Confronting a calamity: to combat the world's most menacing epidemic, the UN mounts a new joint programme.

With a quick smile and flashing eyes, Wingston Zulu of Zambia stood at the threshold of his adult life. it was 1990 and the promise of a scholarship to study abroad had thrown the door to adventure wide open for him.

"We were supposed to go to the Soviet Union in about five days time, so they asked us to go for a quick medical check-up", he told a World Health Organization (WHO) team in Lusaka. That routine examination, however, brought devastating news: Wingston had contracted the human immunodeficiency virus (HIV), which ultimately leads to the crippling acquired immune deficiency syndrome (AIDS).

Unheard of before the late 1970s, the medical condition known as HIV/AIDS now dominates public health concerns in many countries--and can be expected to for years to come. Transmitted primarily through sexual intercourse, HIV erodes a body's defenses, eventually causing a series of AIDS-related illnesses. There is no cure yet for AIDS, and an effective vaccine is unlikely to be ready by the end of this century.

"I couldn't believe it", said 26-year-old Wingston, recalling the day he and his colleagues received their medical test results. "There were seven of us who went and five were found HIV positive."

Those numbers may sound incredible, but they're fast becoming a reality in some parts of the world, especially in Africa. WHO estimates that currently one in four Zambian adults are HIV positive. In some African cities, as many as one third of all people aged 15 to 49 are infected with HIV. Hardest hit are the youth, since 60 per cent of new infections in Africa are among 15 to 24 year olds.

No region untouched

While sub-Saharan Africa and parts of East and South-east Asia present the greatest challenge in the fight against AIDS, no region has been left untouched. "Countries spared the consequences of this epidemic are getting fewer and fewer", Dr. Michael Merson, Executive Director of the WHO Global Programme on AIDS, told the WHO Executive Board on 24 january

To improve efforts to fight the spread of AIDS now and to prepare for increasing numbers of HIV cases, UN agencies agreed to cooperate in a new joint and co-sponsored United Nations programme on HIV/AIDS.

The effort will bring together the work of six UN organizations--who, the UN Children's Fund (UNICEF), the UN Development Programme (UNDP), the UN Educational, Scientific and Cultural Organization (UNESCO), the UN Population Fund (UNFPA), and the World Bank.

A WHO official described the new programme as a "UN family-wide response" to AIDS, which will combine existing efforts in the form of an overall management structure. WHO will administer the joint programme, which will incorporate ongoing activities. The expectation is that the joint programme will strengthen the worldwide fight against AIDS at a country level.

The task these agencies face is considerable. The cumulative total of HIV infections worldwide by late 1993 topped 14 million adults and 1 million children, many of them in developed countries (see map on page 51). WHO projects that by the year 2000, a global total of at least 30 million to 40 million men, women and children will have been infected with HIV since the start of the pandemic. This is a calamity whose dimensions are scarcely comprehensible.

Focusing on numbers alone, though, may only blur the real image of AIDS--that of a child left motherless, a woman who loses her job due to discrimination, a young man who faces not scholastic honour but rejection by his community.

"AIDS isn't just a statistical chart with breakdowns of Africans, Blacks, Hispanics, Haitians, babies and white homosexuals. . . . AIDS violently strikes our bodies and the bodies are of individuals--people living like me", said Ilka Tanya Payan, an HIV-positive actress and member of the New York City Commission on Human Rights, at the World AIDS Day observance at UN Headquarters in New York on 1 December 1993.

A woman from New York who became HIV-infected at age 16 described her emotional stress. "It can be very lonely to be a 23-year-old woman who has friends who are dating and getting married. There are times when you can't sleep or you don't want to get up in the morning", she said quietly.

With a dark curtain of hair pulled back to reveal a lovely, clear face, the young woman looked perfectly healthy. HIV is a "stealth intruder". It may not take visible form for as many as 10 years, leaving both the virus carrier and any of his or her sexual partners unaware of its deadly presence. "The person sitting next to you could be HIV positive", said a man named Simon at an AIDS discussion in Zambia.

Beyond the immediate impact HIV has on infected individuals, those who survive--often children and the elderly--must struggle to cope with the loss of loved ones and caretakers. The majority of infected people in developing countries are men and women aged 15 to 45, many with dependants. The World Bank estimates that in high-fertility countries in eastern Africa, for every mother dying of AIDS, three children are orphaned.

The disease also threatens to undermine development efforts, depleting workforces and striking many sectors of the economy. Meanwhile, as AIDS cases increase, the demand for health and social services intensifies, creating the possibility of a withdrawal of investments in productive sectors.

