'The Epidemic Is Growing In Frightening Ways'

In spite of medical advances, the AIDS epidemic is worsening. A United Nations study released this week predicts that the illness could kill 68 million people worldwide over the next 20 years if prevention and treatment programs are not "drastically expanded."

Ane while anti-retroviral drugs are prolonging the lives of HIV sufferers in industrialized nations, some 96 percent of the infected in the developing world have no access to the medication they need so desperately.

The UNAIDS report was released in advance of the 14th International AIDS Conference, which begins in Barcelona on Sunday. Thousands of AIDS activists are gathering in the Spanish city to discuss new treatment and prevention options for a pandemic that is spreading faster and more widely than epidemiologists once believed possible. Drew Altman, president and CEO of the Kaiser Family Foundation--an independent California-based philanthropy that focuses on major health-care issues--will be at the six-day gathering to announce a new global prevention campaign involving Kaiser and MTV International. He will also be part of a team releasing the findings a study showing the alarming spread of HIV among young people.

Altman spoke to NEWSWEEK's Arlene Getz shortly before leaving for Barcelona. Excerpts:

NEWSWEEK: What do you hope to achieve at the conference?

Drew Altman: It's a critical time for everyone interested in HIV to come together. The epidemic is growing in very frightening ways just at a time when the U.S. public--and to some degree the world public--are diverted by the aftershocks of 9-11 and the economic problems that many countries are facing. This conference is part of leading and educating, a part of putting AIDS more centrally on the U.S. agenda and also the global agenda.

The new UNAIDS report warns that the AIDS epidemic is still in its early stages--and that HIV prevalence is climbing and spreading more rapidly than predicted a decade ago. Why this turnaround from a perception that the situation had stabilized?

Modeling is an imprecise science. Everybody agrees that the ability of this epidemic to spread around the world was underestimated, both in countries where they thought AIDS would have plateaued and also in other countries which just a few years ago weren't expected to become such a central part of a growing epidemic.

Which areas will be worst-hit in the future?

The epicenter of the epidemic is--and for some time will continue to be--in sub-Saharan Africa. Then everyone is looking toward India, China, former republics of the Soviet Union and Eastern Europe.

If you step back from particular countries what you really see is two different epidemics, two different challenges. There are countries with generalized epidemics, where AIDS is spread largely heterosexually and throughout the entire population--sub-Saharan Africa is a perfect example of that. And then many countries who have more concentrated epidemics, for example IV drug users, commercial sex workers. Those two very different epidemics require different interventions.

How much of a schism exists between the developed and developing world over the way to handle AIDS?

Everybody believes the first responsibility [for treatment] lies with the countries themselves who are most affected by HIV but that the wealthier nations need to step up and do dramatically more. At the same time, nobody should be fooled about the obstacles to that and how hard that will be to make that happen. The public only has a dim awareness of the magnitude of the epidemic because problems at home have shifted the focus of the American people.

But in areas like the U.S. and Europe, fear of AIDS seems to have receded as medications to cope with the condition have improved.

The impact of new AIDS drugs has caused people to let down their guard a little bit more, or to be confused about [whether] there is or isn't a cure for AIDS. It's shifted the focus off AIDS at exactly the wrong time.

Do you expect infection rates to rise in wealthier countries as well if AIDS is no longer seen as a death sentence there?

No, because the epidemic is so concentrated among certain high-risk communities and populations. It has plateaued at an unacceptably high rate in the U.S. What I do think the [new treatments] affect is the priority the public gives to the epidemic, the willingness to mobilize resources.

The Kaiser Family Foundation will release a report at the Barcelona conference showing that the rate of HIV infection is rising dramatically among youth. What lessons can be learned from the study?

Our new report shows that to a large extent HIV is a youth-driven epidemic [and] that the number of young people affected by HIV is going to continue to grow strikingly. About half of all new infections are among younger people. In South Africa, for example, where we have worked intensively for 15 years, there are 12 million kids below the age of 15. If the rate of HIV infection [there] stays the same, the projections are that 6 million of those 12 million young people in South Africa will die as a result of AIDS. That's half of the young people in a major country. The implications are that we need to make youth prevention a much higher priority than it has been.

