Historical Interviews

This issue of the Epi Monitor is a special double issue featuring an interview with Jonathan Mann describing recent developments in the global AIDS epidemic and providing a comprehensive review of the World Health Organization’s activities over the past year. Dr. Mann is currently head of WHO’s Special Programme on AIDS, and will be familiar to our readers as the former editor of our MMWR Recap feature.

The interview is remarkable because of the clarity of thought and expression that is in evidence throughout. It makes for highly recommended reading and is reproduced here in its entirety.

Epi Monitor: What is the global overview of the AIDS pandemic as it stands now?

Mann: When we take a look at the AIDS problem worldwide, we can actually distinguish three separate epidemics which are related to each other and which have followed each other.

The first epidemic is the worldwide epidemic of infection with the human immunodeficiency virus (or HIV), called the AIDS virus. We don’t know where the AIDS virus started and we may never know. But we do know it was already causing infections in people in several parts of the world by the mid-1970s. Since then, the AIDS virus has probably spread to every country. And even though in some countries there has been little or no effort to determine whether the virus is present, wherever the effort is made the virus is usually found.

The second epidemic is the epidemic with AIDS itself and diseases associated with the virus. In most infectious diseases, we think of days or weeks between the time the person is infected and the time he or she develops the disease. We don’t know how long the AIDS incubation period may ultimately be in some people. But since we are talking about the possibility of years you can see that the epidemic of infection will be followed several years later by an epidemic of the diseases the virus causes, particularly AIDS.

When AIDS was first recognized in the United States in 1981, it was also already occurring elsewhere in the world. The worldwide epidemic of HIV infection started in the mid-1970s and the epidemic of the disease started in the late 1970s or early 1980s in various parts of the world. One distinction that we often make is between an epidemic and a pandemic. A pandemic is an epidemic affecting multiple continents. So you’re really talking, as we are with AIDS, of a pandemic, a worldwide problem.

The third epidemic is the epidemic of reaction and response to the first two epidemics: in other words the cultural, social, economic and political impact of AIDS. This impact is very widespread and even involves areas not yet strongly affected by the virus or the disease.

In any event we must consider all three epidemics together because we cannot begin to control this problem if we don’t understand the virus, the disease and the social, political, economic, and cultural context in which the disease is occurring.

Epi Monitor: What is the situation as it exists right now as far as the number of (reported) cases of AIDS is concerned, and how rapidly is that number increasing?

Mann: As of December 1987, there were over 66,000 AIDS cases reported officially to WHO from more than 125 countries. But that number is not accurate because there remain many barriers to the diagnosis, recognition and reporting of diseases in the world. Even in countries like the United States with its very highly developed AIDS surveillance network, an estimated ten percent of the AIDS cases are not reported to the national government. In some countries, particularly in the developing world where the tools to make a firm diagnosis or a disease reporting infrastructure may be lacking, the reported number of cases may represent only a small fraction of the actual total.

Therefore, we estimate that rather than 66,000, between 100,000 and 150,000 cases of AIDS have probably occurred since the beginning of the epidemic. And the number may actually be higher. More important, though, is that over three quarters of the world’s countries have reported cases of AIDS. The fact that nearly 160 countries are publicly recognizing and speaking of their AIDS problem is testimony to the increased openness characterizing the international scene. A little over a year ago, only about sixty countries reported cases to WHO. The increase does not mean that AIDS has spread to sixty new countries in the course of the past year. Rather, it means there has been an epidemic of openness, if you will, and that is indeed something we at WHO have been working to improve. We all need to know this information, and a country that hides its AIDS cases is hurting both itself and the international community.

Epi Monitor: How difficult, in fact, is it to determine the real number of persons infected with the AIDS virus worldwide?

Mann: One of the questions we often ask is how many infected people there really are. The reason we don’t know is because we can only know what individual countries can tell us. There is no country in the world today, including the United States, France, Sweden, and the United Kingdom, with a really accurate estimate.

Nevertheless, despite these difficulties we would broadly estimate that from five to ten million people are infected with the AIDS virus today worldwide. If that is true--and that is an if--then we could predict the number of new AIDS cases that are likely to occur in the next five years. This is because studies in various parts of the world suggest that between 10 percent and 30 percent of HIV-infected people will develop AIDS over a period of five years. If that’s true through- out the world, and there are five to ten million people infected today, we could estimate that between 500,000 and three million new cases of AIDS will emerge over the next five years from people already infected with the AIDS virus. If this estimate holds true, there will be anywhere from ten to thirty times more AIDS cases in the next five years than there have been in the last five years. So we are imminently