In 1996, more optimistic sounds about the fight against AIDS appeared in the media. There was more hope than ever since new combination treatments had become available. However, the access to the biomedical innovations is likely to be limited, mainly due to high costs. People who suffer from AIDS have different socio­economic positions. Many have very little access to medicines and preventive information. Therefore, social and behaviourial intervention remains necessary for the prevention of further AIDS infection.

During the 1996 XIth International AIDS Conference in Canada, J. Decosas of the Regional AIDS Programme for West and Central Africa held up a glass of water towards the audience. He stated that if the solution for AIDS would be to bring a glass of clean water to everybody in the world, we would not be able to bring that. We have not been able to stop children from dying from simple diarrhoea by providing clean drinking water. Furthermore, although effective polio vaccines have been available for several decades, we have not succeeded in eradicating poliomyelitis. We need more than technological innovations.

The AIDS­underclasses
The new HIV protease inhibitors (see article by Jurriaans), the latest generation of AIDS­medicines, can extend the lives of many HIV­infected people with limited side effects. This important progress, however, further unveils the different socio­economic positions of the HIV­infected people. Such positions were not relevant before treatment existed. In this context the term 'AIDS­underclass' has been used.
The most important discriminating factor is the high price of the AIDS­medicines. Pharmaceutical companies want returns on their massive research investments, which results in high prices. Zidovudine (AZT), the first treatment with anti­HIV activity, was already extremely expensive. AZT was developed with public funds. This medicine was originally meant for cancer treatment and was developed long before AIDS was known. AZT was left on the shelf, but later UK Glaxo­Wellcome retraced and tested AZT as a possible inhibitor of HIV in the 1980s. Even in the USA, many HIV­infected people were not able to pay for AZT treatment because of its high cost (approximately US$ 15,000 annually in the first years), and their poor health insurance. Despite public pressure, the price of AZT decreased only after the sales increased when doctors prescribe AZT in an earlier stage of the HIV­infection.
AZT treatment for pregnant women has been proven to stop the mother­to­child transmission of the HIV virus. However, most HIV­infected pregnant women in Africa, Asia and Latin America have no access to the drug. With an average annual health budget of one dollar per inhabitant in some African countries, AZT is out of reach. In some hospitals in Uganda, AIDS patients  receive no more than a handful of aspirins. The new protease inhibitors are even more expensive. Hence, these are beyond the means of the majority of the world's poor. For instance, an aid agreement between the Brazilian government and some US companies to import HIV protease inhibitors would not make a substantial price difference.
The high costs create separations not only between North and South, but also within Northern countries. Pharmaceutical companies develop drugs with an interesting market potential. In 1996, the Swiss Pharmaceutical company Hoffmann­La Roche had a sales increase of 11 per cent largely due to a new AIDS treatment Invirase. Increasing sales are generated by those who can afford it. Children make up only a small proportion of the infected population in developed countries. At the moment, there are no protease inhibitors developed for children.
Between 10 and 30 per cent of people with HIV infection do not respond to the new protease inhibitors, or suffer unbearable side effects. Becky Trotter of the Newsletter for the People with AIDS Coalition says that "a lot of people tend to minimize the side effects they're experiencing because of the hype". They are supposed to be cured because the media now brings the message that the AIDS problem has been solved. Some patients tend to reinforce the hype because they desperately want to believe that they can be cured. They even go to court to enforce the admission of drugs which have not been approved by medical authorities.

