Global Policy Forum

By Charles Cobb Jr.

On Barcelona's streets outside the Aids conference, treatment advocates, doctors and people with HIV/AIDS plan to stage "massive" protests. South Africa's Treatment Action Campaign chairman, Zackie Achmat, says that treatment advocates are also planning a "new pan-African treatment movement, demanding everything from vitamins to anti-retrovirals."

The protests are just one sign that this may be the most complex of the Aids conferences since the first took place almost a decade and a half ago. And while much of the noise coming from the 14th Aids International Conference in Barcelona, Spain that began Sunday will be the sound of argument about how much weight to give treatment versus prevention, the real battle cry, raised by voices focused on prevention as well as treatment, is for much more money for the Aids fight.

In Africa, twenty-eight million people are HIV positive and the number is growing. A U.S. Census Bureau report, released Sunday, predicted that at the current pace, life expectancy in sub-Saharan Africa would decline to levels not seen since the late 1800s. Already in Botswana, more people are dying than are being born. "It's going to take countries like South Africa half a century to recover from the effects of this," said the report's author, Karen Stanecki in Barcelona.

But one of the reasons Africa's numbers are so grim, says David Serwadda of Makerere University in Kampala, Uganda, and co-chair of the Global HIV Prevention Working Group, is because "we failed to act decisively in the early stages of the epidemic in sub-Saharan Africa and now we are paying the price."

Last week, the Working Group, composed of 40 of the world's leading HIV prevention experts, released a "blueprint" for preventing millions of new HIV infections before the end of the decade. Included among preventative steps are testing, counseling, media campaigns, condom distribution, needle exchange programs along with a variety of school-based and workplace-based programs. Nearly two-thirds of the new HIV infections projected to occur worldwide by 2010 - about 29 million of 45 million people - could be prevented with this effort, according to the group.

But says Helene Gayle of the Gates Foundation which, along with the Kaiser Family Foundation, convened the working group, there is also a "moral imperative... to care for those who are already infected. Treatment not only prolongs lives, but it also supports prevention efforts by encouraging knowledge of HIV status."

Many hope that one thing emerging from the conference will be a clearer understanding that treatment and prevention are integral; few of those infected will see any advantage in being tested - risking all the burdens that come with knowledge of HIV-positive status - if treatment is not on offer.

As UNAIDS Executive Director, Peter Piot said in a speech at the opening ceremony of the Barcelona conference: "Prevention and care are complementary not competing priorities."

Cash shortfall

But this combined effort will take much more money than is in sight now. According to the Working Group's report, beefing up prevention programs alone will require spending US$4.8bn annually through 2010. Research and treatment programs make necessary the addition of billions of dollars more on top of that.

This year, the United States, Japan and Germany - three of the world's wealthiest nations - have given less than US$200m to the UN Global Aids Fund. In total the fund is expected to distribute between US$700m and US$800m in 2002. And while every little bit helps, including this projected expenditure, the picture for African nations and Aids-affected developing nations in other parts of the world, could hardly look less bleak, especially when it comes to treatment.

During a joint satellite meeting Sunday, called "Time to Treat," Médecins Sans Frontií¨res (MSF) and Health Gap accused wealthy nations of "willful neglect". The "refusal of the European Union and other donor governments to commit funds for lowest-cost medicines has already condemned millions to death," said Dr. Alan Berkman, a founding member of Health Gap. "The feasibility of treatment has never been more certain. But as long as wealthy countries refuse to pay, feasibility does not matter."

Two main points underlie the reluctance to make drugs shown to be effective in nations like the United States widely and cheaply available in developing nations.

First, the belief that offering cheap drugs into nations with poor medical infrastructure will lead to drug-resistant strains emerging. And second, the belief that the people of these poor nations are not prepared to follow the rigorous disciplined procedures use of drugs, such as anti-retrovirals, require.

In Sunday's meeting, MSF presented results from seven pilot projects - five of them in Africa - that showed that providing effective treatment has concrete clinical benefits and that patients can stick with the regime. About 95 percent of the patients strictly complied with the treatment schedule. "There are some people who say that in Africa, people will not be able to take these drugs because they cannot tell the time," said Fred Minandi, a farmer from Malawi. "I may not have a watch, but I can assure you that since I started taking my triple therapy in August last year, I haven't missed one dose."

Although the cost of life-preserving drugs has plunged dramatically in Africa, few yet have access to them - just 30,000 of the continent's more than 28 million infected people. But ironically, and much to the relief of pharmaceutical companies, the debate over prevention and treatment efforts has muted the debate over the high cost of Aids drugs.

Similarly, the broader point made to the conference by Jose Luis Garcí­a, coordinator of projects in Mozambique for Ayuda en Acción that "Aids cannot be separated from underdevelopment" is not likely to be central to discussion.

The pandemic is not just spreading across Africa, the conference is being told, but also into areas of the world until now only lightly touched by Aids. UN officials are predicting that the next Aids hot spots will be in China, India, and the countries of the former Soviet Union.

Perhaps the spread of the disease to parts of the world considered less marginal and more strategically important by the world's great powers will give a greater sense of urgency - and more cash - to the fight against Aids.

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