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An unprecedented emergency


By Jean Milligan
Over 20 years after it began, the HIV/AIDS epidemic continues unabated. In the next 12 months nearly 9,000 people will die each day from the disease. International organizations, governments and civil society institutions including the Red Cross and Red Crescent are working together to reverse the pandemic. To increase awareness of the impact of AIDS worldwide and the Movement's response, Red Cross, Red Crescent features an extended cover story on this unprecedented emergency.











Todd Murukai has AIDS and lies in bed with a fever and tuberculosis. Zimbabwe Red Cross care facilitator, Josephine Oliver, provides what comfort she can. "Plenty of the people we care for have passed away. It is painful to lose a friend but we keep doing it. If we don't, no one will. We have to show the community that we care." She explains.

An estimated 225,000 people in 1980 were infected with HIV, the virus that causes AIDS. Today there are some 40 million. The disease has claimed more than 25 million lives with devastating social and economic consequences. And this is just the beginning. Another 3 million are expected to die within the next year. Tragically, it is the young who are suffering the most as AIDS strikes the majority in the prime of their life.

Although the figures are impressive, "it's not the statistics that need attention but the individuals and the real suffering that lie behind them," explains a Federation report on HIV/AIDS. Juan M. Suárez del Toro, Federation president, recalls, "When you can see the drastic physical and emotional toll on people living with HIV/AIDS, with no access to treatment or care and facing discrimination and stigma, and when you see how AIDS has decimated entire communities, leaving behind only orphans, you really begin to comprehend the magnitude and impact of the epidemic. AIDS and other diseases are tearing apart families and communities, robbing people of a life with dignity and the hope for a better tomorrow."

The International Red Cross and Red Crescent Movement has mobilized its worldwide network to tackle the pandemic. By combining education programmes with home-based care intiatives, the Movement is on the frontline of response. But the grass-root efforts of National Societies from Fiji to Malawi cannot stop the epidemic alone. Joint action by governments, civil society, the private sector and people living with AIDS must take place to ensure that this war against the greatest threat to human security and development today is not lost.

A mortal blow

Sub-Saharan Africa is the hardest hit by the pandemic with 70 per cent of the world's HIV/AIDS cases and 75 per cent of its deaths. The United Nations Children's Fund (UNICEF) estimates that a 15-year-old boy in Botswana today has an 80 per cent chance of dying of AIDS. HIV is spread in Africa primarily through unprotected heterosexual intercourse, spurred on by the migrant labour system, widespread sexual violence and the presence of other untreated sexually transmitted diseases.

Poverty aggravates the situation limiting the number and scope of prevention programmes, handicapping overwhelmed health-care systems and making most treatments unaffordable. Add to this the lack of political will among many governments and the international community to address properly Africa's worst-ever disaster in its early phases and it seems as if things are only going to get worse.

The AIDS epidemic will reverse hard-won development gains in southern Africa costing up to 17 per cent of gross domestic product by 2010, according to published reports. Jeffrey Sachs, the noted former Harvard economist, now an advisor to the UN Secretary-General, Kofi Annan, explains: "This single epidemic can undermine Africa's development over the next generation."

While economic development will be severely impacted, what concerns many government officials and those in the international aid community is the dramatic increase in the number of children orphaned and made vulnerable by AIDS. With some 34 million orphans in Africa today, UNICEF predicts this figure will rise to 42 million by the end of the decade, half of them orphaned by AIDS.

Often left behind after one or both parents have died, extended family members try to assume responsibility for these children, but are often overwhelmed and lack the resources to care for them properly.

To make matters worse, the current drought in southern Africa is exacerbating further the HIV/AIDS pandemic. The Federation estimates that at least 14.4 million people are threatened by starvation this year. Lesotho, Malawi, Swaziland, Zambia and Zimbabwe are the most affected by food shortages as a result of bad harvests, economic decline and poor government policies. The HIV/AIDS pandemic, which affects up to 34 per cent of the adult population in some areas of the region, has depleted the labour force and reduced food production as well as wage income. Alex de Waal, director of Justice Africa and an adviser to the UN Economic Commission for Africa and UNICEF, comments, "We are facing a new variant of famine: in societies hurt by AIDS, famine more deadly and less susceptible to existing treatments. The reason is that AIDS attacks exactly those capacities that enable people to resist famine."

 

The face of drought and AIDS

The teacher in a classroom of a primary school in the Lowveld region of Swaziland is extolling the virtues of a balanced diet, a key element, he tells his pupils, in avoiding disease. They look on wide-eyed. Most of them are lucky if they eat one meal a day.

