**2. The globalization of the pandemic**

At present, there is evidence that globalization has affected health care in a variety of ways. In this sense, the majority of the most prestigious institutions and organizations in the field of public health have become standard-bearers for the concept of global health. As such, the concept of global health is a consequence of the process of globalization. The definition of global health pursues equity in health matters worldwide; it is a priority objective for the international technocratic agenda [1].

The globalization process, with its multiple dimensions (economic, political, social, ecological, etc.), has had a significant impact on global health. For instance, economic globalization through the internationalization of trade and the communications revolution has resulted in the globalization of risks and of certain diseases [2]. In addition, ecological globalization, alongside the environmental and ecological changes it entails, has also had an effect on health [3]. This can be illustrated by the following: water deprivation due to scarcity implies major health risks; air pollution has caused an increase in respiratory diseases; climatic change with its ensuing extreme temperature variations affect cardiovascular diseases and the depletion of the ozone layer has increased the incidence of skin cancer [4]. On the other hand, the interde‐ pendence generated between governments and transnational problems, characteristic of political globalization, have shifted power away from the State in favour of the creation of international institutions. Thus, the World Health Organisation is today the largest exponent of health, while UNAIDS serves this purpose in the case of HIV.

Consequently, social phenomena such as health tourism, the migration of health professionals to developed countries, the existence of global risks, the resurgence of diseases that had previously been limited (such as tuberculosis) in developed countries and the global emer‐ gence of infectious diseases (avian influenza, HIV, etc.) are greatly related to the globalisation process. Specifically, globalisation has important repercussions for emerging infectious diseases: "Since the 1970s, newly emerging diseases have been identified at the unprecedented rate of one or more per year. There are now at least 40 diseases that were unknown a generation ago" [5].

In general terms, the relationship established between globalization and global health is not a positive one. However, it is worth noting that globalization has also had a positive impact on certain aspects of global health, given that it offers opportunities and provides improvements related to population health. For instance, globally, the total poverty rate has declined from 20% to 5% over the past 25 years [6]. Globalization, to the extent that it produces greater economic growth, generally involves improvements in population health. For instance, globalization has resulted in better health care conditions. This is evidenced by the success achieved in relation to children's nutritional status and mortality among breast-fed babies, as demonstrated by specific indicators, greater opportunities for health care choices (patients whose health problems cannot be treated in their own countries can explore the international health care available and choose the most convenient option), an increase in the external aid of developed countries as evidenced by the MDGs in the case of malaria, tuberculosis and HIV (the containment of the spread of AIDS in many countries through the implementation of prevention programmes) [7], and the fact that new information and communication technol‐ ogies enable health professionals from anywhere in the world to access scientific evidence and improve their clinical decisions [6].

Concerning the objective of this chapter, however, the relationhip established between globalization and HIV is robust. So much so that HIV, along with other diseases such as tuberculosis and malaria, is presently termed a "global disease". To a large extent, this is the result of the movement of goods and people, which has also increased the likelihood of diseases spreading worldwide. Diseases, like goods and people, also commute across oceans and borders. For this reason, one of the main concerns of international public health is the speed, as well as the high rates, of the worldwide spread of highly contagious diseases, as illustrated recently by the alarm triggered concerning Ebola infection.

HIV is a clear exponent of transnationalization and constitutes a global epidemic that now poses one of the major threats to global health. Such has been the scope of the pandemic and the resulting consequences that today, it can be affirmed that HIV represents one of the most severe public health epidemics ever suffered by humanity. Therefore, considering the gravity of the situation, the international organism UNAIDS was created to respond to this issue.

