Acting now to make a difference.

With an estimated 5,000 people infected each day with HIV, urgency is a feeling Dr. Michael Merson knows well. The devoted Executive Director of WHO's Global Programme on AIDS (GPA) speaks movingly to groups and individuals around the world about the need to act now to fight the deadly virus that leads to AIDS.

"In Africa, south of the Sahara, some communities have been hit so hard that there are funerals every day or two. Soon this will be happening in parts of Asia and Latin America as well", he said on World AIDS Day--1 December 1993--in New York. "For a family already living at the poverty line or below, the loss of their breadwinner and caretaker is catastrophic for those left behind--the children and the elderly."

Encouraging people to talk frankly about a sexually transmitted disease (STD) that's often shrouded in fear and mystery, dealing with Government and public denial about the gravity of the AIDS epidemic, and confronting insufficient resources to care for victims of the disease--these are daily challenges for Dr. Merson, who has been head of WHO's global efforts to fight AIDS since May 1990. Originally from New York, he joined WHO as a medical officer in 1978 and became Director of the Diarrhoeal Disease Control Programme in 1984, where he served until joining the GPA.

"One of my most vivid personal memories is being surrounded by hundreds of people with AIDS in a clinic in Uganda", he recalled recently. "They were just clamouring for medicines to treat their throat infections, so they could at least swallow their food. Can you think of a more basic necessity of life?"

Despite the tragic numbers of AIDS-related deaths, this compelling advocate takes heart in the fact that attitudes are changing and Governments are showing greater commitment to combatting the epidemic.

In an interview with the UN Chronicle, Dr. Merson shared his reflections on the daunting task ahead in preventing the continued spread of AIDS.

How effective has the GPA been? How has it changed?

If you look at the early stages of the epidemic, most of the initial work was in advocacy and focusing on prevention. That remains a large amount of what we do. The other part of what we do, which I added when I became Director, was the treatment of sexually transmitted diseases. People who have an STD, such as chlamydia or gonorrhea, are at greater risk of getting and transmitting HIV.

I think this Programme has done a great deal to raise awareness. I can't think of any country in the world that is not undertaking some kind of response. There's been a fivefold increase in condom sales in Africa in the past three years. In Thailand, the national budget for AIDS awareness and prevention was less than $100,000 a few years ago; now it is $50 million. In country after country, we're seeing a greater sense of commitment.

Has the annual incidence of HIV infection dropped in any country since WHO's Global AIDS Strategy was introduced in 1987?

There are some indications of stabilization in Central and Eastern Africa. That's not to say that it's getting any better, but it's not getting worse. One of our top priorities for the next few years is to help the countries where the disease has not spread as greatly to prevent that from happening.

Tell us about the proposed new joint and co-sponsored UN programme on HIV/AIDS. How will it improve coordination of the UN's fight against AIDS?

We haven't finished working out the details of the programme, but the main objective is to strengthen the UN response to the AIDS epidemic. We want UN agencies to work in the most cohesive and coordinated manner. I also hope such a united effort would be more attractive to donors. it will be administered by WHO, with its headquarters in Geneva, but it would be a truly inter-agency effort.

How strong is the political commitment to national AIDS programmes? Are you still encountering government denial regarding the extent of the AIDS crisis?

Just about every developing country has a programme and every developed country has one. But political commitment is a big issue. It seems to occur late. What we advocate is the sooner the commitment, the better. I worry about this in country after country. I try to convince Heads of State that preventive measures taken later are a lot more costly and less effective than if they were taken earlier.

As for denial, in low-prevalence countries in Asia, Latin America and the Middle East, there's still a tendency to think that "it won't happen

here", that we're protected by our culture. One of our main jobs is to keep raising political awareness.

You've mentioned that there is one universal problem AIDS patients sufFER from--the shame and stigma attached to the disease. Have advocacy efforts by WHO reduced this problem? How do you approach changing attitudes?

Fear about AIDS is complex due to the fact that it's fatal and sexually transmitted. People must be made to understand how you get the disease and how you don't. The issue is what I call learning to live with AIDS. You can only obtain strong community-based support for care of AIDS patients if there is no discrimination.

If popular figures in society or politicians hug or are seen with AIDS patients, that helps defend the message. Changing attitudes is mostly done through information and education. You can get messages out to people through health services, ministries of transport, universities, ministries of information, the ministry of labour, youth, agriculture . . . You name the sector and there is probably a way that that sector can get out information and condoms.

What kind of funding does AIDS prevention receive worldwide? How much more is needed to prevent its spread?

One WHO study concluded that $2.5 billion a year would provide enough for every developing country to implement the basic package needed for AIDS prevention. Right now, developing countries receive around 10 per cent of that. And that's not enough. We need more resources from the countries themselves, from donor countries and from the private sector. The private sector has a lot at stake. Here you have a disease that takes people in the prime of their work lives, and also cuts down on the consumer market base. In more and more countries, the private sector is responding--especially with AIDS education programmes in the workplace. The private sector needs to provide care and support for those infected, and information on prevention for those that aren't.

For both biological and social reasons, women are more susceptible to HIV infection. What special efforts is WHO making to prevent the spread of AIDS in women?

First and foremost, we have tried to be loud in our advocacy of the greater risk of women. Secondly, you need to get women involved in control programmes as much as possible. Thirdly, we have to work with Governments to make sure that educational programmes take into account the needs of women and not just men.

We're interested in developing a vaginal creme that would be virucidal. We're also interested in improving the social and economic status of women in general. Some transmission occurs in commercial sex, and that's largely a result of the lower status of women.

Is WHO involved in vaccine development or other research? Are there hopes that a vaccine might be made available by the year 2000?

We have a very large investment in research--in the areas of intervention, development, social behaviour and virucides. Our budget is about $20 million. We hope one day to have a vaccine, but there's nothing on the immediate horizon. A couple of vaccines might go into field trial this year, but I don't think we can count on having one available in the near future.

What are the major accomplishments to date in the fight against AIDS?

I don't think there's ever been any virus or disease in which so much information has been gained in such a short time. We don't know all we need to know about pathogenesis. We don't know why some people don't get sick as quickly as others, why some people who have sex with infected partners don't get the disease. But we have learned a lot about HIV We know how it is transmitted, and if we can apply preventive measures, we can really slow down transmission. One can take heart that a lot has been learned.

Your work in the field--visiting AIDS clinics around the world--must have a tremendous personal impact on you. Would you share a few of your field experiences with the UN Chronicle?

When you visit an area where the epidemic is severe, you're struck by its impact on the population. it really overwhelms a society--not just the health sector, but also the family and the community. These people aren't dying overnight, they're sick for a year or two. It involves a tremendous amount of suffering and pain. At times, you feel a sort of desperation that there is no cure. In young adults, it's a very striking phenomenon.

I'm also struck by the impact of this disease on children. When parents are sick, kids stay home and take care of them. And there are so many orphans.

Our role as an organization is to provide leadership to convince people what they need to do and that if they do it, it will make a difference. Our goal is to constantly remind people that no population group is naturally immune, that no culture is devoid of high risk behaviour. What keeps our staff motivated is that when we accomplish that, it really makes a difference.