"Yesterday we didn't eat until afternoon when Mum cooked porridge," says Nkosinginphile Mamba, 13, who along with his friends often spends a whole day in school with an empty stomach. Even so they are the lucky ones. The hunger affecting this little kingdom landlocked by South Africa means many children do not go to school at all. Their impoverished parents have a choice: feed the family or pay school fees. Many are unable to do either.

Nkosinginphile lives in one of the regions of Swaziland hardest hit by the southern African drought. A 70 per cent reduction in crop yield was reported here after the last harvest, partly the consequence of drought, partly HIV/AIDS.

Says the boy's mother, Busangani Dlamini, "We did plough but couldn't look after the crops properly because my husband was already getting seriously ill."

Busangani's family is among the most vulnerable in Swaziland. Her husband, Samuel, 34, used to work in the mines of South Africa and, relatively well paid, could easily support his two wives and six children. But like over 38 per cent of the adult population he was infected by HIV and is now dying of AIDS.

"I don't have any money left," he says wearily from the bed he has been confined to for the past six months, "so I cannot feed the children properly, and to send them to school is getting more and more difficult."

The family is heavily dependent on Red Cross food rations but they still have to acquire other food to keep going, and the choice between food and education comes ever closer. For the US$20 a year it costs to send a child to school you can buy a 50-kilo bag of maize which will feed the family for three weeks.

The Federation is coordinating a five-country relief operation to help such families through a food crisis in which at least 14 million people are threatened by starvation.

Pia Caspersen

 

 

Next wave

If sub-Saharan Africa is bearing the brunt of the pandemic today, predictions by the US-based National Intelligence Council (NIC) are that the number of people with HIV/AIDS will rise significantly by 2010 in five "next wave" countries. "The increase will be driven by the spread of the disease in five populous countries — Nigeria, Ethiopia, Russia, India, and China — where the number of infected people will grow from around 14 to 23 million currently to an estimated 50 to 75 million by 2010. This estimate eclipses the projected 30 to 35 million cases by the end of the decade in central and southern Africa, the current focal point of the pandemic," explains the NIC report.

The NIC projects that China will have 10 to 15 million HIV/AIDS cases, India will have 20 to 25 million by 2010 — the highest estimate for any country. By 2010, Nigeria is projected to have 10 to 15 million cases, Ethiopia 7 to 10 million, and Russia 5 to 8 million.

The primary cause for the increasing infection rates in all the countries is unprotected sex and sharing intravenous drug equipment. The challenge is to begin tackling the problem now. But without the political will, it will be nearly impossible to stem the tide of the epidemic in these countries by 2010. "The disease has built up significant momentum, health services are inadequate, and the cost of education and treatment programs will be overwhelming. Government leaders will have trouble maintaining a priority on HIV/AIDS — which has been key to stemming the disease in Uganda, Thailand, and Brazil — because of other pressing issues and the lack of AIDS advocacy groups," says the report.

For some there is hope as antiretroviral drugs become much cheaper and more accessible, but for many in developing countries the cost of treatment remains too high. Overlooked in the debate on antiretrovirals is the appalling fact that Africans are often denied even basic drugs and medications to combat illnesses such as tuberculosis (TB), diarrhoeal disease and fungal infections of skin and mouth. For example, many clients of the Red Cross and Red Crescent home-based care programme suffer recurring and drug-resistant TB because their treatment is interrupted when the drugs run out. TB drugs may be free in Africa but that doesn't help when they are unavailable.

The right to treatment

The vast majority of people living with AIDS will continue to be denied access to life-saving antiretroviral therapy (ART) unless considerable additional resources are provided to the Global Fund for the Fight against AIDS, TB and Malaria, said Dr. Massimo Barra, a new representative of non-governmental organizations from developed countries on the Global Fund board.

Barra, founder and director of "Villa Maraini", an Italian Red Cross Foundation that has provided direct assistance to more than 25,000 injecting drug users, said the proposals which the Global Fund has been able to support to date will only provide ART to some 492,000 people over the next five years, leaving the needs of more than 5 million people uncovered.

"This is completely unacceptable and we must do all in our power to impress on the international community how shameful it is that so many people will die when affordable drugs are available on the market," said Barra.

He believes that "the most important thing that the Global Fund can do is to make access to treatment available. Otherwise we condemn millions of people to death. This is a scandal which the Red Cross cannot accept. Therapy is an important part of prevention, it is not possible that it is only accessible to 5 or 10 per cent of the affected population."

Safer fixing

The heroin trade route that runs out of Afghanistan and travels north through central Asia to Russia, then west is increasing intravenous drug use throughout these regions and creating what today is one of the world's hotspots for the HIV epidemic — Russia and central Europe.

