7. Treatment and prevention dilemmas

AIDS is still a major threat. ‘Treatment and prevention dilemmas’ shows that prevention and public health programmes are the most cost-effective way to health. HIV infection is preventable through biomedical strategies, such as ensuring safe blood and blood products by screening donors and testing donations; social interventions advising behaviour change, such as using condoms, having fewer partners, and practicing monogamy or abstinence; and—crucial to behaviour change—community mobilization and leadership. AIDS treatment developments are described along with the current state of antiretroviral therapy. Looking ahead, prevention remains the priority—while HIV infected people can live normal, productive lives, it is challenging and expensive.

5. Production and people

‘Production and people’ examines the socioeconomic impact of AIDS, predicted to decrease economic growth. Yet many countries have nonetheless continued to grow. The effect on the private sector depends on a region’s industry and the scale of its epidemic, but there are more options to combat economic effects than in the public sector. The majority of people in high prevalence countries live in rural areas and primarily depend on subsistence agriculture; AIDS is adversely affecting agriculture, predominantly through its impact on labour. It is at the household level that AIDS is most destructive, creating stress and destroying families—becoming impoverished by their burden of care.

1. The emergence and state of the HIV and AIDS epidemic

‘The emergence and state of the HIV and AIDS epidemic’ outlines the emergence of HIV/AIDS, charting the current state of the disease globally. Acquired Immunodeficiency Syndrome (AIDS) is caused by the Human Immunodeficiency Virus (HIV) virus. The spread of AIDS is a complex, long-wave, epidemic event, with waves of spread followed by waves of impact. The future of HIV/AIDS is, epidemiologically, reasonably predictable. Unless the virus mutates and becomes more easily transmitted it will be contained. Science is advancing, with new treatments becoming available and technological prevention methods, microbicides, and vaccines in the pipeline. The impacts are less certain, but will be confined to the worst affected countries and most marginal groups.

4. Illness, death, and the demographic impact

‘Illness, death, and the demographic impact’ outlines how the effects of AIDS can be measured through demographic indicators. Demographic consequences of AIDS may include: increased deaths especially among adults; rising infant and child mortality; falling life expectancy; changes in the population size, growth, and structure; and growing numbers of orphans. How serious these impacts are depends on the location, size, and age of the epidemic; the underlying demographics of a country; and, increasingly, the availability and uptake of treatment. The impacts of AIDS continue to be felt by families and communities after death. There is evidence that AIDS deaths have more serious consequences for survivors than deaths from other causes.

8. Funding the epidemic

The response to HIV and AIDS has to be funded, whether the emphasis is on prevention, treatment, or both. AIDS is unique in part because of its complex financing. It requires long-term commitments for those increasing numbers on relatively expensive lifesaving treatment. ‘Funding the epidemic’ looks at the history of funding from the mobilization of international money into low- to middle-income countries to the increased domestic funding from government budgets fed from general tax revenues. Looking forward, AIDS resource needs are projected to increase at least until 2020. The problem is that treatment for people living with HIV is long-term and these costs remain unacknowledged by governments and donors.

3. What shapes epidemics?

‘What shapes epidemics’ investigates links between HIV/AIDS and certain biological, socioeconomic, and behavioural factors. The main biomedical drivers of HIV/AIDS (after contact with the virus) are the subtype of the viral strain, and the health status and genetic makeup of the exposed individual. Key behavioural factors are the age of sexual debut, sexual practices, number of partners, frequency of partner exchange, concurrency, and mixing patterns including intergenerational sex. People’s behaviour may determine their risk of infection, but behaviours result from the environment in which people live and operate, which is dependent on economics, politics, and culture. Despite the improving technical and biomedical responses, the real challenge is to reduce risk.

2. How HIV and AIDS work and scientific responses

‘How HIV and AIDS work and scientific responses’ explains how HIV operates and is transmitted, and how science has progressed in the discovery and delivery of practical treatments and prevention measures. HIV attacks the immune system, leaving the victim susceptible to other illnesses. The WHO outlines four stages of HIV from asymptomatic infection to full blown AIDS. Transmission occurs through all bodily fluids—with blood carrying the most risk—and most commonly during sexual intercourse. The gap between infection and illness is around eight years, but healthy lifestyles can prolong this. Antiretroviral therapy is expensive, the drugs complex and toxic. Affordability and access remain a life or death issue.

9. Big issues and major challenges

Unless something dramatic happens, the AIDS epidemic will be under control across the world by 2022. The number of new infections will continue to fall; there will be virtually no vertical transmission from mothers to infants; and for those infected, treatment will be increasingly effective and simple, with fewer side effects. But AIDS will not end by 2030, as hoped by the UNAIDS 2015 report. ‘Big issues and major challenges’ examines key areas for the challenge ahead: the need to focus on specific areas and populations, harnessing new technologies, and the sensible use of finance. In 2016 there is ample reason to be optimistic, but there must be continued vigilance.

6. Development, numbers, and politics

‘Development, numbers, and politics’ first considers the Millennium Development Goals (MDGs) set by the United Nations in 2000 and explains how achieving some of them was difficult due to high HIV prevalence in some countries. It goes on to discuss the changing viewpoints of the links between AIDS, conflict, and security, and why accurate data on HIV/AIDS are important for its management. There is limited potential political impact from AIDS, but what is important is ensuring treatment is available and affordable. Political and economic failure has widespread implications for the health system and is harder to manage.