Combatting AIDS: what more needs to be done?

• Author: Piot, Peter

The first disease to be the subject of debates in the United Nations, both in the Security Council and the General Assembly special sessions, AIDS is one of the top ten leading causes of death worldwide. A quarter of a century into the epidemic, it has become one of the defining issues of our time. According to the Human Development Report 2005, published by the United Nations Development Programme, it is responsible for "the single greatest reversal in human development".

In many respects, AIDS is the ultimate global, as well as local, problem. Originally regarded as affecting gay men in North America, it occurs in every country in the world. Half of all adults living with HIV are female. However, although AIDS has become a global threat, it is by no means a homogeneous epidemic. Clearly, more is needed to be done to address the issue, but what needs to be done will vary from place to place. Different regions are affected to varying degrees, with prevalence and impact highest in Southern and East Africa. In Botswana, Lesotho and Swaziland, one in four adults is HIV-positive. Compare this with Latin America, where in Argentina and Brazil around 1 in every 200 adults is living with HIV.

There may be a number of different localized epidemics within a country. In the northeast part of India, for example, AIDS is predominantly fuelled by injection drug use, while in other areas most infections result from unprotected sex. Major discrepancies often exist between rural and urban areas, with infections being much more concentrated in cities. The impact of AIDS also varies between social groups. It is pre-eminently a disease of inequality. Economic and gender inequalities have a direct influence on sexual behaviour and thus the potential for HIV transmission. Research in Kenya, for example, highlights that, where women's economic and social safety is largely dependent on their partners' occupation and status, they have little choice in determining their own sexual safety. It is therefore important for economic development strategies to adopt a "pro-poor", as well as "pro-women", approach to avoid the risk of increasing income inequalities and inadvertently fuelling the HIV epidemic.

Since the turn of the century, there has been a marked increase in attention and action on AIDS. Governments have agreed on a set of international targets, such as Millennium Development Goal 6: to "halt and reverse the spread of AIDS by 2015". UN Member States in 2001 issued a...