In spite of two decades of research and action against AIDS the global pandemic is accelerating. About 40 million people, including 2.5 million children, are now living worldwide with HIV, 95% in the developing world. Each year five million people are newly infected [1] and the annual death rate has risen from just over two million in 1999 to three million in 2003. At current rates of infection there will be 45 million more with HIV by 2010; but 29 million of these could be prevented if a comprehensive set of measures were implemented immediately in the worst hit countries.[2]

At the release of the 2003 AIDS Epidemic Update, Dr Peter Piot, the executive director of UNAIDS (the joint UN programme on HIV and AIDS) warned that AIDS was tightening its grip on Africa and threatening other regions of the world: 'The world is mounting a greater response to AIDS through individual initiatives like the US government's emergency plan on AIDS and the Global Fund to fight AIDS, TB and Malaria. However it is clear that our current efforts remain entirely inadequate for an epidemic that is continuing to spiral out of control.'[3]

There are some signs of hope. AIDS spending in low and middle-income countries has risen almost 25- fold in the last seven years, from $200 million in 1996 to $4.7 billion in 2003. Money is now coming from a variety of sources: UN agencies, multilateral organisations and also private groups like the Bill and Melinda Gates Foundation, which has allocated $250 million a year for HIV/AIDS since 2000.[4] Reduced drug prices, more funding and a recent trade agreement to allow poor countries to import (or produce) copies of patented drugs have certainly helped. But there is still a huge way to go.

The challenges are four-fold: antiretroviral treatment, palliative care, care for AIDS orphans and prevention.

Antiretroviral treatment

On 1 December 2003 (World Aids Day) the WHO and UNAIDS launched their '3 by 5' strategy to treat five million people with AIDS by 2005.[5] Drug treatment tends to grab the headlines: especially as the cost of medicines has fallen dramatically. The cost of antiretroviral treatment in Western countries where pharmaceutical companies have patents is about $10,000 a year. This was also the cost to developing countries in 2000. But now generic copies made in India, where patent rules do not apply, are being sold to African countries for around $300 a year, and it is hoped that this price will fall by half by the end of 2005.[6] There are six million people with HIV/AIDS, but currently only about 300,000 people in developing countries receive the drugs at all; less than half of the 800,000 being treated worldwide. In sub-Saharan Africa, where 4.1 million people are affected, just over 1%, or about 50,000 had access to antiretrovirals at the end of 2002.[7]

South Africa, with 5.3 million HIV-positive citizens promised drugs to 'anyone who needs them' in November 2003 and aims to treat everyone with a CD4 count of 200 or an AIDS defining illness by 2009 (about 1.4 million people).[8] Currently only those with access to private healthcare (about 30,000 people) have been able to get treatment. India's health ministry has announced an initiative to supply free antiretrovirals to100,000 people in six states from April 2004.[9] But whether these promises will come to fruition remains to be seen.

Palliative care

In African countries palliative care for AIDS sufferers hardly exists; and millions are dying without any pain relief despite oral morphine being incredibly cheap. Legal obstacles to supply and the lack of trained professionals at community level explain much of the gap. Even in South Africa, home to 25% of Africa's AIDS patients, only 250,000 of five million with HIV currently receive home support and pain relief.[10]

AIDS orphans

The number of children in sub-Saharan Africa who have lost both parents to AIDS related diseases is set to double to 20 million by 2010; and could then account for 12% of the region's children, according to a new Unicef report.[11] In countries worst affected (Botswana, Lesotho, Swaziland and Zimbabwe) a fifth of children will be without parents. Many households currently are headed by women and grandparents; and most affected countries still have no policy to deal with the growing needs of AIDS orphans who in addition to the legacy of bereavement, are also economically, educationally, medically and socially disadvantaged.[12]

Prevention

Like most international initiatives, President Bush's five year $15 billion Emergency Plan for AIDS relief focuses mainly on drug treatment, with only 20% ($3 billion) being allocated for prevention. At present it is unclear how this will be spent as some conservatives favour an 'abstinence-only' approach whilst liberals dismiss abstinence in favour of condoms. But as Green and Mlay[13] point out in a landmark article in the Washington Post,[14] exporting any kind of Western solution to Africa wholesale may be a huge strategic blunder.

Condoms are effective in slowing spread amongst those at greatest risk: people with infected partners, sex workers, their 'customers' and those customers' wives. But whilst condoms may arguably have reduced spread of HIV in the West, where AIDS is largely confined to those engaged in high-risk behaviour, they have proved inadequate where HIV is found in the general population. In fact the African countries with the highest levels of condom availability - Zimbabwe, Botswana, South Africa and Kenya - also have some of the highest HIV rates in the world.

It is now widely acknowledged in the secular press that Uganda has been the most successful country in combating HIV transmission. The data are clear and conclusive. HIV prevalence in Uganda declined from 21.1% to 9.7% from 1991 to 1998, continuing to fall to 6.4% among pregnant women. This was observed across[15] antenatal sites with greater declines among younger age groups; and these declines are repeated in other national datasets available at county level; army recruits and blood donors, as well as data from all strata of society, urban and rural.[15]

Uganda's AIDS Commission has adopted what it calls the ABC approach to reducing HIV: 'Abstain (from sex), Be faithful (together), or use Condoms'. This led to a wide range of sexual behaviour change including reducing partners, abstinence, faithfulness, marriage and increased condom use. Between 1989 and 1995 casual sex declined by 65% to levels 60% below Kenya, Zambia and Malawi, countries that had similar casual sex levels to Uganda in 1989. Ugandans were quite clear about the way their behaviour had changed: 48% reported that they stuck to one partner, 11% of men and 14% of women said they had stopped all sex and 2.9% of women and 12.5% of men had started using condoms.[16]

The behaviour change was achieved through a social communication process that began with President Museveni and worked at community level through schools and churches. In the context of postwar poverty, the cheapest approach worked best: public education stressing abstinence before marriage and faithfulness after. 'Zero grazing' was the message repeatedly conveyed by faith-based organisations, prominent cultural figures, political, community and military figures, non-governmental organisations and care organisations.

Comparing condoms to penicillin, Museveni said, 'Just as we were offered the 'magic bullet' in the early 1940s, we are now being offered the condom for 'safe sex'. We are being told that only a thin piece of rubber stands between us and the death of our continent. I feel that condoms have a part to play as a means of protection, but they cannot become the main means of stemming the tide of AIDS.'

Conclusions

The AIDS pandemic is a public health emergency out of control. Effective management has to be comprehensive - involving drugs, palliative care, care for orphans and prevention. Sacrificial and extravagant giving to the poor,[17] compassionate care for the sick,[18] care for widows and orphans,[19] and faithfulness in marriage [20] are right at the heart of God's priorities. Christians have a huge role to play at all levels in giving, caring, implementing prevention strategies and, perhaps most importantly, influencing public policy. The Ugandan model has worked because it based on the biblical principles of wise, strong leadership, responsible communities, generosity, unconditional care and sound community and sexual ethics. There are important lessons here for all concerned about the future of our planet.