Acquired Immunodeficiency Syndrome (AIDS)
The challenges of HIV vary enormously from place to place, depending on how far and fast the virus is spreading, whether those infected have started to fall ill or die in large numbers, and what sort of access they have to medical care. In all parts of the world except sub-Saharan Africa, more men than women are infected with HIV and dying of AIDS. Men's behavior—often influenced by harmful cultural beliefs about masculinity—makes them the prime casualties of the epidemic. Male behavior also contributes to HIV infections in women, who often have less power to determine where, when, and how sex takes place ("Global Summary of the HI/AIDS Epidemic" 2001). Men's enormous potential to make a difference when it comes to curbing HIV transmission, caring for infected family members, and looking after orphans and other survivors of the epidemic has been noted in many countries.
As the number of children orphaned by HIV/AIDS rises, some calls have been heard for an increase in institutional care for children. This solution is impracticably expensive. In Ethiopia, for example, keeping a child in an orphanage costs about U.S. $500 a year, more than three times the national income per person. One solution developed by church groups in Zimbabwe is to recruit community members to visit orphans in the homes where they live—either with foster parents, grandparents or other relatives, or in child-headed households. Households caring for orphans are provided with clothing, blankets, school fees, seeds, and fertilizer as necessary, and communities contribute to activities such as farming communal fields and generating income to support the program. This community-driven approach to orphan support has been reproduced all over Zimbabwe, and replicas are now sprouting up in other African countries ("Global Summary of the HIV/AIDS Epidemic, 2000" 2001).
Internationally, a campaign by AIDS activists succeeded in 2000 in getting drug companies to lower prices for the antiretroviral medications. But even at prices 90 percent lower than in the United States, drugs are still beyond the reach of most Africans. There is a debate among those working on AIDS in Africa and elsewhere about whether the current emphasis on drugs is taking the spotlight off prevention, where many feel it should be. Apart from the staggering costs of drugs, world health leaders say huge sums of money are needed just for basic AIDS prevention and care in Africa and other developing nations ("Confronting AIDS" 2001).
UNAIDS and WHO now estimate that the number of people living with HIV or AIDS at the end of the year 2000 stands at 36.1 million, 50 percent higher than what the WHO's Global Programme on AIDS projected in 1991 ("Global Summary of the HIV/AIDS Epidemic, 2000" 2001). The unique situation in various countries and parts of the world will be presented in order to catch a glimpse of the diverse face of HIV/AIDS in the early twenty-first century. In each area, access to health care and medication, HIV transmission, and political responses will be considered.
Botswana. The first AIDS cases in Botswana were reported in 1985. An estimated 36 percent of adults were HIV positive as of 2000. The highest HIV prevalence rate is among twenty to thirty-nine year olds. An estimated 300,000 adults and 26,000 children under age five are living with HIV/AIDS. The mean age of death due to AIDS in Botswana is twenty-five in females and thirty-five in males, the reproductive and economically productive years.
Unlike many other African countries, Botswana has a strong and developed infrastructure that provides people with such social services as education and health care. The government, as well as many companies, are trying to provide antiretrovirals to all who need them, regardless of their ability to pay. Well-supplied hospitals and adequate foreign reserves make it easier for Botswana than for other African countries to provide the drugs. But even here, where the annual per capita income is $3,700 a year (high for Africa), many people remain poor. In the next ten years AIDS will slice 20 percent off the government budget, erode development gains, and bring about a 13 percent reduction in the income of the poorest households ("Global AIDS Program Countries" 2001).
The hope of treatment encourages people to be tested, and testing is considered crucial for prevention. Even as efforts to treat people get underway, prevention remains the highest priority, including visits to local bars to show people how to prevent HIV using male and female condoms and going to schools to keep the next generation HIV-free.
Brazil. HIV began to spread in Brazil in the 1980s. At of the end of the year 2000, slightly more than 196,000 cases of AIDS had been reported in Brazil, the largest number in South America. Brazil is unique among the Latin American countries in that it provides those people with HIV infection antiretroviral therapy free of charge if they meet the national medical guidelines for treatment.
An estimated 12,898 pregnant women had HIV infection in 1998, while 536,920 people between the ages of fifteen and twenty-nine were infected with HIV. Between the years 1978 and 1999, 29,929 children were orphaned in Brazil due to AIDS. Although rates of AIDS are decreasing among men who have sex with men and injection drug users, the rate of heterosexual transmission of AIDS is increasing. In many municipalities, especially along the coast, the ratio of AIDS between men and women is approaching 1:1 ("Global AIDS Program Countries" 2001).
