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, Ugandas 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 denialby governments as well as populationsthat 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 focusedfor example among drug users in Thailand, Hispanic MSM in New York City, or poor slum dwellers in Brazilconsiderably 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