Providing global leadership

In response to this escalating crisis, the Executive Boards of WHO, UNICEF and UNESCO approved a new joint and co-sponsored UN programme on HIV/AIDS, which will soon go to the Executive Boards of UNDP and UNFPA. Described as an historic action, the joint programme will provide global leadership and ensure collaboration in efforts to combat the worldwide plague.

"As the pandemic has spread to all parts of the world and the social, economic and political consequences have become ever more evident, numerous United Nations organizations have responded to the increasing need for a truly multisectoral response", Dr. Merson has said.

The co-sponsored programme would promote coordinated fund-raising at global and country levels and better integrate ideas and approaches among UN agencies. For Governments struggling to cope with the growing number of HIV infections and AIDS cases, the programme would provide a more comprehensive UN support and help them coordinate efforts of donor agencies. it would also ensure wider application on a global scale of prevention and control activities, such as education programmes and treatment of sexually transmitted diseases (STDs).

The most important objective of the programme would be to "reinforce national capacity to respond to the epidemic", especially through technical advice, according to a WHO report (EB93/27).

A number of problems cited by developing countries and donor Governments led to the programme's formulation. Accepted global policies and strategies were not being carried out effectively in some countries. Governments were receiving conflicting technical advice, and there was confusion about the role of the various organizations involved in the AIDS pandemic. Meanwhile, multisectoral action and financial resources to fight the epidemic were far too limited.

Apart from these difficulties, continuing complacency about and denial of the pandemic, the growing impact of HIV/AIDS on women, the overwhelming burden of the disease on health care systems, and discrimination of infected people were among concerns demanding more coordinated action, WHO reported.

UN vigorously involved

The new co-sponsored programme by no means represents a first attempt to confront the AIDS crisis. Through the work of its various organizations, the UN has been vigorously involved in combatting the pandemic for nearly a decade.

In late 1983, WHO held the first international meeting on AIDS in Geneva. Due to the dramatic evolution of the pandemic, WHO drew up a Global Strategy for the prevention and control of AIDS and proposed a Special Programme on AIDS to administer that plan. Both were adopted by the World Health Assembly in May 1987.

In October of that year, the UN General Assembly addressed the AIDS pandemic for the first time, adopting resolution 42/8, endorsing the Strategy. In 1988, the WHO Executive Board renamed the Special Programme on AIDS the Global Programme on AIDS (GPA).

The main objectives of the Global Strategy are to: prevent HIV infections; reduce the personal and social impact of HIV infection; and mobilize and unify national and international efforts against AIDS.

Prevention is indisputably the most important objective of the Strategy, the GPA states. Action to prevent the disease includes disseminating information about AIDS, including the promotion of safer sex practices and the use of condoms; providing health and social services, especially to detect and treat other STDs; and promoting a supportive environment.

A "supportive environment" refers not only to an absence of discrimination, but also to an absence of poverty. "Poverty makes whole communities vulnerable to AIDS by forcing men to leave their families in search of work, by leaving people hopeless enough to turn to the solace of drugs, and by making prostitution a survival strategy for women and children", WHO states in a progress report on the GPA. "AIDS then completes the vicious circle by making the community even poorer."

Greater knowledge about the disease led to an update of the Global Strategy in May 1992, placing increased emphasis on: health care for AIDS patients; treatment for STDs; improving women's status to reduce her risk of infection; providing more frank information about AIDS; making plans in anticipation of the socio-economic impact of the pandemic; and overcoming stigmatization and discrimination.

As more HIV-positive individuals develop full-blown AIDS, demand for health-care services is expected to skyrocket, making preparation in that area a primary goal.

"AIDS is pushing us with our back against the wall", said Dr. Sandra Anderson of the GPA's Health Care Support Unit in the area of community care. "We need to use all available resources--families, traditional healers, hospitals."

Dr. Anderson, originally from Michigan, United States, helped produce the AIDS Home Care Handbook in 1993. Families, she claims, are indispensable in caring for AIDS patients. "Families can provide warmth and acceptance. But people with AIDS need access to clinics and hospitals, so home and hospital care are complementary, not mutually exclusive", she explained.

Availability of medicine is another area of deep concern for the GPA. "This epidemic is coming at a time when drug supply is not at its highest", said Dr. Anderson. "If a country's drug supply is not functioning well, AIDS puts a tremendous burden on it."

