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 Initiative

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 by 2010.

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 dream."