Are these new infections transmitted sexually?

Yes, it's not drug related. As in most of sub-Saharan Africa, the epidemic is driven by heterosexual contact. The image that many people have of this epidemic is a sex worker or young soldier [who become infected]. Really, the image they should have in sub-Saharan Africa is a 14-year-old girl or boy in a rural village listening to some form of hip-hop music with a Britney Spears or Michael Jordan T shirt on.

What about the other vulnerable populations? U.N. statistics show HIV infection rates are five times higher in young girls than in young boys, and that women too are particularly at risk.

It definitely deals with gender inequality. Part of the challenge here is to reach men, but also to empower women, so that they can protect themselves. That's a formidable challenge in many cultures and many societies. There's also patterns of forced sex and transactional sex--selling sex in order to obtain something you need to survive--and patterns of younger women having sex with older men. All of these things combined are the principal reasons why [HIV] disproportionately affects women and girls.

Then education programs alone aren't enough?

We need a whole new generation of prevention programs. Younger people don't respond well to lectures or scare tactics. They don't trust government or other mainstream institutions, they don't like to go to clinics. But we've learned from many programs around the world that they do listen to their parents when they're younger, they listen to their peers when they become teens, and they are heavily influenced by the media in all its forms. The combination of media and youth-driven outreach services are the essential ingredients of successful prevention programs for kids.

Any examples of these prevention programs?

Overall, when it comes to youth prevention we see a pattern of successful programs that are mostly small scale and not comprehensive. The only example that I'm aware of--and I should say that [the Kaiser Family Foundation] is intimately involved with it--of a nationwide comprehensive prevention program is the loveLife program in South Africa.

It is too early to claim ultimate success for the program. However, the early evaluation results are incredibly encouraging and show significant numbers of young people abstaining from sex, delaying beginning sexual activity, limiting the number of partners, practicing safer sex generally. The challenge is to take [these] programs from small-scale scattered efforts to those that operate on a large enough scale to really have an impact.

What sort of strategies does loveLife use?

LoveLife is a giant concentration of an intense nationwide media campaign aimed at young people and outreach services all across the country. Not all of [these] are health-care services. They include youth centers with computer labs, basketball and community radio, a national youth Olympics in which millions of young people participate--a giant combination of media, message and services, all with an upbeat message of positive lifestyles and responsible decision-making.

How many children have been reached by that?

The early-evaluation results [show] that between 60 and 70 percent of all the young people in South Africa have been reached by the program. One example: the program has a telephone hotline for young people. LoveLife didn't expect that to have much effect in a country where most of the kids are impoverished [and living without phones] in rural areas, but it has been receiving 60,000 telephone calls a month for well over a year.

They're asking all kinds of questions to questions about their own relationships to general questions about HIV. The vast majority of those who have been reached are beginning to report these critical changes in their [sexual] behavior.

Yet South Africa is generally not seen as an AIDS success story. It has the world's highest number of HIV infections and a president who once questioned whether the virus really caused AIDS. Just this week the country's highest court had to order the government to stop blocking the universal provision of anti-retrovirals to infected pregnant women.

That's one of the ironies, and that's been frustrating. Because while this debate has raged about President [Thabo] Mbeki, beneath the radar screen South Africa has mounted the most ambitious prevention program for youth in the world.

But one of the reasons it has escaped notice is that while the government is truly involved, it is not a government program--it is a public-private partnership [between the Kaiser Family Foundation, the Bill and Melinda Gates Foundation and various South African NGOs and government bodies]. And, of course, now there are significant changes in the public posture of the South African government. Many new and more positive steps have been taken.

What lessons should other countries learn from South Africa's late start?

I think in most places we're now coming out of the era of denial. Now we're in a new era where the challenge is to really mobilize the resources and the efforts on the ground.

What will the global HIV/AIDS picture will look like in five years' time?

It's impossible to predict, because it hinges entirely upon the world's willingness to commit the resources to reverse the course of the epidemic.