Since AIDS was first recognized in 1981, the disease has killed more than
25 million people and infected more than 65 million. An estimated 40 million
people are now living with HIV, 95 percent of them in developing countries
and nearly two-thirds in sub-Saharan Africa. And the impact doesn't stop
there. As a disease that strikes mainly at the young and able-bodied, HIV
shatters families, impoverishes communities and hamstrings economic and
social development at the national level. More than 15 million children
have been orphaned by AIDS, including more than 12 million in Africa alone.
In half of the countries in sub-Saharan Africa, per capita economic growth
is falling by around 1 percent each year as a direct result of AIDS.
As these and other numbers confirm, HIV is overwhelmingly a plague of the
poor in the global south. That was already the case when the first effective
treatment with antiretroviral drugs was discovered and approved in 1987.
The limited availability and astronomical costs of the first antiretrovirals
exacerbated the disparity. As more drugs came on line and experiments proved
the effectiveness of combining them in cocktails, HIV became a manageable
chronic disease in developed countries. But for the tens of millions of
infected people in developing countries it remained a death sentence, while
global health experts opined that treatment was too expensive and too complicated
to save the lives of the poor.
Community-based care for HIV – The HIV Equity
"Four Pillars" of the HIV Equity Initiative
1. AIDS prevention and treatment in the context of primary care
Providing general medical services is the fundamental intervention necessary
for engaging the community, for improving overall well-being and for identifying
and earning the trust of HIV patients.
2. Advancing tuberculosis care
Tuberculosis is the leading cause of death among HIV-positive people worldwide.
The two diseases must be battled in tandem.
3. Improving screening and treatment of sexually transmitted infections
Untreated sexually transmitted infections can elevate the rate of HIV transmission
up to tenfold, cause cervical cancer and infertility, and put pregnant
women and their babies at increased risk.
4. An emphasis on women’s health
Childbirth is the second leading cause of death for women in Haiti. Focusing
on women's health holds the key to reducing the toll of maternal mortality
and to reducing the incidence of infant mortality and low birthweight.
It also provides an entry point for HIV counseling and testing, for preventing
mother-to-child transmission of HIV, and for earlier HIV diagnosis for
When PIH launched the HIV Equity
Initiative in rural Haiti in 2000, it
was one of the first programs in the world to provide free, comprehensive
HIV treatment and prevention services to the destitute sick. The program's
unparalleled and demonstrable success helped pave the way for unprecedented
new funding and attention to the diseases of the poor, including the creation
of the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Health
Organization's "3 by 5" campaign and the U.S. President's Emergency
Plan for AIDS Relief (PEPFAR). In a strong endorsement of PIH's innovative
approach, one of the Global Fund's first grants funded significant expansion
of the HIV Equity Initiative in Haiti. Elements of PIH's model have now
been adopted by projects worldwide.
The key to the HIV Equity Initiative's success lies in its comprehensive
approach: nutritional and social support are provided along with life-saving
medicines and treatment is closely linked to prevention and to other health
services. Community health workers provide the "missing infrastructure" that
is often cited as an obstacle to AIDS care in poor countries. This community-based
approach works so well that during the 2004 coup d'état in Haiti
not a single PIH AIDS patient missed a dose of medication.
An agenda for global action –
moving toward one world, one hope
Over the past few years, the global response to the HIV pandemic has been
transformed by a combination of factors. The success of PIH and other groups
proved that treatment can save lives while strengthening both HIV prevention
and primary care. The Bill and Melinda Gates Foundation and other private
donors dramatically increased funding for HIV research, training and treatment.
Generic drug manufacturers, negotiating leverage from the Clinton Foundation
and pressure by AIDS activists helped drive the price of antiretroviral
treatment down from several thousand dollars a year to less than $150.
In a matter of months, the global agenda turned from debating "prevention
versus treatment" to scaling up treatment to deliver universal access
As global AIDS experts, policymakers and activists gathered for the International
AIDS Society conference in Toronto in 2006, PIH co-founders Paul Farmer
and Jim Yong Kim laid out six lessons from the past decade as signposts
for reaching the goal of universal access and delivering on the slogan
put forth ten years earlier – "One World, One Hope."
1. Charging for AIDS prevention and care will pose insurmountable problems
for people living in poverty. Such services should be seen as a public
good for public health. Policymakers and public health officials should
adopt universal-access plans and waive fees for HIV care.
2. Scale-up will require strengthening and even rebuilding health care
systems, including those charged with primary care. Only the public sector,
not nongovernmental organizations, can offer health care as a right.
3. AIDS funding should be used to overcome the lack of trained health care
personnel in poor countries, not only by recruiting doctors and nurses
to underserved regions but also by training and paying community health
workers to supervise treatment for AIDS and many other diseases.
4. Poverty is far and away the greatest barrier to scaling up treatment
and prevention programs. The social and economic barriers to adherence
can only be removed by providing "wrap-around services": food
for the hungry, help with transportation to clinics, child care, and housing.
5. Funding must be increased and sustained to slow the increasingly complex
epidemics of HIV and TB, particularly in the face of the ominous advent of highly
drug-resistant strains of both pathogens.
6. There must be a renewed basic-science commitment to vaccine development,
more reliable diagnostics, and new classes of therapeutics.
In conclusion, Farmer and Kim argue, "The unglamorous and difficult
process of increasing access to prevention and care needs to be our primary
focus if we are to move toward the lofty goal of equitably distributed
medical services in a world driven by inequality. Without such goals, the
slogan "One World, One Hope" will remain nothing more than a