The Red Cross and Red Crescent is scaling up its programmes to help drug users. Several National Societies are running centres that offer needle exchange, free testing for AIDS, and support groups. These programmes follow the harm reduction approach and aim to help the drug user while preventing the spread of HIV into the general population. As the Croatian Red Cross health coordinator, Sinisa Zovko, notes: "You cannot separate HIV from drug programmes. Along with safer sex we must have safer fixing."

Although a preventive public health strategy, harm reduction is not without controversy. Some people question the value of reaching out to such a marginalized group whose behaviour is unacceptable to some. But most health professionals point out that while HIV infection may first occur in those on the fringe of society, it does not take very long for it to enter the mainstream and become a widespread public health problem. Zovko explains: "Drug abusers are members of the community. They are ill because of addiction, and they have rights. My job is to help and advise them, reduce the risk they are exposed to. We must help them to protect themselves and in doing that protect the community."

 
 

The problem of complacency

While much of the developing world is fighting to gain access to treatment and expand prevention programmes, in Western Europe and the United States the greatest threat is a widespread and alarming complacency among young people. Although new drugs are succeeding in prolonging the lives of people with HIV/AIDS, prevention programmes have not kept pace and involved younger generations. The danger is that infection no longer seems so life threatening. As proof, a recent study by the Terrence Higgins Trust, the largest AIDS organization in the UK, revealed that one-third of 18- to 24-year-olds in the country believe there is a cure for HIV/AIDS.

And infection rates are rising as a result of the complacency. In 2001, there were 4,419 people diagnosed with the disease in the UK, an increase of 17 per cent on 2000 according to the Guardian newspaper. The profile of those infected is also changing. HIV/AIDS is no longer primarily an infection of gay men or intravenous drug users in the UK; an estimated 54 per cent of new infections were between heterosexual couples.

The situation is repeated in the US. According to the US Centers for Disease Control (CDC), while the number of AIDS cases in the country is declining, the number of people living with HIV is growing. "This increased prevalence of HIV in the population means that even more prevention efforts are needed, not fewer," explains a CDC report.

To prove their point, the CDC refers to research done among gay and bi-sexual men. It suggests that some respondents are less alarmed about the threat of becoming infected than in the past and "may be inclined to take more risks". The research also states that this is most likely true for other groups as well who may have unprotected sex in the belief that the available medication is effective in treating HIV. The CDC concludes with a warning: "The truth is, despite medical advances, HIV remains a serious and usually fatal disease that requires complex, costly, and difficult treatment regimens. These treatments don't work for everyone."

Prevention through puppets

"What's the matter? Don't you love me?"
"Of course I love you, my darling, but you promised not to hurt me..."


The audience's eyes are glued to the stage where a girl finds herself alone in a boy's apartment. He says he doesn't need a condom — everything will be just fine. Besides, he loves her very, very much.

The boy is blue with yellow-greenish hair, the girl is orange with purple hair.

That's all right — it's all make-believe. The boy and the girl are puppets, given movement and voices by young Red Cross volunteers from Pacific countries who have gathered in the Fijian resort town of Nadi for a two-week Federation-sponsored workshop on puppetry and HIV/AIDS awareness. This is the last day of the intensive workshop and they're rehearsing for a performance for a local community group and a secondary school this afternoon.

Not only have they made the puppets from scratch, they've also written the script and built the stage. Now they're heading home to make puppets in their own National Societies and to take their HIV/AIDS awareness puppet shows to local communities.

"Puppet theatre can be a very good tool in our communities," says Norman Ben from the Vanuatu Red Cross. "Puppets are a good source of entertainment and therefore a good way to convey powerful messages to the public."

And the message certainly needs to be conveyed. HIV prevalence is on the increase in the remote and isolated communities of the Pacific island countries.

The Fiji Red Cross has been using puppets to spread various messages to local communities for a number of years. It has been difficult to get the church to accept the HIV/AIDS-prevention message. The one time Fijian Red Cross puppeteers performed in a church setting, they were stopped in the middle of the show — and haven't been invited back.

"We are hoping to be able to support a number of societies in the region to develop relevant programmes in this field," says Milja Heinonen, the Federation's regional health delegate in the Pacific.

"So far — sorry to say — the Red Cross is not really recognized in the Pacific as a key player when it comes to HIV/AIDS. Puppetry is one of the tools we have and that appears to have an appeal here," she says. However, she points out that the National Societies need to commit themselves to this work, in collaboration with other actors.