Reviewing the progress

While these problems pose a tremendous challenge in the fight against AIDS, it is important to remember how much has been achieved during the past decade. information from national AIDS programmes, according to WHO, yields an encouraging picture in many areas: people are much better informed about how they can protect themselves and others from HIV transmission; more condoms are being produced and distributed; donated blood is increasingly being screened for HIV; and there are more resources and staff involved in HIV/AIDS prevention.

Because AIDS is not only a health problem but also a social, economic and development issue, numerous organizations within the UN have become involved in the war on AIDS.

While continuing to carry out the work they have already undertaken, under the new joint and co-sponsored UN programme on HIV/AIDS, the six agencies will offer a united force to fight back the advance of this devastating epidemic.

To date, their efforts have included the following:

World Health Organization: The WHO Global Programme on AIDS works with individual countries, helping them with short-term measures for responding to the crisis and then with support for a national AIDS programme capable of taking on long-term prevention, control and care. Today, national AIDS programmes have been established in virtually every country of the world--most of them guided by the Global AIDS Strategy, which was updated in 1992, and with advice from WHO.

GPA's mission is to mobilize an effective, equitable and ethical response to the pandemic. It strives to raise awareness, stimulate solidarity and unify worldwide action. Dedicated to strengthening the capacity of countries and communities to prevent HIV transmission and reduce the suffering of people already affected, it provides technical and policy guidance to governments, other agencies and nongovernmental organizations (NGOs). At the same time, it promotes and supports research to develop new technologies, interventions and approaches to AIDS prevention and care.

UN Development Programme: Under the 1988 WHO/UNDP Alliance to Combat HIV/AIDS and the 1992 Memorandum of Understanding for the Implementation of the Alliance, UNDP's particular responsibility is to provide support in tackling the social and economic dimensions of the epidemic and minimizing its impact on human development.

More specifically, its mandate is to: increase awareness of the development implications of the epidemic: strengthen and expand the capacity of communities to respond to the epidemic; promote and assist prevention, care, support and treatment programmes for women; and assist Governments to develop effective multi-sectoral HIV strategies and minimize the devastating consequences of widespread infection.

World Bank: By acting as the largest source of finance for AIDS prevention programmes, the World Bank plays one of the most important roles in AIDS prevention.

Since the first loan for an AIDS-prevention programme was approved in 1986, the World Bank's efforts have expanded rapidly There are AIDS projects or components of projects in about 40 countries, and several nations now run free-standing projects with World Bank financing. By June 1995, cumulative World Bank lending for AIDS prevention and control is expected to have reached more than $500 million.

UN Population Fund: During 1992, UNFPA supported AIDS prevention and control activities in 84 countries, a marked increase from 41 in 1991.

The range of its activities also increased, with more attention placed on socio-demographic research and programmes aimed at women and young people. Most UNFPA support goes to incorporating AIDS-related information in population, family life, and family planning education and communication programmes; providing counselling on AIDS prevention; distributing condoms under maternal and child health and family planning programmes; and training family planning workers.

UN Educational, Scientific and Cultural Organization: UNESCO's primary aim is to develop educational strategies adapted to different sociocultural contexts that help young people adopt responsible attitudes and behaviour to avoid HIV infection. These strategies are then provided to decision-makers and educational planners to assist them in developing programmes to prevent AIDS and STDs.

UNESCO also develops advocacy material for school-based AIDS education programmes, such as the film called "AIDS, it's time for schools to act!", released in 1993.

UN Children's Fund: UNICEF also supports AIDS education activities--through school curricula, health education and other outlets--to reach women and children at risk. For instance, in Uganda, it launched a school programme that emphasizes the importance of "loving carefully".

UNICEF provides orientation and training for those likely to come into contact with AIDS patients or their relatives, and promotes advocacy efforts to raise awareness and mobilize resources. it has worked tirelessly to expand Primary Health Care (PHC) networks and has placed particular attention on the sterilization of medical equipment. it is also examining ways to care for the growing number of AIDS orphans.

Through the work of these agencies, countless NGOs and Governments around the world, AIDS does not need to be a permanent plague. "True we do not have a vaccine or cure--though scientists are working hard in many countries to find one", said Dr. Merson recently. "But we are not defenseless. Our years of experience have yielded precious knowledge on how to protect people from HIV infection."

What is AIDS?

The acquired immune deficiency syndrome (AIDS) is caused by a virus known as HIV, or the human immunodeficiency virus. When HIV enters a cell, it begins to attack and destroy certain white blood cells--called T4 lymphocytes and monocytes/macrophages--essential for the body's immune system.

