HealthPad

This year the World was gripped by who would get the keys to the White House. One thing we all learnt from the 2012 Presidential election is that America is a deeply divided society and this is no more evident than in the nation’s capital.

Washington DC, the capital city of the richest country on Earth, has an HIV infection rate of 3.2%, the highest HIV rate of any large city in America and placing it well above many African cities renowned for their high prevalence of HIV AIDS. How can this be so in the world’s wealthiest nation with a plentiful supply of antiretroviral drugs, efficient systems to administer them and effective popular ways of interrupting the spread of the disease?

In North America alone, there are 1.4 million existing cases of HIV AIDS and in the US the disease is the sixth-leading cause of death among 25 to 44 year-olds. Over the past decade, the US has been stuck at about 50,000 new infections of HIV AIDS each year, while in the rest of the world the rate of new infections has slowed. Washington’s high rate of HIV infection is a story of two Americas brought into sharp relieve during the Presidential election: one of affluence and another of neglect, poverty and unresolved social issues.

In July 2012 a premier gathering of some 30,000 people comprised of those working in the field of HIV, as well as policy makers, persons living with HIV and other individuals committed to ending the pandemic, converged on Washington DC to participate in the 19th International AIDS Conference. It was the first time the conference could be held in the US thanks to bipartisan action by Presidents Obama and George W. Bush and the Congress to lift the ban on people living with HIV entering the US.

Participants celebrated the fact that the global AIDS pandemic is under control and over the past five years, the rate of new annual HIV AIDS infections dropped significantly. A fact ceased on by Secretary of State Hilary Clinton in her opening remarks to the conference, “The ability to prevent and treat the disease has advanced beyond what many might have reasonably hoped 22 years ago.”

Since the AIDS pandemic started in the early 1980s, more than 60 million have been infected with HIV and nearly 30 million died of HIV-related causes. HIV is one of the world's leading infectious killers, claiming more than 25 million lives over the past 30 years. In 2011, there were approximately 34 million people living with HIV. HIV AIDS affect economies, health systems, households and individuals by reducing labour productivity, increasing medical treatment costs and lost savings.

HIV AIDS is most threatening to people between the ages of 18 and 44 and therefore affects economies and households by killing off young adults. It significantly weakens nations and slows their economic growth by reducing the taxable population and resources available for public expenditure, such as education and health services. At the household level, HIV AIDS increases the cost of medical care, while the ability for a family to earn income or undertake productive work decreases. The loss of adults in a family has dramatic implications for family wellbeing and the growing prevalence of women infected by HIV AIDS has significant repercussions for future generations.

For many years, there were no effective treatments for AIDS, but things are very different today as sufferers can use a number of drugs to treat their infection. Although there is no cure for HIV infection, antiretroviral therapy (ART) can suppress HIV by controlling the replication of the virus within a person's body and allow an individual's immune system to strengthen and regain the power to fight off infections. With ART, people with HIV can live healthy and productive lives.

The 2012 Washington International AIDS Conference closed with the message that, short of a vaccine and cure, getting treatment to more of the world's 34 million sufferers is critical to curbing the epidemic. Nobel Laureate Francoise Barre-Sinoussi, co-discoverer of the AIDS virus said, "It is unacceptable," that scientifically proven treatment and prevention tools are not reaching people who need them most. However, in recent years there have been significant successes in this regard. By the end of 2011 more than 8 million people living with HIV in low- and middle-income countries were receiving ART. This is a 20-fold increase in the number of people receiving ART in developing countries between 2003 and 2011 and a 20% increase in just one year: from 6.6 million in 2010 to more than 8 million in 2011.

In the US and other rich countries many HIV patients are taking a combination of antiretroviral drugs; a regimen known as highly active antiretroviral therapy (HAART). When successful, combination therapy can reduce the level of HIV in the bloodstream to very low levels and sometimes enable the body's immune cells to rebound to normal levels.
In May 2003, when antiretroviral therapies were not generally available, especially in developing countries, the US Congress approved President George W. Bush’s request for a five-year, $15 billion programme that launched the US Global AIDS initiative and the President's Emergency Plan for AIDS Relief (PEPFAR). Although President Bush advocated HIV AIDS as a health and human rights issue, it is reasonable to assume his motivation was also influenced by the pandemic’s negative impact on economic development.

Fast forward to December 2012 and Secretary Clinton commemorated World AIDS Day by unveiling the PEPFAR Blueprint: Creating an AIDS-free Generation that provides an actionable strategy to reduce and control the AIDS epidemic within the next four to five years. PEPFAR spends nearly US$7 billion a year in more than 35 countries. It is supported by state-of-the-art technology, scalable global distribution systems and influential organisations such as the Melinda and Bill Gates Foundation and the Clinton Foundation.

