'The situation is already worse than the Black Death of the 14th century'

The Dublin conference on AIDS gave rise to both hope and despair, writes Dick Ahlstrom , Science Editor.

The Dublin conference on AIDS gave rise to both hope and despair, writesDick Ahlstrom, Science Editor.

One could experience hope and despair in equal measure at the conclusion of the two-day ministerial conference on HIV/AIDS. Hope springs from the efforts of governments and NGOs as they battle relentlessly against the disease, but despair blackens the horizon given the overwhelming challenge they face in this struggle.

The meeting was designed to be the Government's showpiece during our Irish EU presidency, ranking as the largest single event to take place during the six months. Not unexpectedly it managed to deliver its goal, the Dublin declaration on combating HIV/AIDS in Eastern Europe and Central Asia.

These two regions, encompassing areas as large as Western Europe, are the latest major crisis point for the world AIDS pandemic. The meeting was called specifically because countries in these regions collectively have experienced a 50-fold increase in the numbers afflicted with the disease, this increase seen in just eight years.

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The case load rocketed from a few tens of thousands to upwards of 1.8 million over this period, projecting Eastern Europe and Central Asian countries into the unenviable position of having the highest HIV infection rates anywhere on the planet.

The conference focus was sharply on these two regions but speakers were quick to indicate there was no attempt to divert attention away from the ongoing crisis in Africa where 27 million people are now known to have HIV.

Rather, the African experience has been so bad that bodies such as the United Nations Development Programme, the UN AIDS programme, World Bank, World Health Organisation and others believe that concerted action is necessary to prevent the African catastrophe from becoming typical of HIV's progress elsewhere.

Yet while the rising incidence figures look familiar, there are significant differences between the African and Eastern European experience of HIV/AIDS. In Africa the disease is driven mainly through heterosexual sex. This puts women at risk in particular, and the statistics there testify to this. Eight women there are infected for every one man, and teenage girls are most at risk.

The growth of AIDS in Eastern Europe and Central Asia was driven initially by intravenous drug abuse. Eight men are infected for every one woman, with teenage boys at greatest risk.

It is also a young person's disease there, with 80 per cent of HIV positive individuals aged under 30.

"Yet those who are the most vulnerable are also the least likely to have the information or services they need to prevent HIV infection," said Ms Carol Bellamy, executive director of the United Nations Children's Fund.

She turns to Africa to gain insights into what is likely to happen in Eastern Europe and Central Asia unless treatment and prevention programmes can be made to work. "It is virtually eating societies, destroying them from the inside," she told The Irish Times.

She points to Botswana as a prime example of that AIDS can do. It was a model of what African democracy might look like, with a progressive economy and improving services for its citizens.

Botswana today has been devastated by the disease. The financial burden imposed by treatment costs has crippled its ability to pay its way and the social impacts are astounding. Average life expectancy has plummeted by 20 years, to the low 40s.

Alarmingly, the disease was likened to the bubonic plague by Dr Richard Feachem, executive director of the Global Fund to fight AIDS, TB and malaria. "We have seen nothing like it in human history," he said. "It is already worse than the Black Death of the 14th century." Nor are there signs of a quick fix provided by the research community. Tremendous efforts are under way to find a vaccine for the disease. When the HIV virus was unmasked as the cause of AIDS in the mid-1980s, scientists confidently predicted that a vaccine response would be available within two years. Yet the search is still on and efforts so far have failed to deliver.

Not surprisingly, there has been greater success with drug therapies. Companies developing treatments will always prefer to provide disease containment based on daily drug use rather than disease cure through a once-off vaccine. Containment pays very well if the disease is intractable but the person survives for a long time.

The current gold standard in the pharmaceutical response is a triple-drug combination therapy using anti-retroviral drugs which in effect clear the disease and leave the person largely symptomless - provided of course you can afford to pay. Drug costs run into the thousands over the course of a year, and this is a price that is simply too high for most developing countries.

The result is a huge patient case load that goes untreated, representing a death sentence for the individual who can't pay.

The UNDP estimates that of the 80,000 people in Eastern Europe and Central Asia who require the triple-drug treatment for AIDS, only 7,000 now receive it. Many countries are still relying on the less effective single-drug anti-retroviral therapies, but the UNDP warns that this only increases the risk of generating a drug-resistant strain of HIV.

Is it time for despair to take hold and drive off any room for hope? The experts who spent the last two days discussing these problems delivered an emphatic No when this was put to them by The Irish Times.

The UN Secretary General's special envoy for HIV/AIDS in Eastern Europe, Mr Lars Kallings, acknowledged that it was already too late, but only in the context that the disease is with us and spreading. It was never too late to do something to counter it.

"When you start to take action you can slow the spread of HIV," said Mr Henning Mikkelsen, UNAIDS European regional co-ordinator. "It is never too late."

Clearly it is not too late if bodies such as the World Bank are funding AIDS treatment and prevention programmes around the world. The global fund put together in support of the campaign against the virus now has commitments amounting to a substantial $5.3 billion, so financial resources exist for an assault on the disease's progress, Mr Feachem said.

"There is hope now we can mount a counter-attack that is so overdue and so essential," he said. Yet success is predicated on finding leadership qualities in the regional politicians who face the crisis. There was general acknowledgement that without this, there could be no counter-attack. Unfortunately politicians are not always known for their ability to lead from the front.