In Focus — HIV/AIDS
Anatomy of a Pandemic
As AIDS extends its ruinous reach, Rotarians confront new challenges.
(THE ROTARIAN-Dec. 2003 扶輪月刊2004/1 )
In less than three decades, AIDS has run a deadly marathon around the globe. Since 1981, when public health experts in the United States first identified it as a new disease, AIDS has become the fourth-leading cause of death worldwide and the leading killer on the African continent.
An estimated 42 million people throughout the world are living with either AIDS or HIV, the virus that causes the disease. Last year, 14,000 new HIV infections occurred each day, and 3.1 million people died of AIDS.
在這個疾病邁向第三個10年之際，印度醫療協會愛滋病防制計劃全國協調人，同時也是德里南區都會(Delhi South Metropolitan)扶輪社社員坦頓醫師(Dr. Rajiv Tandon)說：「全球沒有一個洲、沒有一個國家、沒有一個社區可以倖免於難。」
As the disease enters its third decade, "no continent, no country, no community has escaped its vicious trail," says Dr. Rajiv Tandon, national coordinator of the Indian Medical Association's AIDS Control Program and a member of the Rotary Club of Delhi South Metropolitan.
愛滋病的悲劇發生在社會各個階層，破壞經濟與社會結構。因為愛滋病主要是透過性接觸來傳播，因此對正值生產力巔峰的年輕人殺傷力也最大。亞特蘭大艾莫里大學公共衛生系系主任兼愛滋病研究中心主任的庫博士(Dr. James Curran)說：「我們在非洲看到大部份的勞動力量都病患垂危。」
The tragedy of AIDS touches society at every level, eroding economic and social structures. Because it spreads primarily through sexual contact, AIDS kills young adults in what would otherwise be their most productive years. "What we see in Africa are large portions of the work force becoming ill and dying," says Dr. James Curran, dean of public health and director of the Center for AIDS Research at Emory University in Atlanta.
"AIDS tends to devastate whole families," explains Curran, a member of the Rotary Club of Atlanta. "The wage earner dies, or both [parents] die." The result: More than 11 million children in sub-Saharan Africa are AIDS orphans.在開發中國家各地，提供愛滋病帶原者的醫療照顧十分缺乏，或根本付之闕如。聯合國愛滋病計劃署監督與評估組主任德雷博士表示，在需要抗逆轉性濾過性病毒藥物來遏止愛滋病毒繁殖，延緩愛滋病發作的600萬人當中，只有30萬人可以取得藥物。其中只有5萬人居住在撒哈拉沙漠以南的非洲，而這裡有近3000萬人感染愛滋病毒。開發中國家缺乏藥物、實驗室、診所、及受過訓練的人員來照顧愛滋病患者/帶原者。
Throughout the developing world, medical care for HIV infection is scarce or nonexistent. Dr. Paul De Lay, director of monitoring and evaluation with UNAIDS (Joint United Nations Programme on HIV/AIDS), says that of the six million people who need treatment with antiretroviral drugs, which keep HIV from reproducing and can significantly slow the development of AIDS, only 300,000 receive it. Only 50,000 of those are in sub-Saharan Africa, where nearly 30 million are HIV-infected. Developing nations lack the drugs, laboratories, clinics, and trained staff to care for those with HIV/AIDS.
Vanquishing HIV ultimately hinges on the development of an effective vaccine or a treatment to cure AIDS. Strong government commitment also is needed in countries with scant resources. Without these vital elements, says De Lay, "we will be facing major problems in many countries 50 to 100 years from now."
The AIDS pandemic is at varying stages throughout the world. But on 1 December 2003, communities, organizations, and institutions affected by HIV/AIDS will observe World AIDS Day with common solemnity and resolve. On this 16th annual World AIDS Day, we take a region-by-region look at the issues and challenges posed by HIV and AIDS worldwide. We also show how Rotarians are working to prevent the virus from spreading and how they are helping those affected by the disease.
