The Other War: By Martin Markowitz

Prof. Markowitz confers with Prof. Edward Karanja, of KAWI, during his visit to Kenya. Prof. Markowitz was hosted by KAWI.

THE staggering events of September 11, 2001 have forced America to take the lead in a "multi-national" war on terrorism. This is a battle that must be waged against a worldwide terrorist network established to wreak havoc and destroy the lives of innocent civilians. However, there is another menace which is destroying nations and claiming innocent lives that I fear has either been forgotten…or perhaps relegated to a "less urgent" place in the minds of Americans, that is the international struggle against HIV/AIDS.

It is now 20 years into the epidemic, and the situation in sub-Saharan Africa has become dire. The International Conference on HIV/AIDS held in Durban, South Africa in July 2000 successfully raised the consciousness of the world to the plight of sub-Saharan Africa. With the theme, "Breaking the Silence", a deafening roar was heard, perhaps best by those of us who were there to witness our generation's holocaust. 

Coincidentally, data presented at this meeting confirmed that treatment for HIV/AIDS could be accomplished with simple regimens that could conceivably be administered in resource challenged settings. An immense amount of activity ensued which culminated in June 2001 when the General Assembly of the United Nations adopted a Declaration of Commitment on HIV/AIDS, outlining the importance of leadership, prevention, care and support, societal issues, and the need for local, national, and international cooperation. Then came September 11th and since then nothing has been the same.

I have just returned from a week in Kenya, an African country blessed by nature's beauty and cursed by the scourge of HIV/AIDS. A newly formed group, the Kenyan AIDS Watch Institute or KAWI, invited me to visit and learn more of the challenges imposed by the current epidemic. KAWI is a non-government organization (NGO) formed and supported to date by concerned Kenyans whose sole purpose is to lend a sense of urgency to the battle against HIV/AIDS. 

In Kenya alone nearly 15% of the population is infected with HIV/AIDS. Over 700 Kenyans die of complications of the infection daily. At least half and up to 75% of hospital beds are occupied with HIV/AIDS patients. Some beds are occupied by up to 3 Kenyans simultaneously dying of AIDS. Of those infected the vast majority is between the ages of 15 and 49, many of who are parents and breadwinners. With over 2 million infected, conservative estimates are that over 700,000 meet treatment criteria for initiating antiretroviral medications (ARVs). Currently, it is estimated that less that 3,000 HIV infected individuals are receiving appropriate therapy.

In a speech given on November 25, 1999, the President of Kenya, Daniel arap Moi, declared HIV/AIDS a national emergency. Despite this declaration of war, as well as the U.N. Declaration adopted nearly 2 years later, the battle has been approached both internally and externally with a "business as usual attitude". Efforts and dollars have been spent on well intentioned but poorly organized educational and prevention campaigns. 

Words, not action, abound, and the pace and success of the efforts contrast sharply with the current rapid mobilization of resources and personnel being employed to wage the war against terrorism. The stigma of HIV/AIDS remains enormous. Effective large-scale screening measures are essentially absent, and even the most basic care is lacking for most. Despite recognition of the word HIV/AIDS, true understanding of the illness and its consequences are generally lacking. 

Perhaps most frightening is that despite the catastrophic death rate, prevalence is increasing due to the rate of acquisition of new infections. As these new cases progress to AIDS and death, the social, spiritual, and economic backbones of this nation will be broken.

We Americans, as part of the international community, now dedicated to destroying terrorism cannot ignore the "other war". We must be part of an urgent international effort to assist KAWI, Kenya and other countries in assembling organized, comprehensive, and effective national programs to combat the disease. 

The effort to combat HIV/AIDS must not be handled in the traditional manner of tying foreign aid to politics. We must act with a sense of urgency and purpose and approach the battle against HIV/AIDS with the same resolve and commitment that we are using to fight terrorism. Toward this goal we require international cooperation and leadership. 

It is time for the Global Fund to Fight AIDS, TB, and Malaria, as proposed by the well-known Harvard economist, Jeffrey Sachs, to be organized, empowered and adequately funded so that it can act. In concert with governments and NGOs such as KAWI, an effective battle against the spread of HIV/AIDS must be immediately mounted.

Infected individuals must be identified, educated, and referred for treatment. The uninfected must be counseled on how to maintain their health. It is particularly important for serodiscordant couples to be identified, counseled, and appropriately triaged for care. However, as we learned here in the U.S., screening can only be successful if those identified as infected are protected. 

Destigmatization efforts must be active, not passive. Foreign aid must be tied to advocacy for the rights of the HIV infected individuals so that they are not denied housing, employment, education, the right to marry, and access to medical care. Furthermore, unless an effective treatment program is put into place, then knowing one's status will never be looked upon as an opportunity to preserve health, prevent further transmission to loved ones, and allow for planning to prevent vertical transmission to infants. 

The cost of lifesaving antiretroviral drugs (ARVs) to treat HIV infection has dropped precipitously over the past year. Due to availability of generic drugs as well as the response of the pharmaceutical industry, treatment that once cost in excess of 1000 USD per month, can be delivered for as little as 1 to 2 USD per day. However, the cost of these drugs must be assumed by an International Fund. 

Furthermore, the use of funds must be strictly controlled and supervised. Misuse of these funds for personal gain should be considered a serious crime against humanity and punished accordingly. Training of health care providers is required for the responsible use of these potentially life saving drugs. HIV/AIDS treatment centers are urgently needed to provide treatment to significant numbers of infected individuals. Not only will treatment relieve human suffering and keep young people productive and healthy, but also it will assist in stemming the spread of HIV/AIDS. Treatment options will encourage individuals to be tested. With reduction of levels of virus in HIV-infected persons, sexual transmission and vertical transmission to newborns during breast-feeding are likely to be reduced. 

The war against HIV/AIDS needs to be re-invigorated, today, with action and not words. As is the war against terrorism, the battle against HIV/AIDS needs to be coordinated, well funded, purposeful, and mounted with a sense of urgency and righteousness. Only then can we, as an international community, succeed.

Prof Markowitz is Clinical Director at the Aaron Diamond AIDS Research Center, and Associate Professor of Clinical Investigation at Rockefeller University. Both institutions are in New York City, USA. He was in Kenya at the invitation of the Kenya Aids Watch Institute and GlaxoSmithkline, the pharmaceutical conglomerate, to help Kenya strategize on how to best counter the threat posed by HIV/AIDS.