According to an UNAIDS 2013 report, it is estimated that on a global scale, 35.3 million people were living with HIV in 2012, an increase compared to previous years [8]. This is largely due to greater accessibility to treatment. In other words, there are progressively more people in the world receiving antiretroviral therapy, which raises their life expectancy. The distribution according to population group is 31.8 million adults and 3.2 million children [8]; 2.3 million new cases of HIV infection were reported throughout the world in 2013, compared to the 3.4 million cases recorded in 2001 [8]. Consequently, these figures show that there has been a decline of approximately 33%. In the case of new infections HIV in children, 240 000 children worldwide (210 00-280 000) contracted HIV in 2013, compared to 580 000 (530 000-640 000) in 2001, signifying a decrease of 58% [8]. Similarly, the number of deaths from AIDS has also declined: 1.6 million deaths were recorded in 2012, compared to 2.3 million recorded in 2005. Specifically, 1.3 million deaths occurred among adults and 190 000 among children.


Source: UNAIDS, 2013

**2. The globalization of the pandemic**

28 Trends in Basic and Therapeutic Options in HIV Infection - Towards a Functional Cure

of health, while UNAIDS serves this purpose in the case of HIV.

international technocratic agenda [1].

ago" [5].

At present, there is evidence that globalization has affected health care in a variety of ways. In this sense, the majority of the most prestigious institutions and organizations in the field of public health have become standard-bearers for the concept of global health. As such, the concept of global health is a consequence of the process of globalization. The definition of global health pursues equity in health matters worldwide; it is a priority objective for the

The globalization process, with its multiple dimensions (economic, political, social, ecological, etc.), has had a significant impact on global health. For instance, economic globalization through the internationalization of trade and the communications revolution has resulted in the globalization of risks and of certain diseases [2]. In addition, ecological globalization, alongside the environmental and ecological changes it entails, has also had an effect on health [3]. This can be illustrated by the following: water deprivation due to scarcity implies major health risks; air pollution has caused an increase in respiratory diseases; climatic change with its ensuing extreme temperature variations affect cardiovascular diseases and the depletion of the ozone layer has increased the incidence of skin cancer [4]. On the other hand, the interde‐ pendence generated between governments and transnational problems, characteristic of political globalization, have shifted power away from the State in favour of the creation of international institutions. Thus, the World Health Organisation is today the largest exponent

Consequently, social phenomena such as health tourism, the migration of health professionals to developed countries, the existence of global risks, the resurgence of diseases that had previously been limited (such as tuberculosis) in developed countries and the global emer‐ gence of infectious diseases (avian influenza, HIV, etc.) are greatly related to the globalisation process. Specifically, globalisation has important repercussions for emerging infectious diseases: "Since the 1970s, newly emerging diseases have been identified at the unprecedented rate of one or more per year. There are now at least 40 diseases that were unknown a generation

In general terms, the relationship established between globalization and global health is not a positive one. However, it is worth noting that globalization has also had a positive impact on certain aspects of global health, given that it offers opportunities and provides improvements related to population health. For instance, globally, the total poverty rate has declined from 20% to 5% over the past 25 years [6]. Globalization, to the extent that it produces greater economic growth, generally involves improvements in population health. For instance, globalization has resulted in better health care conditions. This is evidenced by the success achieved in relation to children's nutritional status and mortality among breast-fed babies, as demonstrated by specific indicators, greater opportunities for health care choices (patients whose health problems cannot be treated in their own countries can explore the international health care available and choose the most convenient option), an increase in the external aid of developed countries as evidenced by the MDGs in the case of malaria, tuberculosis and HIV (the containment of the spread of AIDS in many countries through the implementation of

**Table 1.** Structural indicators of HIV

Despite the progress that has been made, epidemiological data continues to show alarming figures, as reflected in Table 1. As such, there remain major obstacles in the eradication of the pandemic. According to UNAIDS' most recent report (2013), some of these challenges are [8]:


HIV constitutes a clear example of social inequality in relation to health. In overall terms, the highest prevalence of the pandemic occurs in countries with low human development indicators. This increases social injustice and accentuates existing inequalities in these countries. According a UNAIDS report (2013), some of the countries that present higher prevalence rates with regard to global prevalence are [8]:


Source: UNAID, 2013

1 Table 2 shows the existing discrepancies in the pandemic's global distribution; some countries show a higher HIV prevalence, according to a 2013 sample, while other continental regions show lower levels of prevalence.

