Canadian Medical Association Journal 1995; 153: 1613-1616
[résumé]
Voir aussi :
World AIDS Day
Voluntary anonymous linked study of the prevalence of HIV infection and hepatitis C among inmates in a Canadian federal penitentiary for women
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Introduction
Dec. 1 is World AIDS Day 1995. To mark the occasion Dr. Catherine Hankins reflects on the global implications of the growing HIV epidemic in Asia.
The HIV/AIDS pandemic continues to evolve inexorably and with increasing predictability. The epicentre is shifting from sub-Saharan Africa to Asia, and it is expected that the annual incidence of new HIV infections in Asia will exceed that of sub-Saharan Africa by the year 1997.(1) In many Asian countries, where decision makers and the public had judged that religious and cultural traditions would prevent the epidemic from gaining ground, HIV transmission is now in high gear. Because the number of AIDS cases is still comparatively low, the need to mobilize individuals, communities and governments to counter this largely invisible menace presents an urgent challenge. This theme was paramount at the recent Third International Conference on AIDS in Asia and the Pacific, held from Sept. 17 to 21, 1995, in Chiang Mai -- the worst-affected city of Thailand, which is itself the country with the highest per capita HIV prevalence rate in the region. Sponsored by the World Health Organization (WHO), the AIDS Society in Asia and the Pacific and the Asia Pacific Council on AIDS Services Organization, the conference was attended by more than 2500 scientists, academics, activists and government officials, including a dozen Canadians.
As the millennium approaches and political and economic boundaries weaken, a number of questions concerning AIDS in Asia should preoccupy us all. What are the characteristics that define societal vulnerability to HIV in Asia? How effective are the responses that have been mounted to date? What are the implications for Canadians of the growing epidemic?
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Social vulnerability in Asia
A combination of factors have contributed to the denial of the threat of AIDS that has prevailed in many nations of Asia and the Pacific Rim. Among these is a general perception that family and community structures as well as cultural norms and religious beliefs are capable of protecting the population from HIV transmission and that sufficient care and support for those who do become ill with HIV-related disease will be provided within the family and the community. The economies of Asia are booming: annual growth rates of 8% to 10% have not been unusual over the last few years in Thailand, Vietnam, Malaysia and other countries of the region. Expectations and aspirations are high, with the result that it is difficult to overcome complacency (official and otherwise) about AIDS by painting negative pictures of the future that will result from today's unbridled HIV transmission. Moreover, HIV infection remains relatively invisible, a figment of epidemiologists' prevalence studie!
s and estimates. For example, only 885 cases of AIDS had been reported in India by the end of 1994, when estimates of the number of people living with HIV infection in that country ranged from 900 000
to 2.1 million.(2)
By all accounts the impact of HIV infection in Asia is likely to be devastating. Half of the world's population lives there; heterosexual sex has emerged as the dominant mode of transmission in the region; poverty and illiteracy are widespread despite economic growth; and a large proportion of the population is in the sexually active years. Injection drug use involving unsterile needles and unprotected commercial sexual activity are found in many major cities. As many as 74% of people who use injection drugs in Myanmar (Burma)(3) and 51% of commercial sex workers in Bombay(4,5) are already infected with HIV. Finally -- and critically -- the unequal economic, educational and social status of women creates the conditions that undermine the ability of even informed women to make sexual decisions that will protect themselves and their unborn children against HIV infection.
Results reported at the Chiang Mai conference of a study of the potential impact of HIV/AIDS on human development in the region(6) brought into stark relief the societal consequences of inaction. Human development, which is broadly defined as the process by which people's choices and capabilities expand,(7) can be measured by the United Nations Human Development Index (HDI). This index combines indicators such as life expectancy, real gross domestic product (GDP) per capita, school enrolment and the adult literacy rate.(8) For the study, measurements were reported in country-specific "development-years" (the amount of improvement, calculated as an HDI value, that a country could be expected to make over a 1-year period). According to current HDI indicators and prevalence estimates for HIV infection, by the year 2005 Thailand will have lost 9 development-years and Myanmar will have lost 5.(6) In a rousing call to action Anand Panyarachun, former prime minister of Thailand,! claimed that actions to minimize the scale of the epidemic and reduce the social and economic impact of projected decreases in productivity and the los s of skilled workers must be effective within the next 12 months. Otherwise, no less than 20% of GDP will be at stake in every country of the region.
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Taking action
The responses mounted to date have been uneven; "international best practice" is found alongside denial, complacency, inaction, discrimination and outright neglect. Thailand, where an estimated 800 000 people are infected with HIV, has lead the way in responding to the crisis. Commitment at the highest political level has resulted in action on an unprecedented scale and is beginning to achieve positive results. AIDS is viewed as a
national development issue rather than as a health problem. When Panyarachun accepted the chair of the National AIDS Committee while he was in office in 1991, he gave full responsibility for the formulation of Thailand's National AIDS Action Plan to the National Economic and Social Development Planning Board, which then wrote AIDS into the country's national plan for development. Such vision is lacking in most countries of the world.
