPINTRODUCTIONAIDS EMERGES FIRST WITHIN...AIDS IS A DISEASE...AIDS PREVENTION WORKS, BUT...BIOMEDICAL RESPONSES MAY NOT...CAREFUL ANALYSIS OF INITIAL...HOW WILL HISTORY JUDGE...References |
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Because of the stigmatizing attributes of the epidemic and the additional associations with death and contagion, AIDS is a disease of denial at the individual, group, and national level. These attributes often mean that serious public health responses are tardy, making effective prevention and treatment responses to the epidemic even more difficult to fund, to field, to evaluate, and to maintain. Because so many controversial issues directly shape the AIDS epidemic, governments will continue to be tempted to respond by funding unproven programs that convey the impression of restoring traditional cultural values rather than fielding scientifically proven prevention approaches that directly target issues of sexual safety or drug use.7
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AIDS PREVENTION WORKS, BUT MORE PROGRESS IS NEEDED |
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TOPINTRODUCTIONAIDS EMERGES FIRST WITHIN...AIDS IS A DISEASE...AIDS PREVENTION WORKS, BUT...BIOMEDICAL RESPONSES MAY NOT...CAREFUL ANALYSIS OF INITIAL...HOW WILL HISTORY JUDGE...References |
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A series of meta-analyses of randomized, controlled trial outcome evaluations has shown that AIDS prevention model programs that directly target the topics of safe sexual practice or drug use yield significant positive effects among a variety of risk groups8–12 and among HIV positive people.13–14 Despite the overall success of the efforts that have tested conceptual models of HIV prevention, barriers remain that hinder translation of scientific knowledge into frontline prevention practice.15–16 These barriers include not only the considerable operational challenges of faithful diffusion of science-based interventions into the field but also the translation of those interventions so that they are appropriate within specific cultural contexts. Most frontline HIV prevention work has been fielded without careful evaluation, thereby making the outcomes susceptible both to ideological interpretations for their success17 and to the paradox of prevention (wherein prevention program success is used politically as evidence to end support for the program). Ongoing partnerships between public health scientists and frontline prevention workers are necessary to show that AIDS prevention work is effective and to define new opportunities to increase the effectiveness of frontline prevention work.18
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BIOMEDICAL RESPONSES MAY NOT BE ENOUGH TO END THE EPIDEMIC |
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TOPINTRODUCTIONAIDS EMERGES FIRST WITHIN...AIDS IS A DISEASE...AIDS PREVENTION WORKS, BUT...BIOMEDICAL RESPONSES MAY NOT...CAREFUL ANALYSIS OF INITIAL...HOW WILL HISTORY JUDGE...References |
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Because of the many challenges that face prevention programs, biomedical interventions such as vaccines, microbicides, and HIV antiretroviral treatments to manage the epidemic will have great appeal for the foreseeable future. This appeal is certainly understandable and appropriate—a highly efficacious vaccine, over time, could render moot the dangers posed by this epidemic. Furthermore, antiretroviral treatments have given hope for survival to tens of millions of people now living with HIV in the developing world. Nonetheless, the eagerness to achieve a biomedical fix to the AIDS epidemic should be constrained by a sober assessment of the limitations encountered by other vaccines used to combat other epidemics that are especially virulent among the same populations, such as Hepatitis B,19 or the mixed record of antiretroviral therapies in managing the epidemic itself.20 Thus, because of the strength of the potent sociocultural forces that continue to shape the AIDS epidemic in marginalized populations, a conjoined social and biomedical effort will almost certainly be necessary to end the epidemic.
