Good News at Home
Despite falling AIDS death rates here, the epidemic rages on across the world.
By Anne-christine d'Adesky

The headlines say it all. After 15 years of HIV, AIDS-related deaths in the United States fell a dramatic 47 percent from 1996 to 1997, and they are still falling, according to statistics released by the Centers for Disease Control in late September. HIV infection has dropped to become the fifth-leading cause of death among adults age 25 to 44, down from the No. 1 spot only three years ago. The good news stems directly from the success many people have had in using a variety of potent new antiviral drugs (although many are still failing to benefit from new therapies due to myriad reasons, including the high cost of drugs).

Highly active antiretroviral therapy, or HAART, is linked to better health and extended survival, even in those with advanced HIV disease. Not all infections are covered; cancers and sexually transmitted infections remain a threat (see "Double Trouble"). But the CDC figures do chart a continuing trend: From 1995 to 1997, HIV-related illnesses dropped 44 percent-a remarkable decline. Looking ahead, there are encouraging signs that we have crossed a threshold in our search for a cure. The new goal of treatment has shifted toward long-term remission of HIV, a prize that looks more feasible every day (see "Slouching Toward a Cure?").

Behind the statistics, however, the larger HIV picture is hardly rosy. A serious racial and economic gap has been created in the United States with the arrival of pricey new HIV therapies. Whites and people with higher incomes and insurance are gaining greater access to costly HIV therapies, while African-Americans and Latinos lag behind in their access to care. Breaking it down by gender, women are being left furthest behind, including young women, who are being exposed to HIV through heterosexual sex with male partners who also use intravenous drugs. With 40,000 new infections annually, HIV rates continue to climb disproportionately among African-Americans and Latinos.

The gains we've made domestically also highlight the enormous and growing gap in care that exists elsewhere. Although it's a brave new world for some people with HIV, more than 90 percent of people affected by this virus in places such as Africa and Asia are living without any medicine at all. And they're dying of AIDS in large numbers. Compare these statistics with the CDC's and the big picture becomes starkly clear: Right now, more than 16,000 people a day are infected with HIV around the world, many of them women and children.

Here's a snapshot: in hardest-hit Africa, where one in four adults are infected in some countries, new surveys show that 38 percent of pregnant women in Botswana are HIV positive. In nearby Zimbabwe, 10 percent of its 12 million residents have HIV, and every week, 700 people are dying from HIV-related illness. Looking ahead, 60 percent of the adult male population of Ethiopia will carry the virus within 10 years. Sixty percent! Beyond all that, we now face another deadly HIV virus in Africa, mysterious group N, that's crossed over from primates (see "Missing Link").

For the vast majority of people on the planet, then, only two things are likely to provide some control over this raging epidemic: a vaginal microbicide to protect women from exposure to HIV and a vaccine. Here and in Thailand, clinical trials are under way using AIDSVAX, a candidate vaccine. But promising microbicide trials are lagging far behind, with little funding from drug companies or the government (see "Vaginal Dreams").