Select Committee on International Development Third Report

Section 1 — The Nature of the Epidemic

HIV/AIDS — a medical account

6. AIDS — an acronym for Acquired Immune Deficiency Syndrome — is a clinical diagnosis of a range of symptoms seen in people at an advanced stage of infection with HIV - human immunodeficiency virus. We must state unequivocally at the outset of this Report that AIDS is caused by HIV infection. Those who deny this are a small and unrepresentative group, whose views have been repeatedly refuted by the scientific community. Such "dissidents" claim that poverty causes AIDS. Poverty profoundly worsens the impact of HIV/AIDS, but does not cause it.

7. There has been recent debate in both academic circles and the media as to the origin of HIV. Many scientists believe that AIDS was transferred from other primates to human beings via the eating of chimpanzee flesh, but an alternative view, championed by Edward Hooper and others, is that it was caused by a polio vaccination used experimentally in Congo in the 1950s. Such controversy is no doubt interesting but we do not consider it relevant to the far more important question of how to stem and turn back the current HIV/AIDS epidemic. HIV/AIDS is currently the greatest humanitarian crisis facing our planet. That is why we need to act. Added to that, in a world ever more interdependent, the implications of the pandemic and its appalling statistics in the South for the health, economies and security of the North are most serious.

8. There are two strains to the HIV virus, HIV-1 and HIV-2.[2] HIV-2 is less infectious and progresses more slowly. It is found primarily in West Africa. HIV-1 is the most common form of HIV, and has at least nine different sub-types, each predominating in different parts of the world (although there has been increasing dispersion in recent years). The HIV virus attacks immune system cells and has three stages to its development. The first stage, known as primary infection, begins at the time of infection and lasts a few weeks, until the body's initial immune system gains some measure of control over viral replication. The second stage accounts for about 80 per cent of the time between infection and death, during which period most HIV positive people remain clinically healthy. Only from the beginning of this second stage do antibodies to HIV become detectable in the bloodstream. Thus HIV tests, which work by detecting these antibodies, are not effective prior to this second stage. During this second stage the virus destroys vital immune cells (CD4+ T-cells). Once the CD4+ T-cell count diminishes to around 200 per cubic millimetre of blood, the rate of decline accelerates and the individual becomes susceptible to opportunistic infections and other illnesses. This is the late stage of the infection — clinical AIDS.

9. The opportunistic illnesses often diagnosed in HIV-positive people in developing countries include tuberculosis, pneumococcal disease (which causes pneumonia, and also amongst the HIV-infected bacteremia, sinusistis and meningitis), toxoplasmosis (causing encephalitis), oral thrush, and cryptococcosis. As the immune system continues to deteriorate the number and variety of illnesses increases, leading eventually to death. An important issue to consider is the length of survival after infection. It is apparent that important factors are the general state of a person's health and access to medical treatment for opportunistic infections. UNAIDS states that "The bulk of evidence now suggests that a few relatively inexpensive drugs could help ward off severe illness and add months, if not years, to the lives of HIV-positive people in even the poorest developing countries".[3] The absence, however, of such treatments in the greater part of the developing world means that the life of an HIV-positive person in poorer countries is both shorter and more miserable than a similarly infected person in the developed world.

10. How are people infected with the HIV virus? It is important to stress that HIV is difficult to transmit except through sex or other direct contact with the bodily fluids of an infected person. Thus the main modes of transmission are heterosexual activity, sex between men, and intravenous drug use. UNAIDS gives some sense of how HIV is being transmitted in different regions of the world. In Eastern Europe and Central Asia intravenous drug use is the main mode of transmission. In North America and Western Europe it is mainly sex between men, with intravenous drug use also having an impact. In sub-Saharan Africa, the Caribbean, South and South East Asia it is sex between men and women which is the main mode of transmission.[4]

11. In addition to these three modes of transmission we must mention a fourth — mother to child transmission. In 1999 620,000 children under the age of 15 were infected with HIVand 500,000 children died of AIDS. The vast majority would have contracted the virus through mother to child transmission. The child acquires the virus in the womb, around the time of childbirth or during breastfeeding. In the absence of any intervention, around a third of HIV-positive mothers pass the virus to their babies — about half of all these infections occur during breastfeeding.[5]

HIV/AIDS — a disease of poverty

12. We have given a medical account of the HIV/AIDS epidemic, of the progress of the disease and of the modes of transmission of the virus. Already in passing we have had to make the point that how rich or poor you are will have a profound effect on the length of your survival and of the quality of your life during your illness. HIV/AIDS is not just about health. It is also about wealth. "A decade ago, HIV/AIDS was regarded primarily as a serious health crisis ... Today, it is clear that AIDS is a development crisis"[6] — the words beginning the UNAIDS June 2000 Report on the global HIV/AIDS epidemic insist that development makes HIV/AIDS a priority concern. More than that, the implication is that there will be no success in development unless there is success in tackling the HIV/AIDS epidemic. Why is that? The answer is found baldly in the statistics — HIV/AIDS is having a disproportionate effect on the poor.


13. Of the estimated global total of 34.3 million people who at the end of 1999 were living with HIV/AIDS, 24.5 million of them were in sub-Saharan Africa. A further 5.6 million were in South and South East Asia, where the epidemic is at an earlier stage. The cumulative total of those orphaned by HIV/AIDS[7] was 13.2 million, 12.1 million of them in sub-Saharan Africa. 2.2 million of the 2.8 million AIDS-related deaths in 1999 were in sub-Saharan Africa. The prevalence rate for sub-Saharan Africa in 1999 was 8.57 per cent, compared to a global prevalence rate of 1.07 per cent. GDP per capita in sub-Saharan Africa in 1998 was US$ 1,607, whilst that of OECD countries was US$ 20,357. That sub-Saharan Africa figure masks some appalling country rates — Botswana at 35.8 per cent, Zimbabwe at 25.06 per cent and South Africa at 19.94 per cent, for example. Furthermore, certain regions and towns within these countries will have much higher prevalence rates. Prevalence is much worse in these poorer countries than in, say, Western Europe, where it is 0.23 per cent. The contrast between Western Europe and sub-Saharan Africa is significant. In both regions the epidemic began in the late 1970s/early 1980s.