Researchers are working to develop new therapies known as fusion and entry inhibitors that can prevent HIV from attaching to and infecting human immune cells. Efforts are also underway to identify new targets for anti-HIV medications and to discover ways of restoring the ability of damaged immune systems to defend against HIV and the many illnesses that affect HIV-infected individuals. Ultimately, advances in rebuilding the immune system in HIV patients will benefit people with a number of serious illnesses, including Alzheimer's disease, cancer, multiple sclerosis and immune deficiencies associated with aging and premature birth.

The management of HIV AIDS is challenged by the fact that in many high-prevalence countries, the number of people becoming infected with HIV each year exceeds the number starting antiretroviral therapy, which perpetuates the growth of the epidemic. For AIDS to be controlled this phenomenon needs to be reversed. A 2011 study showed that antiretroviral therapy reduces an infected person’s chances of transmitting the virus through sexual intercourse by 96%. When HIV positive pregnant women take antiretroviral drugs fewer than 5% of their babies become infected. Circumcision reduces a man’s chances of acquiring HIV sexually by about 60%. Secretary Hilary Clinton’s Blueprint to reduce and manage the global HIV AIDS epidemic is simple: control HIV by a concerted effort that starts more infected people on antiretroviral therapy, ensures that every HIV-positive pregnant woman is treated and circumcise men in high-prevalence countries. Within four to five years, this strategy is expected to produce a tipping point that would allow the disease to start burning itself out.

Despite continued intensive research we are still a long way from achieving a safe, effective and affordable AIDS vaccine. Until such a time, using condoms is by far the most cost effective and scalable means of preventing the transmission of HIV. The No1 means of transmitting HIV infection is unprotected sex, which encompasses oral, anal and vaginal sex. Since the surest form of transmission is blood-to-blood, this risk is greatly increased with trauma to the oral cavity. Persons with bleeding gums, ulcers, genital sores or STDs have an increased risk of transmission through oral contact.

Washington’s high incidence of HIV infection is a story of sex and the city. Today, the majority of the world’s poorest people live in urban areas, which are incubators of disease and Washington DC is no exception. Worldwide, there are some 600 cities with more than one million inhabitants. In cities throughout the world there are entrenched and unresolved social issues, under privilege, lack of education, low esteem, drug abuse and alcoholism and too much unprotected sex and too many citizens not having a clue about their sexual partner’s HIV status. In the US this will manifest itself every week throughout 2013, when about 1,000 Americans, with a high concentration in Washington DC, will acquire HIV infection and some will eventually die from it.

Is it possible for doctors to provide care without being perceived as taking sides during conflicts? This question is posed more and more as attacks on health workers in war zones increase.

In January 2012, Khalil Rashid Dale, a doctor travelling in a clearly marked International Committee of the Red Cross (ICRC) vehicle to Quetta, the capital of Baluchistan province in Pakistan, was abducted by unknown armed men. Some four months later the doctor’s beheaded body was found in an orchard. Also in January two Médicins Sans Frontières (MSF) health workers were killed in Mogadishu, Somalia. The consequences of such attacks are disproportionate in their impact. A consequence of the Somalia killings led to the MSF closing two 120-bed medical facilities in Mogadishu, which served a population of some 200,000 and which over the previous year, had treated close to 12,000 malnourished children and provided measles’ vaccinations and treatment to another 68,000 patients.

In 2011 Robin Coupland, a former trauma surgeon, now a medical adviser with the ICRC, co-authored Health Care in Danger, a study, which describes how and why health workers get caught in the cross fire and what the consequences are when they do. The study was used to launch an ICRC campaign to raise awareness of the problem and make a difference to health workers on the ground.

For some people however, it is impossible for doctors to provide care without being perceived as taking sides during conflicts. Some argue that as the quantum of humanitarian aid has increased over the past decade, so humanitarian aid agencies have been compelled to rely on sub-contracting in actual conflict areas. This, it is suggested, provides a breeding ground for aid corruption to finance nefarious elites and to further destabilize conflict areas, implying that healthcare activities of humanitarian organisations in war-torn regions have become increasingly politicised. Even agencies that make considerable efforts to disassociate themselves from political actors and project an image of neutrality have not been immune from attack.

Do warring factions perceive health workers as supporting the enemy and therefore see them as legitimate targets? Or are health workers targeted because they represent an opportunity to amplify messages to a global audience? It is likely both are true, but the impact on society as a result of removing vital healthcare in war zones, due to these attacks, can have devastating consequences.