The AIDS battle: taking stock

WASHINGTON — High-level delegations from around the world gather at the United Nations in New York this week for a five-year review of global efforts against AIDS that will highlight both progress and worrying trends.

An encouraging note has been sounded by reports that infection rates are falling in some heavily affected African countries, at least in part as a result of modified behavior among African youths.

But with the overall number of HIV cases still increasing — 5 million new ones last year — alarms will be sounded. Chief among them is concern over the growing concentration of the disease among women — with some experts demanding that global prevention and treatment efforts be more seriously focused on them.

"Twenty-five years into this pandemic, it is having a disproportionate impact on girls and women," says Adrienne Germain, president of the International Women's Health Coalition (IWHC) in New York. "We need to change our policies and budgets to reflect" this evolution, "and the U.N. meeting is a major opportunity to do just that."

Five years after the last major international tally of AIDS — and 25 years after researchers first diagnosed an emerging global health challenge — the world has reached an uneasy consensus on the need for more and better AIDS prevention and treatment programs.

U.S. outlays grow

The United States in particular has boosted HIV/AIDS funding, with the Bush administration paying special attention to the impact of AIDS in Africa — and Congress regularly approving higher spending on AIDS than what the administration requests. But that does not mean this week's meeting will be free of the kind of controversy that has marked similar international gatherings in recent years.

For one thing, many development and health groups focused on Africa are critical of U.S. policy. They say it favors a wasteful, unilateral approach instead of joining existing AIDS programs. Beyond that, they argue that U.S. policy harbors an ideological "abstinence only" bent in prevention work that is undermining the widely favored "ABC" approach — abstinence, be faithful, use condoms.

But in particular, some international health and development organizations are demanding a greater linkage of AIDS prevention and treatment campaigns with international reproductive-health efforts. That faces stiff opposition from anti-abortion groups, which see the campaign as a back-door effort to expand abortion rights.

"What this language of 'reproductive health' is really about is the relentless ideological effort to make certain things a part of universally recognized human rights, and specifically abortion," says Austin Ruse, president of the Catholic Family and Human Rights Institute (C-Fam) in Washington.

Proponents of the linkage say it is a matter of efficiency — reaching more women at a crucial point in the evolution of AIDS.

Thoraya Ahmed Obaid, executive director of the United Nations Population Fund, says "scaling up" prevention and treatment programs would be easier and more efficient if existing reproductive-health networks are used.

But beyond practicalities, Obaid says, linking the two efforts has become imperative as AIDS has increasingly affected women, in particular those in developing countries.

"ABC is a package that is having an impact in many places, but it is not enough when a growing number of infections are among women, and young married women," she says. "We need accessible reproductive-health policies that empower women, put more of the decision making in their hands, and address the cultural issues affecting them, such as violence against women."

Today half of all people with the AIDS virus are female — up from 41 percent in 1997 and 35 percent in 1985, according to the IWHC. And in many developing countries, well over half of newly infected people are female.

This trend is also appearing in countries like the United States. Today, AIDS is the leading cause of death among African-American women ages 25 to 34, notes Yolonda Richardson, president of the Centre for Development and Population Activities.

In the U.S., AIDS infection rates are climbing again after a sustained decline. "So, to the extent that AIDS is increasingly affecting women," Richardson says, "we can say that our conventional strategies are not working because they are not working for women."

Ruse of C-Fam agrees that "conventional strategies" have not been effective, but adds that he means the focus on condom use has been no panacea. "The world is flooded with condoms, but it doesn't seem to have much impact on the HIV rate," he says.

Conflicting assessments

One obstacle to resolving the "reproductive health" controversy is that even some success cases in lowering AIDS rates cannot be laid clearly at the feet of a particular strategy. A dramatic decrease in infection rates in Uganda, for example, is claimed by both "ABC" proponents and backers of abstinence-only programs.

One undeniable factor in Uganda's results is that both men and women have reduced their number of sexual partners, notes Germain of the IWHC. But after visiting sex-education classes in Uganda, she is convinced that Uganda would not be where it is today if condoms were not part of the curriculum.

One question some AIDS prevention and treatment organizations are asking is what tone the U.S. delegation to the U.N. meeting will take in some of the controversial debates. That is especially true since the delegation is being led by Laura Bush, who is seen to be less socially conservative than some forces in the administration.

Critics of the administration say the so-called "gag rule" it imposed on even mentioning abortion in the context of U.S.-funded reproductive-health programs has confused private groups on the limits for using U.S. funding. They say a provision that at least one-third of American AIDS-prevention funding be spent on abstinence-only programs has added to the confusion to a point where some successful AIDS-prevention programs have decided to turn down U.S. funds.

With all the opportunity for controversy at the U.N. meeting, some AIDS activists are hoping enough common ground can be found to deliver on what they say should be less-contentious issues — such as higher funding of the Global Fund to Fight AIDS, Tuberculosis and Malaria; or a stronger focus on women in the battle against AIDS.

"I am alive today because I have overcome stigma, ignorance and poverty," says Inviolata Mwali Mmbwavi, who heads Kenya's National Empowerment Network of People Living With HIV/AIDS. "If more women are able to determine their own economic status and take control of their lives without fear of violence, that will have an impact."