**Table 2.** Prevalence rate of HIV infection in adults

Similarly, the overall distribution of AIDS-related deaths shows that the greatest incidence occurs in countries with low and moderate development rates: Nigeria (13%), South Africa (13%), India (8%), Mozambique (5%), United Republic of Tanzania (5%), Zimbabwe (4%), Uganda (4%), Kenya (4%), Malawi (3), Ethiopia (3%), China (2%), Russian Federation (2%), Democratic Republic of the Congo (2%) and Indonesia (2%)[8]. In the aforementioned coun‐ tries, the epidemic represents a major public health issue. Not only is it a medical and health care issue, but it also constitutes one of the major obstacles to economic and social development [9]. For example, the high percentage of adult AIDS-related deaths results in the loss of the youngest and most productive individuals in a society, who are vital to economic develop‐ ment. Economic productivity also decreases, because AIDS sufferers and their caregivers stop working. Additionally, the educational system in these countries is affected by the percentage of teachers who die from AIDS, which means the loss of a significant part of the most educated population. Furthermore, the health care expenditure generated by providing health care services for people living with HIV and AIDS entails budgetary restrictions within the public sector. This constrains investments in other sectors aimed at promoting social and economic development. Finally, the scope of the epidemic in these countries is increasing, deepening poverty and existing social inequalities, and consequently inverting the human development trend. The HIV/AIDS epidemic has therefore become a priority for public policies in these countries. As a result, the response to HIV/AIDS and the fight against poverty has become the same battle [10]. For this reason, the elimination of HIV/AIDS has been established as a Millennium Goal, the sixth MDG [11], specifying the need to: "Halt and begin to reverse the spread of HIV/AIDS by 2015". Thus, the inclusion of HIV as a Millennium Goal evidences the global acknowledgement of the destructive and generalized effects of HIV/AIDS, as well as the belief that it is possible to overcome the situation by means of greater and more intensive national and international action, as well as the active will to do so.

**1.** Reducing the sexual transmission of HIV in African countries where a decline in the use

**2.** Reducing HIV transmission among people who inject drugs, since data shows this

**3.** Reducing new infections in children, as well as maternal mortality during pregnancy. **4.** Improving the availability of and accessibility to antiretroviral therapy in low and middle-

**6.** Eliminating stigma, discrimination and coercive laws and practices in relation to HIV. **7.** Eliminating gender inequalities, abuse and violence that cause the feminization of HIV.

HIV constitutes a clear example of social inequality in relation to health. In overall terms, the highest prevalence of the pandemic occurs in countries with low human development indicators. This increases social injustice and accentuates existing inequalities in these countries. According a UNAIDS report (2013), some of the countries that present higher

Table 2 shows the existing discrepancies in the pandemic's global distribution; some countries show a higher HIV

Similarly, the overall distribution of AIDS-related deaths shows that the greatest incidence occurs in countries with low and moderate development rates: Nigeria (13%), South Africa

prevalence, according to a 2013 sample, while other continental regions show lower levels of prevalence.

remains highly prevalent, whereas HIV prevention coverage remains low.

**5.** Reducing the number of tuberculosis-related deaths in HIV patients.

of the masculine condom has been detected.

30 Trends in Basic and Therapeutic Options in HIV Infection - Towards a Functional Cure

**8.** The integration of people affected by HIV.

**9.** The overall lack of resources in the fight against AIDS.

prevalence rates with regard to global prevalence are [8]:

**Swaziland** 28.3% **Lesotho** 24.7% **Botswana** 24.4% **South Africa** 18.4% **Zimbabwe** 15.6% **Namibia** 15.2% **Mozambique** 12.9% **Malawi** 11.4% **Equatorial Guinea** 9.7% **North America** 0.8% **Canada** 0.3% **Western and Central Europe** 0.2%

**Country/ Region1 Prevalence of HIV (2012)**

income countries.

Source: UNAID, 2013

**Table 2.** Prevalence rate of HIV infection in adults

1