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CAREFUL ANALYSIS OF INITIAL SUCCESSES FOR FUTURE ACTION |
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TOPINTRODUCTIONAIDS EMERGES FIRST WITHIN...AIDS IS A DISEASE...AIDS PREVENTION WORKS, BUT...BIOMEDICAL RESPONSES MAY NOT...CAREFUL ANALYSIS OF INITIAL...HOW WILL HISTORY JUDGE...References |
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Designing an effective response to the AIDS epidemic requires that we identify not only challenges but also initial successes on which future advances in fighting the epidemic can be modeled. Among these successes are the strength and wisdom of lay community responses to the epidemic, ranging from the design of model prevention programs to the development of AIDS care strategies to the mobilization of groundbreaking activism and public policy initiatives. In the case of needle exchange programs, community-based responses have been among the most effective tools yet developed to lower HIV transmission.21
On the scientific front, the advances made since the advent of AIDS activism to support increases in funding for research in the fields of retrovirology, immunology, pharmacy, and the scientific study of sexual behaviors have been transformative. Structural interventions, which seek to change the contexts of risk through policy, legal, or environmental change, are also among the more successful responses to the epidemic. For example, testing the supply of transfused blood to eliminate HIV-infected plasma, a simple intervention, has reduced the scope of the epidemic and saved thousands of lives. Other structural interventions such as the use of antiretroviral medications to interrupt vertical HIV transmission from mother to child, needle exchange, and the 100% safe-sex program to prevent HIV transmission in brothels in Thailand have also had similarly powerful effects.
On the cultural front, there have been attempts at activism by groups such as ACT UP to confront the stigma associated with HIV, the goal of which is to change the cultural context in which stigmatized populations live. Although it is difficult to identify a thread common to these initial successes, it is notable that each of these initiatives has been characterized by the use of then-innovative scientific or theoretical advances that could be pragmatically fielded and maintained within specific community or institutional contexts.
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HOW WILL HISTORY JUDGE OUR ACTIONS? |
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TOPINTRODUCTIONAIDS EMERGES FIRST WITHIN...AIDS IS A DISEASE...AIDS PREVENTION WORKS, BUT...BIOMEDICAL RESPONSES MAY NOT...CAREFUL ANALYSIS OF INITIAL...HOW WILL HISTORY JUDGE...References |
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At the first quarter century of the AIDS epidemic, it is important to weigh our accomplishments against our failures in the fight against AIDS. Perhaps the most useful vantage point would be as future historians, several centuries hence, viewing our current efforts to fight AIDS, much as we consider the responses of medieval Europeans combating the Black Plague.
Certainly future historians will have ample evidence that we recognized that AIDS was one of the great public health catastrophes of our time and will show that, whatever else motivated our responses, we were not ignorant of the dangers of the disease, of the means by which it was transmitted, of the groups who were at gravest risk of transmission, or of effective strategies to prevent further HIV transmission. Future historians will conclude that we cannot escape responsibility for our failure to use effective, scientifically proven strategies to control the AIDS epidemic.
Future historians will be heartened that some of our leaders accurately perceived that AIDS was a global health problem that respected no borders. These historians will also be saddened to see that the resources to fight AIDS on an international basis were insufficiently marshaled in the crucial first decades of the fight against the calamity. They probably will be impressed with the rapid progress made in scientific understandings of the pathogenesis and treatment of AIDS, yet appalled by the instances when the ancient curses of racism and homophobia prevented us from fully responding to AIDS epidemics unfolding in our midst, as is the case now with African American MSM.22
Historians centuries hence will likely find our ongoing controversies over how best to fight the epidemic to be interesting windows on our evolving standards regarding sexual behavior and drug use, our views of social groups with whom we have limited contacts, and our ethical responsibilities to each other. They will also likely regard as tragic those instances when we allowed scarce resources to be used to support ideologically driven "prevention" that only served a particular political agenda. And from their distant vantage point, future historians would also tell us that, however difficult, controversial, and expensive we perceive the fight against AIDS to be, those costs are trivial compared with the price that we will all pay if we do not make every effort to bring AIDS to an end.
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Acknowledgments |
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Mark Friedman, Michael Plankey, Robert Goodman, Martha Terry, Tony Silvestre, and Elizabeth Kim provided helpful criticism of earlier versions of this editorial.
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Footnotes |
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Contributors
Ron Stall and Thomas C. Mills jointly co-authored all aspects of this editorial as a collaborative effort.
Accepted for publication February 25, 2006.
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References |
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