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Although the first AIDS case was diagnosed in 1981, little
global recognition of the disease or response to the epidemic was seen before
1986 when, at the World Health Assembly, Uganda’s health minister declared that
his country had an enormous problem with AIDS and needed help. The Minister and
the Assembly called on the World Health Organization (WHO) to act. In September
1986, a WHO program for prevention and control of AIDS was formed, which, in
February of 1987, became the Global Programme on AIDS (GPA).
By January 1990, the GPA was working in 123 countries to
develop national AIDS prevention plans. The national programs that emerged from
these plans emphasized public education and information on how HIV is and is
not transmitted, and encouraged people to avoid unprotected sex. This was the
main function of these first programs: urgent public education in the face of
widespread denial—by governments as well as populations—that AIDS was a “local”
problem.
Starting in the mid-1980s in the United States, Europe, and Australia, and throughout the 1990s in Uganda, Thailand and Brazil, a handful of pragmatic programs
focused on equipping vulnerable populations with prevention information and
services. Many of these programs implicitly incorporated human rights principles
and produced impressive results.
In the United States, Europe, and Australia, outreach and
education programs were initiated by new organizations created by men who have
sex with men (MSM) and injecting drug users (IDU) who were concerned about the
vulnerability of their peers. These programs emphasized reducing the number of
sexual partners, condom distribution, and needle and syringe exchange, often in
the face of great stigma and risk of criminal prosecution. As these programs
became more established, some local government health departments extended
cooperation and funding.
In Uganda, a national program was developed based upon a
grassroots community dialogue explaining the new disease and emphasizing
partner reduction (“zero grazing”). Community groups and religious institutions
spoke out about the disease, and initiated programs of home-based care for
those falling sick. In 1988, partly in response to a WHO review, Uganda made several key changes in its program including increasing the resources dedicated
to HIV/AIDS prevention; decentralizing information, education, and
communication activities; encouraging stronger community-based organizations
and efforts; and increasing outreach programs to the illiterate and the poor.
In 1990 in Thailand, after the Ministry of Health revised
the estimated number of HIV-infected persons from 1,700 to 150,000, a program
emphasizing mass education and 100 percent condom use in brothels was
established.
In Brazil, HIV/AIDS prevention programs made aggressive
efforts to reach sex workers (including by organizing national sex worker
conferences) and MSM with HIV information and instructions on how to use
condoms and negotiate condom use with partners. Broader messages to the general
population were conveyed through the mass media to “humanize” the disease and
fight stigma and discrimination.
Although taking different approaches, these programs were
all initiated by individuals from the most affected communities, supported by
local or national governments (often through financing as well as new
legislation), and based on the dignity and autonomy of each individual. The
programs quickly saw results. In New York, HIV prevalence among white MSM at
STD clinics decreased from 47 percent to 17 percent between 1988 and 1993. In Uganda, adults reported increased condom use and decreased numbers of sexual partners,
while youth reported delayed onset of sexual behaviors. Uganda saw the start of a downward trend in HIV prevalence, peaking in the early 1990s at over 15
percent and decreasing to 6-7 percent by 2003. In Thailand, decreases were seen
in the number of men reporting commercial sex, while increases were reported in
condom use. HIV prevalence declined to 1.5 percent in 2003. In Brazil, the percentage of young people who reported using condoms the first time they had
sex increased from less than 10 percent in 1986 to more than 60 percent in
2003, and national HIV prevalence among pregnant women remained below 1
percent.
Despite these visible successes, in communities where
outreach efforts were less focused—for example among drug users in Thailand,
Hispanic MSM in New York City, or poor slum dwellers in Brazil—considerably
less success was noted.
Nonetheless, these comprehensive programs, remarkable for
their mobilization of resources, political will, engagement with the community,
and respect for human rights, were seen as models for expanding the HIV/AIDS
response worldwide.
Through the mid-1990s emphasis was also put on understanding
the epidemic as a multi-dimensional problem, requiring a multi-sectoral
response. This strategy emerged in part because HIV/AIDS was expanding
unchecked with massive social and economic consequences and in part because of
difficulties generating the resources required to fight the epidemic properly.
Concerned officials and donors sought to leverage resources simultaneously from
multiple sources including ministries of education, agriculture and industry.
Then, from the mid to the late-1990s, international efforts
to fight HIV/AIDS foundered and splintered. The earlier focus and success in
places like Thailand and Uganda were not replicated elsewhere, and the global
leadership at WHO waned. Fast-growing epidemics were recognized virtually
everywhere. Bilateral programs expanded, as did the prominence (and budget) of
the World Bank, but these developments were unable to keep pace with the
increasing demands of the pandemic. Increased attention was placed on the
biomedical aspects of HIV/AIDS, including vaccine development and the use of
anti-retroviral drugs to treat people living with HIV/AIDS and reduce the risk
of mother-to-child HIV transmission.3
