PIH Medical Director Joia Mukherjee reflects on two decades of fighting the spread of HIV/AIDS

One world, one hope, a multitude of voices

In 1988 there was little to celebrate—antiretroviral therapy was still years away, and the epidemic was already sweeping through Africa and other poor areas of the world.  Life for those with HIV could be prolonged a little by treating the opportunistic infections (such as pneumonia and herpes), but the prognosis was grim, indeed terminal. Nearly two decades ago, the first World AIDS Day originated at the World Summit of Ministers of Health on Programs for AIDS Prevention. It began as an occasion to remember the dead, to mourn the untreatable epidemic that was before us, and to focus on preventing its further spread.  

The world has changed.

Within 10 years, AIDS became a treatable disease with the advent of highly active antiretroviral therapy (ART). Suddenly, people literally on death’s doorstep became well. Clinicians saw Lazarus. And World AIDS Day became an occasion to celebrate. In 1996, the theme of World AIDS Day was “One World, One Hope,” with the vision that all would have access to this lifesaving and miraculous therapy. Yet, globalization’s geopolitics would not let one world be one world… but rather two or three or four: those who had access to free ART, those who had to pay for ART and in some way were able, and those—fully 90% of the epidemic—who had no chance of obtaining ART. People living with HIV in poor countries (who already numbered 26 million) were told that ART wasn’t possible, wasn’t affordable, wasn’t feasible.  AIDS remained a death sentence. In Cange, Haiti, a handful of patients began receiving ART in 1998, and improved just as remarkably as the patients in the United States and Europe that had access to ART. NGOs followed suit with providing the therapy. Brazil began manufacturing ART to provide its citizens treatment for AIDS as part of their constitutional right to health.  However, few countries followed Brazil’s lead, and “One World” had a tragic disparity in hope.

But in 2000, fully four years after the miracle of HIV therapy became the standard in rich countries, activists began fighting. At the International AIDS Society Conference in Durban, South Africa, the conference’s theme “Break the Silence” gave voice to the millions of people living with HIV who had no access to treatment.  Nelson Mandela, the former president of South Africa, gave the closing address, saying, “If 27 years in prison have done anything to us, it was to use the silence of solitude to make us understand how precious words are and how real speech is in its impact upon the way people live or die." He called upon the collective leadership in Africa to face the HIV/AIDS epidemic. “We have to rise above our differences and combine our efforts to save our people,” he added. “History will judge us harshly if we fail to do so now, and right now."

A seminal year followed the Durban conference. During 2001, our group worked with faculty members from Harvard to publish the “Consensus Statement on Antiretroviral Treatment for AIDS in Poor Countries.” Partners In Health and Zanmi Lasante published the first report of The HIV Equity Initiative in the Lancet and the Bulletin of the World Health Organization.  In these articles, we described 60 and then 150 patients in Haiti on antiretroviral therapy.  We reported on the general outcomes: the patients were doing well and had gained weight; the price of ART had dropped considerably with the entry of generic drugs on the market (thanks to activism by Doctors Without Borders (MSF) and others); and community health workers accompanying patients on ART were the backbone of the program addressing adherence and social support.

Activists cheered the “Haiti Model,” although many public health experts were skeptical (link to the editorials).

In that same year, Secretary General of the United Nations Kofi Annan called the UN General Assembly together for a special session on AIDS.  At this meeting, heads of the world’s heavily HIV burdened countries sounded a clarion call for assistance.  For the first time, a massive mobilization of international aid began for an epidemic which was at that time already 20 years old. The assembly called for the creation of an empty coffer for donor governments to put billions of dollars in order to actually bring ART to the people in the world’s poorest countries. This coffer became known as the Global Fund to Fight AIDS, TB and Malaria.

	2003 World AIDS Day celebration in Lascahobas, Haiti

In Haiti, we received the money in the first round of the Global Fund, and our project, the HIV Equity Initiative, suddenly went from 250 patients to more than 1,000 in just one year.  The advent of the Global Fund brought a new opportunity to Zanmi Lasante—scaling up the access to ART not just in Cange and our charity hospital Clinique Bon Sauveur, but in the long neglected public sector.  In short, interest in and money for AIDS allowed us to rehabilitate basic health infrastructure in Haiti’s central department. Our philosophy was that we could not find AIDS cases or treat them if clinics stood understaffed, empty and without essential medicines.  Thus, the investment in AIDS became our Chwal Batay, or battle horse—a tool to bring us into a larger battle against poverty, inequality and poor health.

This Chwal Batay of AIDS funding eventually lead us to Rwanda, and then Lesotho and Malawi—other places stricken by HIV/AIDS, but also in need of health infrastructure and primary care. In partnership with the governments of these countries, the Clinton Foundation, Irish Aid, and Mission Aviation Fellowship, PIH used the newfound attention on AIDS to open, revitalize, and renovate 21 public clinics in just 5 years.

The AIDS movement has become the movement for health care, and today, almost 20 years after the first World AIDS Day, we can stand on the mountain that we have climbed and reflect on the lives of the people living with AIDS who are now healthy human beings. World AIDS Day is now a day to celebrate the lives and dignity of those affected, wherever they live, so that they won’t remain closeted in fear and shame.  World AIDS day is about solidarity and what the voices of communities can accomplish when raised together.

Click here to read how PIH's partners around the world celebrated World AIDS Day 2007.

[posted January 2008]