AIDS Conference Highlights Need For Broader Prevention Strategy

LABELING current AIDS strategy ``terribly incomplete, outdated, and inadequate,'' a prominent expert on the epidemic has called for a broader approach.

Jonathan Mann, the founding director of the World Health Organization's Global Programme on AIDS, urged an audience of scientists, activists, and health workers at the 10th International Conference on AIDS to recognize and act on the link between health and human rights. Defend and promote people's rights - to education, to employment, even to free association - and the incidence of HIV and AIDS will decline, he argued.

Dr. Mann doesn't want to abandon the present strategy - AIDS education, health and social services, and anti-discrimination efforts - but to augment it with a new focus on human rights.

For years researchers have been dampening hopes that a quick-fix medical cure would end the AIDS epidemic. Gatherings such as this year's conference, held Aug. 7-12 in the Japanese port city of Yokohama, have grown increasingly grim amid reports of AIDS' persistent spread.

Mann, who now teaches at Harvard University's School of Public Health, is sensitive to criticisms that his prescription amounts to a call to end poverty and social inequities. But ``what we are doing today,'' he said during a talk before the conference began, ``isn't...effective. We're not controlling the epidemic.''

Indeed, what Mann calls a ``muted sense of unease'' is perceptible in Yokohama. Michael Saag, director of the AIDS clinic at the University of Alabama, says that conference participants have stopped expecting breakthroughs. ``We're ...treating this disease as an ongoing process.''

The numbers are not encouraging. WHO estimates that 17 million people are now infected with HIV, 3 million more than a year ago. Some 4 million have developed AIDS since the disease was identified in the early 1980s.

Holding the conference in Yokohama - the first time outside the Western world - has focused attention on Asia. ``The HIV epidemic here is growing at an alarming rate,'' says Michael Merson, current director of WHO's AIDS program. ``Estimated infections in Thailand have risen tenfold since early 1990.''

An estimated 600,000 to 800,000 Thais are HIV positive, according to Yun Fong Ngeow of the University of Malaya. She says the prevalence of HIV among prostitutes in Bombay grew from 2 percent in 1984 to 54 percent in 1992.

By the year 2000, WHO estimates, as many as 10 million Asians may been infected with HIV, and the rate of new cases may exceed those in Africa, where it has so far been most destructive.

The focus on Asia has also underscored the lopsidedness of resource allocation in the struggle to contain and treat HIV and AIDS. According to figures compiled by Harvard lecturer Daniel Tarantola:

* While $14 billion was spent in 1993 to prevent and treat AIDS, 92 percent of that was spent in the developed world.

* Of the almost 7 million people who have contracted AIDS, over 93 percent are in the developing countries. (His figures differ from those of WHO, which calls its statistics conservative.)

There have been glimmers of hope in Yokohama. Some women and people with AIDS say they feel more included in this year's gathering. Participants have been encouraged by medical reports, such as one on a treatment that inhibits transmission of HIV from a pregnant mother to her child.

Health workers have exchanged information on HIV-prevention programs that work, and those from countries where the disease is now gaining strength are learning from those with more experience.

Mann wants these health workers to join forces with human rights workers, because ``when rights are not respected, vulnerability increases.'' He offers as an example the prostitutes of Asia's large cities. Mann argues that when families send girls to work in brothels in Manila, Bombay, or Bangkok, they are being deprived of rights and their risk of HIV infection rises.

The connection between migrant labor and HIV has been well documented. Men who spend long periods away from their families - a common phenomenon in developing countries - frequently turn to sex with prostitutes or other men, both high-risk behaviors. When they return home, they may in turn pass it onto their wives. Underlying this pattern, says Mann, is a violation of men's right to a ``just and favorable work environment,'' part of the UN Declaration of Human Rights.

The epidemic in many developing countries begins among the relatively rich and quickly moves to the poor. Affluent gay men were the first to contract HIV and AIDS in Brazil, Mann says, but now the epidemic is found mainly in the slums of Rio de Janeiro.

Dennis Altman, an Australian colleague of Mann's from La Trobe University, says that a focus on AIDS-awareness programs is not enough, for instance, in the case of street children forced by circumstance or design into the sex trade. ``Just... telling them to use condoms is not enough,'' he observes. They need education and other economic opportunities in order to extricate themselves from situations that put them at risk of HIV, he adds.

Dr. Merson of WHO takes a similar view. ``Disempowered people are vulnerable,'' he told a plenary session of the conference. He asked them to consider ``the untold numbers of women who fear infection from their partner, but do not have the power to insist on condom use or the economic power to leave the relationship.''