South Africa. The HIV/AIDS epidemic started in sub-Saharan Africa in the late 1970s and early 1980s. Half of all HIV positive people in the nine southern African countries hardest hit by the pandemic live in South Africa. The government estimates that 4.2 million persons, and 19.9 percent of the adult population, are infected with HIV, and by 2010 adult HIV prevalence could reach 25 percent, similar to infection rates in neighboring Zimbabwe and Botswana. In 1998 South Africa had approximately 100,000 AIDS orphans, and by 2008, 1.6 million children will have been orphaned by AIDS ("Global AIDS Program Countries" 2001).
Reasons cited for high rates of HIV/AIDS in South Africa are the realities of migrant labor, high prevalence of sexually transmitted disease, and presence of multiple strains of the disease. Exacerbating factors include a society in denial about an overwhelming epidemic that is ravaging the lives and bodies of many persons within a context of poverty and a thriving commercial sex work industry.
Families are especially hard hit by HIV/AIDS in South Africa. One in five pregnant women in South African clinics is HIV positive. Studies have shown that treating pregnant African women with the drug AZT significantly reduced the risk that they would transmit the virus to their babies. However, if these women then breastfed their infants, the risks of transmission rebounded, making it more urgent than ever to find acceptable alternatives to breastfeeding among infected African women. The AIDS virus accounts for most pediatric cases in hospitals. The worst is yet to come because most of the infected have not yet developed AIDS symptoms, and many still feed an infection spiral that is creating about 1,700 new cases every day. Thailand. Thailand has experienced a rapidly escalating and severe HIV epidemic since 1988. Among the sixty million inhabitants of Thailand, as many as 800,000 people are currently believed to be living with HIV. Despite innovative and persistent prevention efforts, HIV continues to spread rapidly, particularly among Thailand's population of injection drug users (IDUs). Methadone treatment, education, counseling on HIV prevention, and easy access to sterile needles have helped to slow the epidemic. Yet, among IDUs in Bangkok, 6 percent continue to become infected each year.
As part of the Thai National Plan for HIV vaccine research, the Bangkok Metropolitan Administration is leading the three-year collaborative research trial to evaluate the ability of AIDSVAX to prevent HIV infection among uninfected IDUs in Bangkok, Thailand. For people infected with HIV, the Thai government and health officials feel very strongly that treatment should follow the protocols that they have established for their country. Therefore, the triple drug therapies currently being used elsewhere are not considered feasible for use in Thailand, not only because of cost constraints, but also because of issues related to the complexity of the regimen, the necessary follow-up and monitoring of patients, and tolerance to the therapies.
United States. In the early 1980s, a number of unexplainable phenomena began to surface across the United States. As the incidents of pneumocystic pneumonia and Kaposi's sarcoma were reported to the Center for Disease Control, a pattern began to emerge. The CDC first published a report reflecting these observations in June of 1981, identifying all of the people demonstrating these symptoms as gay men (Black 1985). In the absence of services in established medical centers and social agencies, many gay men and lesbians joined with activists to establish community-based AIDS service organizations to meet the needs of people affected by HIV. The Names Project Quilt, or AIDS Quilt, has been an important mechanism for people within the United States to recognize the lives of those who have died of HIV/AIDS. The quilt was first displayed in Washington, DC, in 1987, and then in its entirety for the last time in October of 1996, with more than 30,000 panels.
In the United States, as of December 2000, 774,467 AIDS cases had been reported including 640,022 cases among men and 134,441 among women. The main modes of transmission for adults living with HIV/AIDS were men having sex with men, intravenous drug users, and heterosexual transmission. In the United States HIV and AIDS have disproportionately affected the most disadvantaged and stigmatized groups in American society (Barbour 1994). Analyzed by race, 330,160 AIDS cases have been reported among whites, 292,522 among blacks, and 141,694 among Hispanics.
In early 1998, AIDS deaths in the United States dropped by 47 percent. "In recent years, the rate of decline for both cases and deaths began to slow, and in 1999, the annual number of AIDS cases appears to be leveling, while the decline in AIDS deaths has slowed considerably" ("A Glance at the HIV Epidemic" 2001, p. 3). Overall, HIV prevalence rose risen slightly, mainly because antiretroviral therapy is keeping HIV positive people alive longer. Thousands of infections are still occurring through unsafe sex between men. In this era in which few young gay men have seen friends die of AIDS, and some mistakenly view antiretrovirals as a cure, there is growing complacency about the HIV risk, judging from reports of increased sexual risk behavior among this population.
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