AIDS Impact: Biopschosocial Aspects of HIV Infection, 3rd International Conference

22-25 June 1997, Melbourne

Clive Aspin
Research Fellow and Lecturer in Māori Health
Wellington School of Medicine
Ngati Manu ki Hauraki

"The AIDS epidemic as we have known it may be over but the epidemic itself is far from over." This was the overwhelming message from the Third International AIDS Impact Conference on the biological, psychological and social aspects of AIDS. Papers presented at the conference made it clear that the AIDS epidemic has moved into a phase that will present programme developers and policy makers with new and unforeseen challenges. Those who came to the conference expecting to hear news of breakthroughs that would bring the epidemic to an end were to return to their countries of origin with a list of tasks determined by our knowledge of past successes and the future demands of the AIDS epidemic.

The conference reminded participants that 90% of all cases of AIDS are located in developing countries, and that the burden of the epidemic will continue to be felt in these parts of the world. The impact of the epidemic in the developing world is expected to lead to continued social disintegration, increased orphanhood, an increasing demand on services and an alarming decline in economic development. While significant advances have been made in Western countries, the lessons learnt here cannot be applied to the pattern of the epidemic in developing countries.

Dr Gary Dowsett, Macquarie University, reminded the conference that "We mustn't obliterate difference in our race to obliterate AIDS." Rather, we must ensure that cultural difference and community diversity are enshrined in policies designed to prevent the transmission of HIV. Programmes designed and developed by affected communities are likely to meet with the greatest degree of success.

Dr Elizabeth Reid, Director, HIV and Development Program, United Nations Development Program, described her agency's work in Malawi and emphasised the need to integrate local cultural components into all elements of programme development. She referred to the population of this country as having been traumatised by the epidemic, saying that this has led to the emergence of myths about cures that place young women, and girls as young as five at serious risk of rape and sexual violation. Many people have come to believe that an HIV-infected man can be cured of his disease by having sexual intercourse with a virgin. Such beliefs have had a profound effect on the behaviour and attitudes of people, and illustrate the point that programmes must focus on social networks if they are going to have any degree of success.

Overwhelmingly, presenters who talked about AIDS in the developing world described an epidemic that is now out of control. Massive injections of resources may go some small way to arresting the spread of the virus in the short term, but only a long-term policy commitment by Western countries to sustained economic development will lead to a decline in AIDS notifications in developing countries. If this does not happen the devastation described by Dr Reid will spread rapidly across continents. In some parts of Malawi, as many as one in four people over the age of fifteen are infected by HIV. Such widespread infection will contribute to massive social and economic decline in many developing countries.

The irony of this economic decline being predicted to occur at a time when Western countries are drastically reducing their defence budgets was not lost on Dr Sam Friedman of the National Development and Research Institute, New York, who spoke of a declining international economy which, among other factors, saw the US halve its defence budget between 1985 and 1995. The billions of dollars saved as a result could be used to raise the socio-economic conditions of the poorer countries and hold back the spread of the AIDS epidemic. Instead, we now see clear signs of marginalised people, such as those with HIV / AIDS, being used as scapegoats to explain the withdrawal of social services and benefits. Dr Friedman's paper called for increased vigilance to ensure that the needs of those most affected by the epidemic be included in governmental policy on AIDS support and care.

A second major theme that emerged from this conference focused on the impact of the new treatment regimes that have been introduced in some countries. Several presenters reported on new patterns of behaviour within communities most affected by AIDS. Of concern is the fact that people most at risk of HIV infection may perceive protease inhibitors as the equivalent to a cure, a perception that may lead to an increase in risk behaviour with a subsequent rise in HIV infections.

Some presenters reported that the new treatment regime has led to a decline in AIDS-related deaths and that this placed new and unexpected demands on social services. Many people with AIDS are reported to have withdrawn from the workforce, using their life savings to maintain their standard of living. Some, however, now have undetectable viral loads and, in light of their new diagnosis, have been forced to consider a future with limited income, resources and employment opportunities.

The overwhelming diversity of peoples and communities affected by the AIDS epidemic was a third major theme of this conference. Now that AIDS has been a reality for over fifteen years, it has become clear that approaches to HIV prevention must be as diverse as the communities which have been affected. Many presenters reported on the partnerships that have developed between communities, policy makers and service providers. Non-governmental organisations were singled out as having played a particularly important role in stemming transmission in some countries and were identified as playing a key role in future developments related to AIDS policy and prevention. In contrast, governments were described as having the necessary resources, but lacking the will to deploy these much-needed resources. In both developing and Western countries, only a concerted effort by government and communities can bring the epidemic to an end.

In his summary of the conference, Professor Peter Aggleton, Director of the Health and Education Research Unit, Institute of Education, University of London spoke at length about the role that researchers could play in assisting government agencies to identify priorities for the development of AIDS policy. Policy makers must capitalise on the successes that have been achieved so far and devote funds to ensure the development of similar initiatives. He stressed the fact that some of the most successful HIV prevention strategies have grown out of community approaches rather than from scientific inquiry. As examples, he cited safe sex, needle exchange and negotiated safety. At the same time, Professor Aggleton stressed that the conference had highlighted the fact that many people's needs were still going unmet. He identified indigenous peoples, families, youth and orphans as examples of people with the greatest needs in relation to HIV / AIDS. Efforts must be made to develop ongoing alliances among academics, politicians, policy makers, researchers and the researched in order to bring the AIDS epidemic to an end.