World AIDS Day: Putting a Human Face on the Numbers

The real question this World AIDS Day is not, "how did we miscount the infected by 6 million?" but rather, "how did we allow another 2.1 million to perish from a treatable disease?"
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The recent announcement by UNAIDS and the World Health Organization that they may have overestimated the number of HIV positive people worldwide by as much as 20 percent has obscured the two most important issues that should be discussed this World AIDS Day. The first is the extraordinary success of the billion dollar initiatives of the past six years, which have resulted in putting over a million people in developing countries on anti-retroviral therapy. The second is that, despite this success, we continue to fail to meet the larger need: last year more than two million people died from AIDS -- nearly all in the developing world, 78 percent in sub-Saharan Africa alone.

How has it happened that the international news story should focus on statistical abstractions rather than the human face of the continuing pandemic? There are those who would lay responsibility at the feet of UN, and to be sure, they bear a good deal of blame. Despite the warnings of health experts and observers, the UN was content to oversimplify, accepting data without critical review or revision. Now, critics are blasting the sloppy results, while the toll of the disease on individuals may be lost amidst the noise.

It's important this doesn't happen. An overlooked reason for the suffering of Africans was a fundamental breakdown in health systems which allowed HIV to thrive, undiagnosed and untreated, for several decades. AIDS is now estimated to have emerged in central Africa in the 1940s, and as epidemiological forensics improve, that date may roll back substantially. Through the 1960s and '70s, a deadly "slimming" disease destroyed swaths of humanity long before hitting our radar screen in the early 1980s. Decades of underinvestment in the public health system and the utter exclusion of services for the poor made it possible for the international community to miss the disease until it was globally established.

AIDS is now treatable but this requires well-trained health professionals, infrastructure, and management. Rwanda, where I work and live, is a crucible of sorts for the pandemic. Before the emergence of the Global Fund to Fight AIDS, Tuberculosis and Malaria just five years ago, Rwandans who had AIDS simply died. With financing from the U.S. government and the Global Fund, surveillance and testing of HIV improved dramatically, and effective treatment began. By 2004, testing in urban clinics indicated that from 10-30 percent of women showing up for pre-natal care were HIV positive.

It was figures like these that, until recently, informed data analysis which led to higher figures of AIDS prevalence. In Rwanda, these initial studies implied a 12-15 percent overall prevalence of HIV in the population. Previous studies had shown that any time prevalence moves above the five percent mark (five times higher than the international average), epidemics can grow to staggering proportions, as was seen in Botswana where nearly half of all adults are HIV positive.

Rwanda recognized the potential catastrophe and took quick action. It designed new strategies and programs, streamlined management, and attracted international donor money. From the head of state to local leaders, the country was engaged in fighting the virus.

In the past couple of years, it's become apparent that Rwanda didn't have the whole picture. It's prevalence rate is closer to three to five percent -- far below what had been originally estimated. While this figure is a relief, enormous challenges test the public health infrastructure. Understaffed health centers without running water are hard pressed to deliver HIV/AIDS services. AIDS funding that has been committed to Rwanda, even when the higher statistics prevailed, has gone into much-needed medical and management training and infrastructure improvement, providing a better health setting for all patients.

While the numbers of people living with HIV may have been exaggerated due to poor data, the consequences of not doing more to serve the needs of the poor have not been. Millions in sub-Saharan Africa continue to go untreated and undiagnosed, and more -- not less -- needs to be done. The real question this World AIDS Day is not, "how did we miscount the infected by 6 million?" but rather, "how did we allow another 2.1 million to perish from a treatable disease and another 2.5 million to be infected?"

Josh Ruxin is Assistant Clinical Professor of Public Health at the Mailman School of Public Health at Columbia University and Director of the Access Project in Rwanda.

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