Foreword

THE ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS) is a profound human tragedy. But it is much more besides: it is a threat to economies and to the very fabric of our societies. In badly affected countries, the socioeconomic effect of this most destructive disease is measured in declining per capita incomes, shrinking profits in labour-intensive businesses, loss of productivity from cultivated land, and deteriorating public services such as health, welfare and education, as key staff fall ill and die. AIDS undermines the future, too, as families and communities struggle with the burdens of sick people and orphaned children, building up debts and frequently having to remove children from school because of lack of funds or because the labour of even the littlest is needed to help the family survive.

As the human immunodeficiency virus (HIV) continues its devastating spread, blighting the lives of another 16,000 people every day, the virus is increasingly targeting women, babies and young people. By the end of 1998, there were close to 14 million HIV-positive women of childbearing age. Well over half of all new infections are in people below 25 years of age - a large proportion of them newborn babies who contracted the virus from their infected mothers before or during birth, or from breastfeeding.

Behind these dry statistics are women from traditional families caught in the terrible bind of pressure to produce children, and unable to admit that they have contracted HIV from a husband who is unfaithful. There are teenage girls from very poor homes whose only way of staying on at school is to barter sex with teachers or “sugar daddies” who will pay for books, uniforms and fees. There are young men whose initiation into adulthood involved visits to brothels with older friends, often fired up with alcohol, and no thought or perhaps knowledge of the risk of disease. And there are babies born healthy to HIV-positive mothers and who acquired the infection from breast milk because their mothers had no real choice: they were unaware of the risks of breastfeeding, or there was no safe and affordable alternative. Many will have been too afraid of drawing attention to their HIV status by not breastfeeding, and suffered the silent agony of putting their babies at risk because of the cruel stigma of AIDS.

HIV does not strike at random, and over the years we have learnt a great deal about what makes people vulnerable. Where once the focus was solely on personal risk behaviour, today we know that there are factors way beyond the control of the individual that encourage risk behaviour and make it hard for people to protect themselves. These factors include poverty, discrimination, lack of education and opportunity, and, crucially, the subordination of women which puts young females at even greater risk than males. Thus in some of the worst affected countries, HIV-infected women outnumber infected men by as much as 16 to one in the younger age groups.

Besides being a personal tragedy, the disproportionate risk for women has enormous social implications, since they are the principal guardians of future generations, the carers and nurturers of society. Yet women’s health and wellbeing have always had low priority. So, too, have the special needs of young people for healthy development. The case for righting these wrongs has never been more pressing.

On the AIDS front, we know what must be done. We must expand and intensify HIV prevention measures, because we know from experience that prevention works. And we must act on two levels simultaneously - at the level of the individual to increase knowledge and skills and encourage safe personal behaviour, and at the level of society, its institutions and attitudes, to create an environment supportive of safe behaviour. Furthermore, our prevention campaigns must give higher priority to the most vulnerable groups. They must actively involve their target populations to ensure they are relevant. And they must strive for equity so that people in all countries and all walks of life are able to benefit from the advances in science and technology that only a tiny minority enjoy at present.

However, turning the tide on AIDS will require much greater commitment of time, energy and resources. Let us determine now to make those commitments, and to make the most of what we have learnt and the weapons we have developed to challenge this crippling epidemic.

Peter Piot, MD, PhD
Executive Director
UNAIDS