14. Not only is prevalence much worse in sub-Saharan Africa than in Western Europe — AIDS-related deaths are also far greater. In 2000 there were 540,000 adults and children living with HIV/AIDS in Western Europe, and 7,000 AIDS deaths, a ratio of about 77 to 1. In sub-Saharan Africa there were 25.3 million living with HIV/AIDS and 2.4 million AIDS deaths, a ratio of about 10.5 to 1. Although a crude measure, for epidemics of similar duration the discrepancy in the numbers of deaths is telling. One reason for the difference is the use of anti-retroviral therapy (ART) in Western Europe, itself a medication unavailable to sub-Saharan Africa because of costs. Even before the use of ART, however, death rates in Western Europe were going down as expertise grew in how to "manage" HIV/AIDS. The use of drugs to treat opportunistic infections was resulting in healthier and longer lives for HIV-positive people. Again, in sub-Saharan Africa there is no health service with the funds to afford such drugs or the capacity to dispense them.

15. It is clear then that poverty plays a crucial part in a population's vulnerability to infection and capacity to live with the disease. Clare Short said that "there are special features of life where people are desperately poor. For example, [HIV/AIDS] spreads massively faster where there are untreated sexually transmitted diseases (STDs) and in populations where there has never been or is very little availability of antibiotics. That is highly linked to poverty and people's immune systems are weaker when they are badly fed and in poor health ... There is no doubt that the speed of spread and the degrees of suffering are made massively worse by poverty".[8] The link between STDs and HIV/AIDS is partly behavioural — unprotected sexual intercourse exposes a person to both. But it is also biological. In particular, untreated genital herpes appears to be an entry point for HIV/AIDS. The lack of access to STD treatment in many parts of the developing world (and untreated STDs are much more prevalent in developing countries) is thus a significant factor in the spread of HIV/AIDS.

16. The failure to treat STDs, and its impact on the spread of HIV/AIDS, is merely one example of the wider fact that the poor in developing countries do not have access to primary health care, nor to sexual and reproductive health services. This has an impact both on the spread of HIV and also on the care of those who are HIV-positive.

17. HIV/AIDS, however, is not the only communicable disease devastating the developing world. An anecdote from a Committee visit makes the point. In 2000 the Committee visited South Africa and it was there that we heard a great deal about the impact of HIV/AIDS on social and economic development. At a meeting with a local community group in KwaZulu Natal, Members asked some of the group what they were doing to protect themselves against HIV/AIDS. Why, came the response, are we always asked about HIV/AIDS? Why aren't we asked about malaria? Doesn't anyone care about that?

18. The point is a good one. An examination of the WHO statistics for 1999 reveals that HIV/AIDS accounted for 4.8 per cent of deaths in 1999 (about 2.7 million people). Tuberculosis, however, accounted for 3 per cent of deaths (about 1.7 million people) and malaria for 1.9 per cent (about 1.1 million). Given the concentration of TB and malarial epidemics it is quite possibly the case that in certain areas TB and malaria are claiming as many if not more lives than HIV/AIDS. If we turn to diarrhoeal diseases we see that they account for 4 per cent (2.2 million), nearly as many deaths as were caused by AIDS. Is not the problem a more general one — the poor health of poor people? Why put such a stress on HIV/AIDS?

19. There is certainly a wrong way to go about highlighting the crisis of HIV/AIDS. Professor Alan Whiteside warned against an exclusively AIDS-specific approach, "I think there is a real problem with going into a country and saying AIDS is a problem. The World Bank, I believe, is currently falling into that trap, but if you go in and say, 'AIDS is a problem', the country is going to turn round to you and say, 'If you see it's a problem, you solve it'".[9] We discuss in more detail later the response of the World Bank and other donors to the epidemic. It is true that we should not "hype" HIV/AIDS to the exclusion of other diseases and the poverty which is such a contributory factor to the poor health of the developing world. To do so is simply to export our rich country preoccupation with one of the few diseases about which we still feel vulnerable. It is easy to see how such an approach can be resented by countries which have been struggling for years with poverty and where even diarrhoea claims millions.

20. The point has already been made that the fight against HIV/AIDS must be part of the larger fight against poverty. As poverty declines, so eventually will HIV/AIDS. The epidemic must also be seen in the context of the need for better health services in the developing world and the need for a more effective response to all communicable diseases. Recent work by the European Commission and the G7 have linked HIV/AIDS with TB and malaria in a single communicable disease strategy. This is commendable and necessary. All these diseases are diseases of poverty. The relief of poverty and the provision of health care for the poor will have a fundamental impact on all three diseases.

2   For a more extended account of 'The Natural History of AIDS' see the World Bank publication "Confronting AIDS - Public Priorities in a Global Epidemic" Box 1.2 pp.19-21 Back

3   UNAIDS June 2000 Report p.105 Back

4   UNAIDS AIDS epidemic update: December 2000, p.5 Back

5   UNAIDS June 2000 Report p.81 Back

6   UNAIDS June 2000 Report p.7 Back

7   An orphan is defined for these purposes as someone under the age of 15 who has lost a mother or both parents Back

8   Q.521 Back

9   Q.116 Back

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Prepared 29 March 2001