Editorial
HIV/AIDS: not one epidemic but many Though we tend to call it “the global AIDS epidemic”, what we are facing, as several articles in this week’s journal remind us, is not one epidemic, but many. Each of these epidemics has a different dynamic and course, each varying from city to city, village to village, community to community. The differences often may be subtle but they can be important enough to require a different, and sometimes entirely novel, approach. In Africa, the hardest hit of the continents, the virus now runs rampant through the heterosexual populations of many sub-Saharan nations, while leaving more north African countries relatively unscathed. Within the sub-Saharan region, epidemics take different courses in different settings. In Botswana, a nation with the highest HIV infection rate in the world, 38% of adults are infected; in Zimbabwe, as many as one in four adults carries the virus; and in South Africa, it is one in five. But in other sub-Saharan countries the epidemics have spread more slowly or have been controlled. In Senegal, for instance, the epidemic seems to have been contained. Senegal’s success has been credited to culture, including marriage customs and circumcision, and a government that moved quickly early in the epidemic to implement prevention and education efforts targeting the young and sex workers. Uganda, too, seems to have turned around its epidemic. Across Europe, as described by Françoise Hamers and Angela Downs, we see a very different set of epidemics. Although more than 500 000 people are infected and there are 30–40000 new cases each year, the explosive spread of disease that was once feared has not occurred. Most people have been spared, even the sexually active heterosexual young. Instead, epidemics have become established in high-risk populations: men who have sex with men, injecting drug users, and sex workers. Even within these groups there are variations from country to country and even city to city. The prevalence of infection among sex workers in western Europe has remained relatively low, but may be considerably higher among sex workers in eastern Europe because of the higher use of injecting drugs in this group. As European expansion and integration take place, the migration of sex workers from the east to the more prosperous west could mean that interventions which have successfully reduced the www.thelancet.com Vol 364 July 3, 2004
spread of HIV among sex workers and their clients in one place may no longer be effective in another. Although the heterosexual community in Europe has for the most part not seen a serious epidemic develop, a subset of that population—migrants—is facing its own more circumscribed threat. As Hamers and Downs point out, in the 12 European countries with available information, two-thirds of all heterosexually acquired HIV infections during 1997–2000 were in migrants from high-prevalence countries, and in 2002 three-quarters of heterosexually acquired HIV infections diagnosed in the UK are thought to have been acquired in Africa. Because these migrant groups can be difficult to reach and because they include people with different languages, cultures, and attitudes, dealing with epidemics in these communities will require new strategies. In Asia, much is not known about the spread of the virus, as Kiat Ruxrungtham, Tim Brown, and Praphan Phanuphak point out. To date, the epidemics seem to have remained mainly in high-risk groups. But whether some Asian nations will still see massive epidemics such as those seen in sub-Saharan Africa, or whether they will see more limited spread, is too soon to tell. The outcome, will depend, as it has in the West and Africa, on the course of the many sub-epidemics now ongoing. Cambodia and Thailand saw a huge growth in infection rates among sex workers and there was fear that the epidemic would quickly spread into the general population, but both countries have curtailed these threats. How each of these many epidemics will develop and evolve depends on many variables, some known and some yet undiscovered. Biology may play a part, with certain strains and subtypes spreading more easily than others. Host genetics may make some populations more or less susceptible. Culture, economics, and politics certainly shape each epidemic’s course. Economic change in Africa and Asia has triggered huge migrations from rural villages to urban slums, leading to social fragmentation and a rise in high-risk behaviours. But perhaps the most important factor is the willingness of political leaders to acknowledge the crisis and implement needed interventions swiftly even in the face of political opposition. Where there has been responsive political
See Seminar pages 69–82
See Review pages 83–94
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Editorial
leadership, as in Uganda, Thailand, and Cambodia, the course of epidemics has been changed and millions of lives saved. In other areas, where political leaders have been slow to act effectively, the virus continues to spread unchecked. But given that each epidemic is different and evolving, and that so many variables are in play, how do we determine what are the best interventions? What worked in one place may not work in another. What worked once might not work again. Surveillance is key. We need to know as much as possible about each epidemic, tracking it in each community, and monitoring the effectiveness of interventions. And we
must keep in mind that each epidemic, though interrelated with other epidemics, is essentially a local battle that will be lost or won by people within each community. Community workers must be given the training and resources and independence to devise interventions tailored to their situation. While grand global initiatives are needed to raise funds and to develop new drugs, it will be local people in the field who will defeat the epidemic. As the world’s HIV community focuses its attention and enthusiasm next week on the international AIDS conference being held in Bangkok, this lesson must not be forgotten ■ The Lancet
The Lancet 2004: design, contents, and access Few regular readers enjoy having their journal of choice redesigned. Editors immediately make themselves the target for complaint. But the last major redesign that The Lancet undertook was over a decade ago. Not only was our shape and structure not keeping pace with the evolving needs of readers, but we also wanted to rethink what it meant to produce thelancet.com. The most obvious difference to the journal you see this week is its design. Here we owe a debt of thanks to our designers Antidote, in collaboration with Michaelides & Bednash, together with all The Lancet’s staff, who have translated often whimsical ideas into workable practices—thank you. Our cover now displays a quotation, drawing attention to a central theme of the week’s issue. The contents, after many years of torment for readers, is now united onto a single page, which reveals that we have divided the journal into three separate editorial sections. The first third of the journal (marked by the colour blue) is devoted to analysis and interpretation of current issues in medicine. We have strengthened this material by doubling Editorials, substantially expanding Comment, offering more focused news in World Report, and upgrading book and media reviews (Perspectives), the Obituary, and Correspondence. The central axis of The Lancet (in red) is as it should be— primary research (Articles, Mechanisms of Disease and Research Letters). Although the layout of these sections has altered, we have not imposed any other major editorial changes. Wider margins allow better linking to related content elsewhere in the journal. Mechanisms papers will include a clearer statement about their clin2
ical implications. Our publishing priorities remain the same (see Lancet 2000; 356; 2–4), as does our system for fast-tracking important clinical research. During the next six months, we will be announcing a significant improvement to our peer-review process. The final third of the journal, coded in green, is for review and opinion pieces, including Seminars, Series, Rapid Reviews, and Viewpoints, among other sections. We doubled the review content in the The Lancet two years ago, and we plan no substantial editorial changes to these sections. The final page of the journal is now the Case Report. During the next 12 months, online users of thelancet.com will also see substantial changes. We will announce these shortly. Meanwhile, we do wish to underline one important change to our (and Elsevier’s) publication policy. The Lancet’s editors now encourage authors to post electronic documents of their peer-reviewed and edited papers on personal websites and in institutional archive repositories. Authors do not need our permission to do so. All we ask is that they link their article to The Lancet, which will remain the secure site for the pdf version of their work. This change in policy has been described as a “breakthrough” by open-access advocates. While The Lancet remains a subscription (user-pays) journal, our enthusiastic support for institutional repositories, which can be linked and searched independently of the journal, means that in any ordinary meaning of the phrase, The Lancet’s content is now openly and freely accessible. We hope authors will make use of this new facility for open access to their work. ■ The Lancet www.thelancet.com Vol 364 July 3, 2004