The Thai program for controlling HIV transmission was launched in 1989, after a dramatic increase in HIV prevalence -- from less than 1% in 1987 to 43% in 1988 -- was documented among people using injection drugs in Bangkok.(9) The prevention program was expanded to all areas of the country in 1991. In addition to initiatives aimed at reducing the harm associated with the use of injection drugs, the Ministry of Public Health launched a "100% Condom Campaign" to address the problem of heterosexual transmission of HIV.(10) In 1992 alone the government supplied 45 million free condoms to brothels. Sanctions are brought against commercial sex establishments in which condoms are not used consistently (as judged by the exposure histories of men diagnosed with a sexually transmitted disease). Television and radio campaigns directed at men explicitly advise the use of condoms with commercial sex workers.(11) Mandatory viewing of AIDS prevention videos and HIV counselling session! s at m arriage registration have been introduced in two provinces.(12) General education and publicity about HIV and AIDS are widespread throughout Thailand, and biannual sentinel surveillance studies involving people who use injection drugs, blood donors, pregnant women and commercial sex workers permit close monitoring of the impact of prevention efforts.
Contrary to many predictions, the frank approach taken in Thailand has not affected tourism: more visitors entered the country in 1994 than in 1991.(13) This is a source of reassurance to many governments in the region who are concerned that tourists will be reluctant to visit if the extent of the local HIV epidemic is admitted.
Encouraging results from Thailand's broadly based, multisectoral strategy have now been documented, setting an example for other countries. Between 1989 and 1993 the use of condoms in commercial sex transactions increased from 14% to 94%, and the number of cases of five major sexually transmitted diseases (syphilis, gonorrhea, nongonococcal urethritis, venereal lymphogranuloma and chancroid) declined by 79% among men.(11) A dramatic reduction in the prevalence rate of HIV infection among young men selected by lottery for conscription into the army has recently been reported. Decreases were observed among men from all regions of the country, whether rural or urban, and among men of all educational levels; the greatest decrease was seen in the north, where the rate upon entry into the army fell from 12.4% to 7.9% between 1992 and 1994.(14) Although such reductions in the incidence of HIV infection are extremely important, there remains a considerable distance to travel in o! rder to get this epidemic under control. Recognizing the importance of preventing further HIV transmission, Thailand has embarked on a vaccine trial strategy that leads the world. More extensive data have been collected in Thailand on HIV incidence rates and cohort follow-up success rates than anywhere else.(15) This has set the stage for phase III vaccine efficacy trials to be undertaken once an appropriate candidate vaccine that targets HIV subtypes prevalent in Thailand becomes available.
None the less, as those who are already infected with HIV become symptomatic in increasing numbers, the long-term consequences of HIV infection will continue to plague both Thailand and countries in Asia that have yet to document any progress in preventing HIV transmission. Microlevel effects on families and households will combine with macrolevel effects in the private and public sector to undermine the capacity of governments to provide good governance. The economic and social burden of care will likely exceed the capacity of traditional mechanisms such as support from family members, neighbours, religious leaders and the community. Potential repercussions such as impoverishment and an unravelling of the social fabric loom on the not-so- distant horizon in Thailand, India, Myanmar and other countries in Asia unless the positive coping responses of individuals and communities can be facilitated and strengthened.
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Enlightened self-interest
Why should the HIV epidemic in Asia concern us in Canada, where some aspects of our own national AIDS strategy have born fruit and pragmatic programs such as community needle exchanges and condom provision to prison inmates hold the promise of future returns? The basic answer is that just as international borders have afforded no protection against the spread of HIV, neither will they prevent the economic and social consequences of the epidemic in Asia from being felt in Canada in quantifiable ways.
Declining productivity and the increasing health care costs associated with HIV-related disease can affect Canadian investments in Pacific Rim countries and weaken the purchasing power of overseas markets for Canadian products. Social unrest and political instability resulting from the HIV epidemic in Asia will concern us because of the strong economic and diplomatic ties that Canada has established with several Asian countries, not to mention the personal contacts that many Canadians have with people in the region. It is time for us to recognize that distinctions between domestic and international health are no longer useful. In fact, they can be harmful. Given the scale of the movement of people and products across international borders, we can no longer insulate ourselves. It is time to recognize that, our humanitarian preoccupations aside, it is in our own interest to encourage and support programs that address global health concerns, whether these relate to emerging ! and re surgent diseases such as hantavirus pulmonary syndrome and drug-resistant tuberculosis or to the HIV pandemic.
On Jan. 1, 1996, a new United Nations program called UNAIDS comes into effect. It brings together the United Nations Development Programme (UNDP), UNESCO, the United Nations Population Fund, UNICEF, WHO and the World Bank in a collaborative effort to catalyse a global response to HIV infection and AIDS. In addition to strengthening political commitment at all levels and building the capacity of individual nations to mount an expanded response to AIDS, UNAIDS will guide a technically sound, ethical and cost- effective response that is respectful of human rights.(16) It is a unique experiment, an exercise in institutional behavioural change and a test case for United Nations reform fuelled by a realistic sense of urgency. With the cumulative total number of cases of HIV infection conservatively estimated to reach 30 to 40 million by the year 2000, UNAIDS deserves our strong individual and collective support. Although we have perhaps underestimated the extent of our global interrelatedness, it is now time to build solidarity, motivated by both altruism and self-interest, for an effective global response to the threat posed to the health and well-being of humankind.
See also:
World AIDS Day
Voluntary anonymous linked study of the prevalence of HIV infection and hepatitis C among inmates in a Canadian federal penitentiary for women