What if the HIV epidemic first manifested in poor countries?

By Japheth Mati

The first WHO report on neglected tropical diseases[i] highlights the importance of a class of diseases which though medically diverse, are grouped together because all are strongly associated with poverty, all flourish in impoverished environments and all thrive best in tropical areas, where they tend to coexist. Most are ancient diseases that have plagued humanity for centuries. These diseases remain largely silent, as the people affected or at risk have little political voice. As a result, they have traditionally ranked low on national and international health agendas, allowing them to continue causing massive but hidden and silent suffering, and frequently kill, though not to the same extent as in the case of HIV and AIDS, tuberculosis or malaria.

The response to the continuing presence of the neglected tropical diseases (NTDs) in most countries in the Tropics stands in sharp contrast to the unparalleled achievement in addressing the HIV epidemic. The first case of AIDS was diagnosed in 1981. Two years later, in 1983 the HIV virus was identified, and in 1985 the FDA approved the first HIV antibody test, making it possible to diagnose the disease more precisely and to screen individuals (and blood) for the infection. In 1987 the FDA approved the first antiretroviral drug AZT (ziduvidine). Thus, despite remaining a serious global challenge, HIV had changed within a period of less than a decade from being essentially a fatal condition to become a chronic illness, thanks to the unprecedented global cooperation and commitment of massive resources for HIV research and development (R&D) activities.

Source:Working to overcome the global impact of neglected tropical diseases, First WHO report on neglected tropical diseases, 2010

Funding for Research & Development (R&D): HIV and AIDS versus NTDs

From the 1990s until 2009, funding for the HIV epidemic increased substantially[ii]. In 2008, an estimated $15.6 billion was spent on HIV and AIDS compared to $300 million in 1996. These funds mainly derived from donations from national governments, multilateral funding organisations, and private funding. In 2009 the United States of America was the largest donor in the world, accounting for more than half of disbursements to HIV R&D by governments. DFID is the world’s second biggest bilateral donor for HIV/AIDS.

On the other hand, R&D of drugs for NTDs has been very significantly under-funded. The first comprehensive survey of global spending on R&D for neglected diseases[iii], showed that in 2007, nearly 80% of the global investment into R&D of new medical products[iv] was consumed by three diseases- HIV/AIDS, TB, and malaria. Many NTDs, responsible for killing millions of people in developing countries, shared the remaining 20%; each received less than 5% of global funding. These diseases include Filariasis, Schistosomiasis, Onchocerciasis, Sleeping sickness, Leishmaniasis (kalar-azar), Chagas disease, Guinea-worm, Dengue, diarrhoeal illnesses, worm infestations, Pneumonia, Meningitis, Leprosy, Buruli ulcer, Trachoma, Rheumatic fever, Typhoid and Paratyphoid fever, and Rabies.

What is peculiar about the HIV epidemic?

AIDS as a disease entity was first reported in 1981 among homosexual men in the United States, and for some time the disease was considered peculiar to homosexuals, being variously labeled “the gay cancer”, “the gay plague” and “the gay-related immunodeficiency disease [GRID]”). These first cases involved highly educated men, many from the upper echelons of the American society. They soon realized their plight and, through a strong well organized lobby movement, fought hard for public attention and support of the search for ‘cure’. No wonder, within less than a decade, several drugs had already received FDA approval. Since then, HIV disease has engulfed the world, and the majority of the cases now live in developing countries. Nevertheless, it is possible that the conscience and momentum built up in those early years continue to play a significant role in sustaining international support for HIV activities.

What is peculiar about the neglected tropical diseases?

The nature of NTDs differs in several respects from HIV[v]. Generally, although these diseases affect the poor and marginalized populations living in rural and urban areas, they are almost exclusively limited to the tropics. These are people that cannot readily influence government decisions that affect their health, and often seem to have no constituency that speaks on their behalf. Also, unlike HIV, most NTDs generally do not spread widely, since their distribution is restricted by climate and its effect on the distribution of vectors and reservoir hosts; in most cases, there appears to be a low risk of transmission beyond the tropics. Consequently, not much is spoken about the impacts of the NTDs, nationally or internationally.

The neglected tropical diseases, also dubbed the ‘ancient companions of poverty’, have an enormous impact on individuals, families and communities in developing countries in terms of disease burden, quality of life, and loss of productivity aggravating poverty, as well as the high cost of long-term care. They constitute a serious obstacle to socioeconomic development and quality of life at all levels. WHO estimates that these diseases blight the lives of 1 billion people worldwide and threaten the health of millions more[vi]; they are a serious obstacle to the achievement of health-related Millennium Development Goals.

These diseases can, at relatively low cost, be controlled, prevented and possibly eliminated using effective and feasible solutions, such as the five strategic interventions recommended by WHO[vii].

What if the HIV epidemic first manifested in poor countries?

The answer to this philosophical question may never be known. However, going by the example of the dilatory international response to NTDs to date, it is worrying to imagine what the status of the HIV epidemic would be if it first manifested in poor countries.

[i] World Health Organization (2010) First WHO report on neglected tropical diseases 2010: working to overcome the global impact of neglected tropical diseases WHO, Geneva 

[iv] Total investment was about $US 2.5 billion.

[v] World Health Organization (2010) First WHO report on neglected tropical diseases 2010: working to overcome the global impact of neglected tropical diseases WHO, Geneva

[vi] World Health Organization (2010) First WHO report on neglected tropical diseases 2010: working to overcome the global impact of neglected tropical diseases WHO, Geneva

[vii] These are: preventive chemotherapy; intensified case management; vector control; the provision of safe water, sanitation and hygiene; and veterinary public health.

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