The young puppet masters from Cook Islands, Fiji, Samoa, Tonga and Vanuatu who have been learning the art in Nadi are fully aware that theirs will not be an easy task. Gradually, they say, as more puppeteers are trained and their message is taken to local communities, attitudes may begin to change.

Omar Valdimarsson

A global effort

If the AIDS pandemic is to be reversed, not only the disease but poverty, ignorance, stigmatisation and violence must be confronted. Efforts are underway but a greater political will and a massive mobilization of resources needs to take place.

Stephen Lewis, the UNAIDS special envoy, explained it this way: "In times of war, resources are somehow found that are thought not to exist — just think of the so-called war on terrorism, with scores of billions of dollars hurled into the fray overnight to avenge the horrendous deaths of 3,000 people. So explain to me why we have to grovel to extract a few billion dollars to prevent the deaths of over 2 million people every year, year after year after year?"

 

Jean Milligan
Jean Milligan is Federation editor of Red Cross, Red Crescent magazine.



Red Cross
Red Crescent


action at a glance

ICRC initiatives

The ICRC HIV/AIDS programmes concentrate primarily on detainees, displaced persons, refugees, unaccompanied minors, armed forces and the war wounded. As a rule, the ICRC implements programmes within the framework of national policies against AIDS as well as those of the Movement and the United Nations.

In the case of detainees, the ICRC focuses on the prevention of AIDS. It works closely with detaining authorities and with local non-governmental organizations running programmes for HIV-positive inmates. It also has developed tuberculosis treatment and prevention programmes, in particular in the southern Caucasus (Georgia, Armenia, Azerbaijan) and in various African countries where multi-resistant strands of tuberculosis are especially acute.

National Society initiatives

In the 50 countries hardest hit by HIV/AIDS as well as China, India and Indonesia, 80 per cent of Red Cross and Red Crescent Societies have either launched new programmes, scaled up existing ones or incorporated an HIV/AIDS component into health initiatives.
Among these are:
— In China's Yunnan and Xinjiang provinces, the Red Cross is running youth peer education programmes. Currently, the programmes are being scaled up in other regions. Last year, the National Society was praised for its efforts by UN Secretary-General Kofi Annan.
— The Thai Red Cross, a pioneer in the fight against the spread of HIV/AIDS in Asia, manages a clinic that provides anonymous counselling and testing. The clinic is considered a national model by the Ministry of Health. The National Society also has a support group for people living with HIV/AIDS. In part through its efforts, stigma and discrimination have been dramatically reduced in Thailand.
— In southern Africa, where drought and HIV/AIDS have combined for a deadly mix, the National Societies of several countries are providing food packages along with crucial home-based care efforts.
— In east Africa, Red Cross Red Crescent Societies are developing new HIV/AIDS programmes and expanding existing ones.
— Several thousand people participated in Red Cross HIV/AIDS education initiatives in central Africa. In particular, peer education programmes, public forums, theatrical productions, chat rooms and anti-AIDS clubs reached out to young people throughout the region. A number of home-based care programmes were initiated offering much-needed care and support to people living with the virus.
— The Croatian Red Cross is implementing ground-breaking harm reduction strategies, including a needle exchange programme.
— More than 50 European National Societies issued a joint declaration in 2002 calling for renewed attention to the health needs of vulnerable people, particularly those affected by HIV/AIDS and tuberculosis. The declaration calls for the use of harm reduction strategies where necessary and appropriate.
— The National Societies of the Dominican Republic and Honduras have provided a powerful example of how collaboration with organizations of people living with HIV/AIDS can reinvigorate the national response

Federation initiatives

The Federation's Governing Board has adopted a new HIV/AIDS policy which recommits the Red Cross Red Crescent to support and scale up efforts on prevention, de-stigmatization, advocacy, the provision of health care and other services related to HIV/AIDS, in particular to vulnerable populations. Most significantly, it endorses and advocates harm reduction strategies as key to stemming the spread of HIV/AIDS.

Guidelines developed by the Federation help National Societies to implement programmes for home-based care and for orphans and other children made vulnerable by HIV/AIDS.

The Federation also has forged strong partnerships with organizations concerned with HIV/AIDS and corporate institutions. These include a partnership with the Global Network of People living with HIV/AIDS. The launch of the world-wide campaign to reduce AIDS related stigma and discrimination, "The truth about AIDS…pass it on", was the highlight last year of this partnership. A formal framework for cooperation was developed with the Pan American Health Organization, focusing on joint health initiatives in the Americas to extend HIV/AIDS prevention efforts and increase supplies of safe blood. And the OPEC Fund for International Development and several National Societies in Asia and the South Pacific are combining efforts to scale up programmes in response to the expanding HIV/AIDS epidemic in the region.




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