As these cells die, the body's defenses weaken and the infected person may begin to experience increasingly serious AIDS-related medical conditions, including persistent diarrhoea, fatigue, severe weight loss and skin lesions. The so-called "opportunistic" illnesses, rare to people with healthy immune systems, may take hold, such as Kaposi sarcoma--a painful skin cancer--or Pneumocystis carinii pneumonia.

In some cases, HIV may enter a cell and remain inactive for years. In fact, HIV-infected people may not enter the late and fatal stage of the disease--AIDS--for more than 10 years. However, 50 per cent or more of HIV-infected people are likely to develop AIDS within 10 years after first becoming infected, according to WHO. Because there is currently no cure, AIDS-related illnesses eventually overpower the body's ability to fight back.

How do people get AIDS?

HIV spreads primarily through sexual intercourse, making it basically a sexually transmitted disease. There are two other less common ways for HIV to enter the body: by contact with contaminated blood or from an infected mother to her child before, during or shortly after birth. Sharing food, glasses or eating utensils, hugging an infected adult, playing with an HIV-positive baby--none of these poses any risk of HIV transmission.

Where did AIDS come from?

Although its exact origins are unknown, initial reports of AIDS occurred in the late 1970s or early 1980s. In the Americas, Australasia and Western Europe, it was first observed in homosexual or bisexual men and injecting drug-users living in urban areas. in parts of the Caribbean and East and Central Africa, it was more often observed during the same period among men and women with multiple sex partners, WHO has reported. The virus spread to Asia and the Pacific (excluding Australia and New Zealand), Eastern Europe, North Africa and the Middle East in the early to mid-1980s. Today, it has affected all continents, travelling from urban to rural areas.

WHO launches tests of AIDS vaccines

Long-term tests of vaccines to prevent AIDS are set to begin in May 1994 in Brazil, Thailand and Uganda, reports the WHO.

The hope is that the vaccines will protect HIV-negative people--those who do not have the virus that leads to AIDS. Developed by manufacturers and universities, the possible vaccines will be tested through the WHO Global Programme on AIDS (GPA) over the course of the next 10 years.

"Our aim is to speed up the evaluation of vaccines in the developing world, because that's where the demand is greatest", Dr. Peter Piot, Director of Research and Intervention Development for GPA, told the UN Chronicle.

"High rates of new HIV infections in developing countries mean that smaller sample sizes are needed over a shorter time period to determine whether a vaccine can prevent infection. Healthy volunteers will be given either the vaccine or a placebo", said Dr. Piot. During such trials, all possible prevention measures will be taken. The vaccine's success will be determined by seeing how many individuals are newly-infected in the vaccinated group, compared with the placebo group.

Other vaccines, still in a development phase, include "therapeutic" or treatment vaccines to slow down the effects of HIV in infected people and "perinatal" vaccines to prevent an HIV-positive pregnant woman from passing the infection to her fetus or infant.

Meanwhile, scientists are making great strides in other areas--such as developing a safe microbicide, capable of inactivating HIV in a woman's vagina. "Women in most societies have a difficult time negotiating safe sex, so we strongly believe that we need a female barrier to HIV," said Dr. Piot, who estimates that such a virucide may be available in a couple of years.

On 26 April, WHO also called for establishing a global network of scientific centres to identify and combat new or re-emerging infectious diseases, particularly AIDS.

Sex education: A controversial necessity

Hotly debated among educators, parents and other social arbiters, sex education for children and young adults is considered by many a necessity for preventing the spread of AIDS.

"A good AIDS prevention programme has to tackle many barriers--and the number one barrier is the fear that adults have regarding sex education for children and youth", Mariella Baldo of WHO's GPA Prevention Unit, told the UN Chronicle. "They think that sex education may encourage people to have sex."

In fact, a 1993 WHO survey, based on 35 studies, found no evidence that sex education in schools leads to earlier or increased sexual activity. Many studies indicated that sex education increased the adoption of safer sexual practices in sexually-active youth; some found that sex education led either to a delay in starting or a decrease in sexual activity.

Such behaviour changes are of paramount importance; to date, at least half of all HIV infections have occurred in young people between 15 and 24 years of age.

Sex education is most effective when provided before a young person becomes sexually active, Ms. Baldo stated. WHO says programmes that promote both postponement of sex and protected sex are more effective than those that promote abstinence alone.

"The most common reaction of young people is to smile and say that they knew it all already", Ms. Baldo said of her meeting with youth around the world. "They're not as naive as adults think. For instance, instead of asking what a condom is, they ask what the best brand is."