Diminishing U.S. Fears About AIDS Not Healthy by Gina Shaw How deadly is AIDS? Your answer to that question likely depends on where you live. If youíre a young woman in Zimbabwe, you might see it as a looming threat, more likely than not to cut your life short long before your time. If youíre a young man in San Francisco, you might consider AIDS and HIV a danger thatís more so in the past. The AIDS picture changes radically depending on whether youíre looking at the developed or the developing worldóhowever, despite the many advantages economically privileged countries have in combating the disease, our diminishing fears about HIV and AIDS may not be doing anyoneís health any good. AIDS will lower life expectancy in 51 countries over the next 20 years, according to a report released by the U.S. Census Bureau at the 14th Annual International AIDS Conference held in Barcelona, Spain, in July. A recent UNAIDS estimate of 68 million worldwide AIDS-related deaths by 2020 was called ìconservativeî by at least one expert at the conference, who predicted 90 million deaths by 2020 without more effective AIDS-fighting programs and treatments. In sub-Saharan Africa, which has been devastated by the disease, seven nations now have a life expectancy that hovers below 40 years. If you live in Botswana, considered an AIDS hotbed, you can expect to live to be 39 years oldóprobably a shorter lifespan than you might have had if youíd been born two centuries ago. Disproportionately affected by the world AIDS crisis are young women and infants in developing countries. Women and girls make up 67 percent of the 8.6 million people in sub-Saharan Africa with HIV or AIDS and 62 percent of the cases in South Asia. AIDS-related infant deaths are climbing after decades in which child survival increased, and in several African nations, AIDS deaths are set to outstrip all other causes of infant deaths combined. In addition, a report released at the Barcelona conference concluded that the number of African children orphaned by the AIDS crisis is expected to skyrocket from 13.4 million to 25.3 million by the end of this decade. Researchers estimate that about 60 million people have been infected with HIV in the last 20 years or so, and about 20 million have died from it. But they predict that an additional 45 million people worldwide will become infected with HIV by 2010. Holding back this global tide of infection and disease will require billions of additional dollars to be invested in prevention and treatment programs. According to a study published in The Lancet in July, nearly two-thirds of the projected new HIV infections, or 29 million, could be prevented with a rapid expansion of HIV prevention efforts, including ad campaigns, public education in schools and workplaces, condom distribution and needle-exchange programsóat a cost of some $27 billion. ìThese deaths are not inevitable,î said World Health Organization epidemiologist and study co-author Dr. Bernhard Schwartlander. ìWe can actually do something which can substantially decrease this epidemic.î But the clock is ticking: The study found that most HIV infections could be prevented with fully funded programs in place by 2005, but half of that projected benefit would disappear if full investment and expansion is delayed until 2008. Another study presented in Barcelona got more specific about what a full-throttle global HIV-prevention campaign, such as the one outlined in the Lancet study, would look like. Among other strategies, the Global HIV Prevention Working Group recommended allowing countries to set their own priorities for funding; boosting health system infrastructure; mobilizing political leadership; improving HIV surveillance; dramatically increasing access to treatment; and expanding successful prevention programs, such as a Ugandan program thatís being credited with contributing to a 37 percent drop in new HIV infections in that country during the second half of the 1990s. ìWe are going to continue to face devastation if we donít, as a world community, wake up to this and put in the resources that we need to make the difference,î said Helene Gayle, co-chair of the working group and an official with the Bill and Melinda Gates Foundation, which sponsored the panel along with the Kaiser Foundation. ìBy presenting some practical solutions, and some things we know are doable, itís not just saying, ëGive us the money and trust us.í Itís ëGive us the money Ö and there are solutions available today.íî Complacency in America Meanwhile, in the United States, the sense of urgency over AIDS as a looming public health crisis, which was prominent in the 1980s and early 1990s, has given way to a view of the disease as a severe and chronic, but manageable, illness. Although the prolonged survival and improved quality of life that anti-retroviral drugs have bought for people with AIDS cannot be considered anything but a giant leap forward, these benefits have come with unintended consequences. Some experts are concerned that people have begun to view AIDS as curable, when itís anything but that. Combinations of anti-retrovirals can halt mutations in the virus and allow many to enjoy a nearly normal life expectancy, said researchers at the conference, but HIV infection remains ìintrinsically incurableî with current therapies, according to Dr. Robert Siliciano of Johns Hopkins University. ìAmericans donít have the same sense of urgency or crisis which characterized the early years of the epidemic. Some are becoming bored with HIV after 20 years, some are simply tired of the messages and behavior change. And many didnít realize they were signing up for a lifetime of condom use,î said Dr. Ronald Valdiserri, deputy director of the National Center for HIV, STD and TB Prevention at the Centers for Disease Control and Prevention (CDC). Indeed, most Americans seem untroubled by AIDS, with only 17 percent of people surveyed rating it as one of the countryís most urgent health problems in a recent Harvard/Kaiser/Washington Post poll. In fact, a good 17 percent of us think thereís already a cure for AIDS (there isnít, nor is there one on the horizon), and 46 percent of Americans surveyed arenít at all concerned about developing AIDS themselves. In fact, even among traditionally ìhigh-riskî populations, such as gay and bisexual men, the sense of urgency over AIDS seems to have given way to one collective shrug of the shoulders. A CDC study presented at the Barcelona conference found that 70 percent of gay and bisexual men who were HIV positive didnít know their HIV status. (African-American men rated even higher, with 91 percent of those with HIV unaware that they were positive.) Most of the study participants, young men interviewed at popular gay hangouts in major cities, including New York and Miami, thought they were at low or very low risk for HIV infection in the first place. Another group that is especially susceptible to HIV infection in the United States is African-American women, who account for about half of all cases of HIV infection acquired heterosexually. It gets worse: Two-thirds of HIV-positive people in the United States are sexually active, but the ìno glove, no loveî message has fallen by the wayside for more than a third of them, who have unprotected sex at least part of the time, the CDCís Valdiserri reported. ìWe canít sit back and wait for a vaccine,î he said. ìWe must revive the passion with which the United States once faced the HIV epidemic, with a strong and preeminent focus on preventing the spread of the virus.î Gina Shaw is the medical writer for The Washington Diplomat.