Is AIDS a chronic disease or a fatal disease? Is HIV infection rising or falling? Do prevention programs work or not? Are there strategies for women that are different from those for men? Can this disease be stopped? Does education work to prevent the disease?

This latter question has taken on new importance as experts convene for the XIV International AIDS Conference, taking place in Barcelona, Spain, July 7-12, 2002.

Recent attention has been given to the sharp increase in HIV infection in three of the world's most populous and powerful nations: India, Russia and China. India has an estimated three million cases, a large uneducated populace, and a political leadership that has not begun to address the problem. China was taken to task two weeks ago by the United Nations for its "lackluster efforts" to combat the disease, which has stricken one million Chinese. Russia's Health Ministry estimates that 5-10 million boys and men ages 15-20 will have HIV in five years.

The destabilizing effect of AIDS in these nations is a source of concern in the highest levels of the U.S. government, as revealed in an analysis of the U.S. National Intelligence Council. The Council also revealed that it feared that the epidemics in Nigeria and Ethiopia had reached a takeoff point where the epidemic, now at about 10% of the populace, would get much worse over the next five years.

While new HIV infections have been on a decline in the United States, local officials in parts of the United States have recently reiterated warnings that AIDS, after a decade of decrease here, is on the rise in some populations. Thomas J. Coates, Ph.D, is the Director of the AIDS Research Institute at the University of California in San Francisco. He estimated in a recent article that new infections in the gay community in San Francisco, which reached a peak of 8,000 annually at the peak of the epidemic a decade ago, fell to 500 per year in 1997 but are slated to rise to 900 annually in 2002. Similar increases are being seen in other U.S. cities in the gay population.

Because of the advent of new antiretroviral therapies, researchers have found that in the gay community and elsewhere, AIDS is seen by many as a chronic disease rather than a fatal disease. This attitude extends beyond the gay community into the general youth and adolescent heterosexual community in many parts of the United States. I was in a mid-sized Ohio city last month, and a nurse told me of a recent encounter with a 16-year-old-boy in a Planned Parenthood clinic who came with his girlfriend and who said in a counseling session: "It doesn't matter if I get AIDS; it won't kill me."

That chilling remark encapsulated the divide between the United States and the rest of the world. First of all, the young man was fortunate to have a clinic to go to. He had a professional to whom he could talk frankly about AIDS. Both the young man and the nurse were able talk about it. The young man had clearly heard of AIDS and knew he was at risk. He knew how to get it. He knew how to prevent it. He also lived in a nation that with its wealth and medical advances had in many cases extended the "normal and healthy" life of many infected with HIV. The extent of this medical miracle has now become its own public health challenge. AIDS is now viewed by some as just another sexually transmitted disease, as if these diseases themselves were not serious, and curable like gonorrhea with a shot. The culture has changed in response to medicine. Education isn't working, so far, to reverse this behavior.

A similar indictment of the powers of education to change behavior was set forth in a U.N. report on AIDS issued on June 23, 2002. The report, "HIV/AIDS: Awareness and Behaviour," said that while education campaigns have raised the awareness of AIDS in some communities around the world, they have not had a major impact on people's behavior or their perception of risk. The report stated: "In none of the countries surveyed did the level of education make a significant difference in the responses. This suggests that education has not been effective in making people aware of their own susceptibility to AIDS."

At the same time a study reported in the British Medical Journal of June 15 concluded that various types of sex education, both abstinence-only and more comprehensive approaches, had failed to deter young people from engaging in risky behavior, including having unprotected sex. In the study, sex education programs were not found to cut teen pregnancy, delay the start of sexual activity or improve birth control use.

The fact that education and communications programs have not proven effective in changing behavior in the gay community in San Francisco, in small-town Ohio, or in Chad, Mali or the Niger should not deter us from looking at successful strategies that have involved education as a part of other programmatic initiatives.

Brazil has emerged, along with Uganda, as one of the few AIDS success stories in the developing world. The infection rate peaked in 1998 and is on the decline, as are hospital admissions. The Brazil AIDS program encompasses both prevention strategies and treatment. Brazil's openness about sexuality enabled frank public education campaigns on sexually transmitted diseases and AIDS. Along with condom distribution programs, sex education and HIV prevention education have been instituted in the nation's schools along with public service announcements on radio and TV.

Brazil also began producing its own antiretroviral medication, which was distributed largely at no cost. Universal access to medical care, along with free medication, enabled sick Brazilians to get treatment locally. Citizens are taking prevention seriously and condom use is way up. As a result, the World Bank estimate that 1.2 million Brazilians would be infected by 2000 proved to be twice the actual number. Brazil's message to the world at the Barcelona meeting is that, not only can it beat the world in football, it can beat AIDS too.

Alex Sanger
7/9/02