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Merson Critiques and Reviews Global Response to HIV/AIDS Pandemic in Graduate School’s Dean’s Lecture Series

Michael Merson, Dean and Anna M.R. Lauder Professor of Public Health, and Director of Yale’s Center for Interdisciplinary Research on AIDS (CIRA), began his lecture with the staggering facts about the human toll that HIV/AIDS has taken on the world since the first AIDS cases were reported in 1981: 71 million HIV infections, 31 million deaths, and 40 million people living with HIV/AIDS.

In a January 21 talk entitled “The HIV/AIDS Pandemic: A Failed Global Response” that was part of the Dean’s Lecture Series “In the Company of Scholars,” sponsored by the Graduate School, Merson argued that the global response to HIV/AIDS has been, for the most part, “delayed, inappropriate, grossly insufficient and poorly coordinated” for a variety of reasons, including that the disease has been associated with marginalized populations and socially controversial behaviors, engendering a moralistic and judgmental response.

Merson first gave listeners in the crowded McDougal Center conference room a sense of the magnitude of the effect of HIV/AIDS around the world today. In 2003, approximately 14,000 new HIV infections were diagnosed each day, more than 95% of which were in people living in low and middle income countries. A report issued by the Joint United Nations Programme on HIV/AIDS (UNAIDS) in the middle of 2002 estimated that without dramatically expanded prevention and treatment efforts, 68 million more people in the 45 most affected countries will die of AIDS between 2000 and 2020. Merson made it clear that AIDS causes far-reaching social and economic problems as well as medical and public health problems: AIDS deaths are causing the population growth rate to decline in certain areas, are projected to leave 20 million children orphaned by 2010, and are negatively impacting the annual per capita GDP growth in countries with high rates of adult HIV infection. In some Southern African countries, the average life span will be below 30 years of age by 2010.

Merson then began to describe and critique the world’s response to AIDS. He noted that early discourse centered on homosexuality, commercial sex, infidelity, illicit drugs and the presumed fatality of the disease, resulting in stigmatization of and discrimination against those with the disease, and paralysis on the part of leaders in the political and scientific communities. Due in part to the response to AIDS, it was not until 1987 that the World Health Organization (WHO) formed the WHO Special Program on AIDS to address the disease on a global scale. By that time, between five and ten million people had been infected by the virus. In 1988, the WHO Special Program on AIDS became the WHO Global Program on AIDS (GPA), which Merson headed from 1990 to 1995. WHO was able to make some progress in the fight against AIDS by, among other things, helping to establish the Global Network of People Living with AIDS and the International Council of AIDS Service Organizations, partnering with and financially supporting non-governmental organizations, reaching out to populations at heightened risk for becoming infected with the HIV virus, and supporting national prevention efforts, a few of which, including those in Thailand and Uganda, achieved marked success. The world’s response was still lagging, however; despite world-wide invitations, fewer than 35 countries sent representatives to the Paris AIDS Summit in 1994.

GPA ended in 1995, and was replaced in 1996 by UNAIDS, which was formed to try to bring about an expanded and more coordinated response. UNAIDS immediately faced a variety of challenges, including coordination of the different United Nations (UN) agencies that comprised it, conflict over the appropriate strategies for confronting the AIDS pandemic, and its limited size and budget. As international political efforts to combat AIDS continued to struggle, the scientific community made an important advance, introducing antiretroviral (ARV) drugs in 1995. While their introduction led some in the U.S. media to speculate about the end of AIDS, the reality of the new drugs was far different. At that time, AIDS treatment required drug regimens and administration that were complex, and the drugs themselves were extremely expensive, making the new treatments unavailable in developing countries.

Since 2000, when the UN Security Council held a debate on the impact of AIDS on peace and security, there has been a flurry of activity relating to AIDS and its worldwide impact. In early 2001, CIPLA, an Indian generic pharmaceutical company, announced plans to sell ARV drugs at reduced prices in sub-Saharan Africa, causing several major pharmaceutical companies to follow suit. Beginning with its Doha declaration on the Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement and public health, which approved in principle the waiver of patent rights in the context of public health emergencies, the World Trade Organization, along with non-governmental organizations, the pharmaceutical industry and many others, has worked to make ARV drugs less expensive and more accessible in developing countries. Following the convening of a special session of the UN General Assembly in mid-2001, the Global Fund to Fight AIDS, Tuberculosis and Malaria was established in early 2002. In his 2003 State of the Union address, President Bush announced his five year, $15 billion Emergency Plan for AIDS Relief. Later in 2003, WHO launched its “3 By 5 Strategy,” which has a goal of providing ARV treatment to three million people by 2005. While all of these initiatives are well-intentioned, Merson said, coordination among them is sorely lacking.

Merson noted that the gap between the AIDS treatment available in the developed and developing worlds has diminished as drug prices have fallen, drug regimens have become simpler and drug administration has become easier. However, he warned that the AIDS epidemic is expanding, and that a sustained, comprehensive approach to prevention is needed to contain the number of new HIV infections. Giving undue attention and resources to care at the expense of prevention would result in a worsening of the pandemic. He listed the scaling up of prevention efforts; increasing access to ARV drugs; coordination of global initiatives, particularly between the United States, the Global Fund and the United Nations; the development of an effective vaccine and microbicide; and sustained political commitment as key to stemming the spread of AIDS.

For additional information, please see CIRA’s website at http://cira.med.yale.edu.

-Story by Christy Gordon.