AIDS in a changing world
As a disease that is fundamentally linked to the way humans live and how they relate to one another, AIDS is inextricably entwined with the future of our world—and our world is rapidly changing.
Regions that once seemed remote from each other have drawn considerably closer as a result of increased international travel, breakthroughs in communications technology, and the internationalization of commerce, social trends, and political groupings. These trends have already had important effects on the pandemic and will continue to do so.
Globalization may bring benefits as well as challenges. Whereas humans have historically concerned themselves primarily with problems in their own countries or communities, the increasing inter-connectedness of our world makes it possible to mobilize global endeavors to address global problems. Thus, an Irish rock star can galvanize global attention on the pandemic's intense burdens in sub-Saharan Africa, and an African-born player for a major European football club can focus attention on problems in his home country.
A key driver of globalization, the revolution in information and communication technology, is changing the ways people communicate about behaviors and issues.45 Although speaking about the "digital divide" between rich and poor countries is common, this gap is narrowing quickly, as use of the Internet and mobile communications technology is growing fastest in developing countries. Technological advances also may upend historic patterns; in developing countries, for example, women are more likely than men to use SMS text messaging to communicate. As with other aspects of globalization, communications advances may provide new avenues for intervention while at the same time raising new challenges. Social networking technologies offer new ways to mobilize communities and societies to take action, but they may also facilitate increased risk behavior; in some countries, sex work solicitation is rapidly transitioning from brothels, streets, and other traditional venues to the Web and mobile phones.
Globalization also teaches us something else. We sometimes speak as if we are living in a unique moment in human history, but this is not the first era of globalization. Between 1890 and 1913, levels of international trade and financial transactions were comparable to today's.46 But unforeseen political and economic shocks, including World War I and the Great Depression, brought this earlier era of globalization to an abrupt end. This history reminds us that although we can—and should—do our best to anticipate future trends, unexpected surprises may well be in store, testing our ability to adapt to a radically different set of circumstances.
Extreme weather events and other disasters associated with climate change, as well as the increased frequency and severity of droughts in developing countries, are likely to generate up to 150 million climate-change refugees in coming decades47 and further accelerate the exodus from rural villages to urban settings. Although mobility itself is not a risk factor for HIV, large-scale population dislocations frequently place people in situations of increased risk and vulnerability. By exacerbating the degradation of agricultural sectors, climate change may worsen the well-documented effects of AIDS on household food security and agricultural economies in sub-Saharan Africa.
Climate change could have other real, although indirect, effects on the future of AIDS by reducing funding for health programs in low- and middle-income countries. The United Nations Framework Convention on Climate Change projects that developing countries will incur annual costs of adapting to climate change of US$27 billion to 66 billion by 203048; other researchers predict that associated costs will be considerably higher.49 With such extraordinary costs looming, developing countries and external donors may struggle to accommodate other competing needs, such as AIDS, other infectious diseases, or health-systems strengthening.
By 2031, the global population is projected to exceed 8 billion people. Countries are already finding that stability in the percentage of the national population infected with HIV translates over time into increasing numbers of people living with the disease. Population growth also has the potential to increase social conflict regarding natural resources such as water or food, which could give rise to greater population mobility and further increase risks of and vulnerabilities to HIV.
A changing global power structure
Existing global structures and mechanisms for AIDS decision-making arose out of political and economic power structures put in place after World War II. The victors in that conflict forged global institutions that have played central roles in the AIDS response, including the United Nations system and the World Bank. The major AIDS donors also have largely reflected the Atlantic orientation of global power in the second half of the 20th century.
These power dynamics are rapidly changing. China, India, and other Asian economies are growing far more rapidly than those represented by the Group of Seven major industrialized countries. Brazil, Russia, South Africa, and other countries are also rapidly coming into their own as global and regional powers, illustrated most vividly by the G20's replacement of the G7 as a key forum for global decision-making. Meanwhile, the traditional global powers, most recently buffeted by the global financial and economic crisis, confront worrisome structural challenges associated with economic stagnation, long-term budget deficits, and rapidly aging populations.
How these trends will affect the future of AIDS is uncertain. The relative political and economic decline of the donors that have helped underwrite the massive build-up of financial resources for AIDS is a cause for concern, at least. And the transition to a more multipolar world could conceivably make it even more difficult to marshal coordinated global action on major problems. But these trends also offer potential opportunities, as the corresponding development of new global powers offers the prospect of new AIDS donors coming on the scene in future years.