As reported in a special section of Science two weeks ago, in the U.S., AIDS has become a disease of the poor, minorities, rural residents and disenfranchised groups—and as a result, has largely fallen off the mental radar screen of the rest of the country. A lengthy analysis published last December by Duke University’s Center for Health Policy and Inequalities Research made clear the new shape of the epidemic: The Southeast, with only 22 percent of the U.S. population, has 35 percent of new diagnoses, and nine of the 10 states with the highest rates of death from AIDS. And in a measure of how much AIDS has become a disease of poverty, the report found that the Southeast—one of the poorest and least healthy regions of the country — is home to 99.5 percent of people on waiting lists for AIDS drug-assistance programs.
In the rest of the world, particularly sub-Saharan Africa, AIDS has always been a disease of poverty and disenfranchisement. Its continued spread points like an arrow to the marginalization of racial and ethnic minorities, sex workers, and gay people in areas and cultures where homosexuality is frowned on, and especially to women’s inability to participate equally in societies. Globally, the group most at risk of infection is young women aged 15 to 24.
The many pieces of good news also may mask a crunch point: faltering investment. UNAIDS says that 2011 marked the first time low- and middle-income countries contributed more to the fight than big international funders, $8.6 billion versus $8.2 billion—a proportion shift made possible by the fact that international funding has not increased in four years. The U.S. remains by far the largest AIDS funder, having spent billions in the past decade via the President’s Emergency Plan for AIDS Relief and the public-private Global Fund for AIDS, Tuberculosis and Malaria. But as J. Stephen Morrison, director of the Global Health Policy Center at the Center for Strategic and International Studies, pointed out in the run-up to the AIDS conference, the economic crisis and looming election are undermining both the administration’s vision for global health action and its ability to fund bold moves—while the Eurozone crisis simultaneously imperils funding abroad.
As the International AIDS Conference opens, the scientific successes and social and economic stumbling blocks will be high on the agenda. But the epidemic has demonstrated time and again how real-world complexities can undermine expectations of progress. Outside its hotspots, HIV research, treatment and education are particularly vulnerable to what longtime AIDS expert Kevin De Cock of the Centers for Disease Control and Prevention, calls “fatigue and forgetting.” Bringing the conference back to the country where AIDS was first recognized may offer a way to make the epidemic feel again like the emergency it continues to be.