The most severely affected region in the world, sub-Saharan Africa is home to 29.4 million people living with HIV or AIDS. Of the world's five million new HIV infections last year, 3.5 million occurred here. Nearly 9 percent of adults are HIV-positive, and 58 percent of those infected are women, since HIV spreads here mainly by heterosexual contact. AIDS claimed 2.4 million lives in the region last year alone. Adult prevalence rates swing erratically, from a staggering 38.8 percent in Botswana to less than 1 percent in Senegal.
Conditions in sub-Saharan Africa are comparable to no other region in the world. With nations ravaged by war, poverty, drought, famine, and floods and too often hamstrung by political corruption, the calamity of AIDS here is as much an issue of social and economic development as of medical care. In South Africa, where the government has been slow to react to HIV, the World Bank has warned of economic collapse within three generations unless elected leaders take more forceful action. As young adults die, agriculture and industry falter. Tax revenue falls, putting more stress on public budgets. In countries with high infection rates, governments may be less likely to support education because high death rates among young adults mean they won't see a return on the investment.
Despite the grim picture, there is cause for some optimism. In Uganda, widespread prevention programs have helped roll back the adult HIV prevalence rate from 8.3 percent in 1999 to 5 percent in 2001. And in Botswana, 5,000 people are receiving antiretroviral drugs, a large proportion given the country's relatively small population of about 1.5 million. In South Africa, public health officials say the political tide is turning: The government announced in August 2003 that it will develop plans to distribute antiretroviral drugs nationally.
Even so, De Lay says rising prevalence in areas of Ethiopia and Nigeria is cause for great concern. He cautions that despite the continent's already overwhelming HIV statistics, Africa could continue to see massive, new epidemics.
Latin America and the Caribbean
About 1.9 million people in Latin America and the Caribbean have HIV or AIDS. The Caribbean itself — where 2.4 percent of adults are infected (440,000 infections in a population of 18.4 million) — is second only to sub-Saharan Africa in HIV/AIDS prevalence. Haiti and the Bahamas have the highest adult prevalence rates in the Caribbean, at 6 percent and 3.5 percent, respectively. Life expectancy in Haiti has dropped six years to about 51 because of AIDS.
Migration between North and South American countries helps drive the epidemic here, as do intravenous drug use, socioeconomic inequality, and high-risk sexual behavior. Social stigmas attached to homosexuality and bisexuality stymie public health efforts and allow the virus to spread rapidly in many parts of the region. Men continue to be more seriously affected in Central and South America; the gender breakdown in the Caribbean is now about fifty-fifty. Experts say heightened prevention efforts should focus on men who have sex with both men and women. The need for effective prevention programs was illustrated by the results of a recent study in two cities in Honduras. HIV prevalence rates were about 13 percent and monogamy was not generally practiced, but condom use was low and there was little recognition that unsafe sex increases the risk of HIV transmission.
The region's biggest success story is Brazil, a middle-income country better able to marshal resources than the hard-hit countries of sub-Saharan Africa. By manufacturing its own antiretroviral drugs, strengthening its hospital system, and quickly training doctors and other health-care professionals, Brazil has been able to provide treatment for almost 100,000 infected people, a per capita rate comparable to the United States, says De Lay. He credits the country's success to the Brazilian government's strong commitment to addressing the problem.
Asia and the Pacific
HIV prevalence rates remain relatively low in Asia and the Pacific region, but public health officials fear major storms are brewing. An estimated 7.2 million people here currently live with HIV or AIDS, a figure that increased 10 percent between 2001 to 2002. In these countries, HIV spreads through both sexual contact and intravenous drug use. In 2002, nearly 500,000 people in the region died of AIDS.
Areas of greatest concern are China and India, which together hold more than a third of the world's population. If localized epidemics reach the general public, experts fear widespread illness and death. India's HIV prevalence is less than 1 percent, but that figure represents four million people living with HIV or AIDS. In China, where about one million people have HIV, experts project a tenfold increase in infections by the end of the decade. In both countries, migration and growing gaps between low- and high-income groups heighten the risk that HIV will spread beyond intravenous drug users and other high-risk groups.