Vaccines and behaviourial changes
According to Jonathan Mann, former director of Global Programme on AIDS of the World Health Organization (WHO), approximately 10 per cent of the global research funds for AIDS goes to developing countries. Also about 10 per cent is directed at social and behaviourial research and intervention. This may have improved slightly in recent years. However, the current hype around successful biomedical research and therapeutic intervention will not be favourable for investments in social and behavioural interventions. Nevertheless, the latter are more relevant to the poor and the inhabitants of the South.
At the 1992 VIIIth International AIDS Congress in Amsterdam, many experts stated that education about HIV/AIDS and risk behaviour, promotion of condom use, and the development of services for Sexually Transmitted Diseases (STDs) can considerably decrease HIV­transmission. Untreated common STDs increase the chance of HIV­infection. However, other experts claimed that intervention in behavioural changes to prevent further wide­scale HIV dissemination was a waste of funds. A biomedical researcher claimed that most people, even if informed, are hard­headed; they continue to have more than one sexual partner, and do not use condoms. Morevover, the setting up of STD services is too costly in poor countries. In his opinion, priority should be given to vaccine development.
It is clear that an AIDS vaccine is essential to end the epidemic. So far, there is no usable end product in vaccine development. Five years since the Amsterdam Congress, approximately 12 million people worldwide have been additionally infected with HIV. On the other hand, behavioural change intervention has also not been able to prevent the infection of these 12 million people. Nevertheless, the number would have been higher without prevention programmes.
Vaccine development remains a controversial issue. At the 1995 Third Asian AIDS Conference in Chiang Mai, Thailand, some researchers proposed to begin human tests of the few candidate vaccines. However, most experts consider such tests unethical and wasteful. Even if a vaccine has an expected 60 per cent effectiveness, 40 per cent of the vaccinated population would still become infected with HIV. This suggests the need to continue preventive and educational campaigns for the vaccinated population. Ironically, the success of such a programme would directly interfere with the vaccine trial. In 1997 we still have a stalemate. Pharmaceutical companies have little interest in human tests with vaccines. With no marketable product in the near future, there is no guarantee of return on investment. Some firms say their lack of commitment to an AIDS vaccine is due to the lack of basic research.

The HIV­pandemic and social position
Many see AIDS not only as a disease, but as a development problem that happens to have medical aspects. Our research shows the interconnection between marginal position and HIV infections. The isolation of people who are at risk is a social, not medical, challenge. Most at risk are the poor, black north Americans, migrants, sex workers, street children, and marginalized people who use intravenous drugs. People's particular positions make them more vulnerable to the risk factors for the acquisition of HIV than others. Those most at risk are exactly those who cannot afford the new AIDS treatments. Hence, it is important to continue looking for appropriate behavioural interventions.
In Zimbabwe, we interviewed HIV­infected women. Most of them were diagnosed after a positive AIDS diagnosis of an ill child. The majority of the women were infected through their husbands who had left them. Despite this, the community blames the women. Street children in Chiang Mai often survive as sex workers. These children have little access to appropriate information. They are not in a position to negotiate about condom use. In three cities in Indonesia, most of the female sex workers we interviewed are educated in protecting themselves against STDs including HIV. However, when their clients refuse to use a condom, these women cannot argue due to their desperate socio­economic position. Furthermore, research on the sexual behaviour of  Bangladeshi migrants in Malaysia shows a language barrier in accessing AIDS educational materials. The Malaysian sex workers also lack  access to AIDS education. In Malaysia the existence of sex workers is denied. This makes it is impossible to develop educational intervention through formal channels. This list can be made much longer, but the examples would become predictable.
Fortunately, we can also report optimistic developments. For the first time in years, we see a decrease in the infection rates (incidence) among young Thai men. In Uganda, it appears that massive education has been successful in changing the pattern of the HIV­pandemic. However, Thailand and Uganda are examples of countries in which the epidemic has been taken seriously. In many other countries, authorities still try to deny the problem and are thus postponing adequate societal reaction.
The prospects of intervention to change sexual behaviour also depends on the openness of the people to discuss sexuality, and the position of women within the family and in public life. What is obviously needed is a concerted effort of different approaches to fight the AIDS/HIV epidemic. The continuous underestimation of the importance of socio­behaviourial intervention and socio­cultural research, however, weakens the possibilities for the underprivileged to deal with the HIV/AIDS problems. Unfortunately, the present hype around the new AIDS treatment only reinforces the naive idea that biomedical technology will be able to solve the problem.
Ivan Wolffers

Section Health Care and Culture, Medical Faculty­HVS, Free University, Van de Boechorststraat 7, 1081 BT Amsterdam, the Netherlands. E­mail i.wolffers.social@med.vu.nl

Sources
J. Mann, D.J.M. Tarantola and T.W. Netter (eds.) (1992), AIDS in the World: A global report. Cambridge: Harvard University Press.

I. Wolffers (1997), "Culture: Media and HIV/AIDS in South East Asia." The Lancet, No. 349, pp.50­52.

M. de Bruyn (ed) (1995), Altering the Image of AIDS. Amsterdam: VU University Press.

D. Gallo, J.R. George, J.H. Fitchen et al (1997), "Evaluation of a System Using Oral Mucosal Transudate for HIV­1 Antibody Screening and Confirmatory testing." Journal of the American Medical Association. No. 277, p.254.