In India, a large proportion of adults know how to prevent HIV transmission, thanks to widespread public awareness campaigns. But Tandon points to a danger sign: In the southern state of Tamil Nadu, mother-to-child transmission increased almost sevenfold from 1999 to 2002. In India and elsewhere, he says, HIV control efforts must focus on fighting stigmas, mobilizing public and private sectors, and relying on science-based prevention programs. Without effective control measures, says De Lay, "India will be unlike anything else we've seen."
Experts forecast growing epidemics in Indonesia and Papua New Guinea, as a result of intravenous drug use and commercial sex. However, HIV prevalence has fallen in Cambodia and Thailand due to comprehensive prevention programs and efforts to fight stigma. What's more, Thailand took the initiative to manufacture its own antiretroviral drugs and train health-care workers to administer them.
Eastern Europe and Central Asia
This region is home to the world's most rapidly escalating HIV/AIDS epidemic. In Eastern Europe and Central Asia, the 1.2 million people with HIV or AIDS represent an adult prevalence rate of only 0.6 percent. But an estimated 250,000 HIV infections occurred in the region last year alone.
"Russia is of major concern," says De Lay. There, rapid social change, high unemployment, and poverty set the stage for a flourishing epidemic. From the end of 1998 to the middle of last year, HIV infections in Russia increased by nearly 2000 percent, from about 11,000 to more than 200,000. The vast majority are attributed to intravenous drug use, and most of those infected are under age 30. A survey in Togliatti, a city of one million, showed that 56 percent of intravenous drug users who took part in the survey were HIV-positive; the majority didn't know they had the virus. Public health officials fear that because of vast underreporting, recorded statistics foreshadow much more severe conditions.
"Concentrated epidemics in injection-drug users are spilling into the general public," explains De Lay. Already, Ukraine's 1 percent adult prevalence rate is the highest in all of Europe. In Central Asia, awareness of HIV and AIDS is extremely low. However, HIV prevalence has remained at very low levels in the Czech Republic, Hungary, Poland, and Slovenia, which have strong national awareness programs.
North Africa and the Middle East
HIV and AIDS didn't arrive in this region until the late 1980s. In 2002, 83,000 new infections were reported, bringing the number of people living with HIV or AIDS in North Africa and the Middle East to 550,000. More than half, 55 percent, are women. Heterosexual contact and intravenous drug use are the primary HIV transmission routes here, though determining trends in the region is difficult because of woefully inadequate public health surveillance. Experts say political instability, migration, and gaps between the rich and poor create conditions ripe for HIV to gain a foothold. Nongovernmental organizations have begun prevention efforts in Iran and Lebanon.
「愛滋病仍然無藥可治，可是愛滋病毒帶原者可以過著健康、有貢獻的生活。」"AIDS still is not curable, but people [with HIV] are living healthy, productive lives,"──庫蘭Curran博士
Some 1.6 million people are living with HIV and AIDS in Australia, New Zealand, and countries in North America and Western Europe. Last year, a total 76,000 new HIV infections and 23,000 AIDS deaths were reported in these countries. Since the introduction of antiretroviral drugs in the mid- to late-1990s, AIDS deaths have fallen dramatically.
"AIDS still is not curable, but people [with HIV] are living healthy, productive lives," says Curran. About 500,000 individuals in high-income countries receive antiretroviral treatment.
However, the U.S. Centers for Disease Control and Prevention warned earlier this year that new AIDS cases in the United States rose in 2002 for the first time in a decade and that increased HIV infection among gay and bisexual men could mean a resurgence is underway. Reports of increases in other sexually transmitted infections indicate similar trends in Europe and Australia. In several Western European countries, the epidemic is spreading more rapidly among heterosexuals and in low-income populations.
Public health experts emphasize the continuing need to tackle HIV/ AIDS on all fronts — social, economic, cultural, and medical. Despite the overall successes in developed nations, Curran cautions: "We can't ignore a problem that has had such an enormous impact on society."
作者：佛克(Rebecca Voelker )為芝加哥的衛生與醫療題材自由作家。
Rebecca Voelker is a freelance health and medical writer based in Chicago