THAILAND: More than 15,000 people are expected in the Thai capital, Bangkok, this weekend to attend the week-long 15th International AIDS Conference, whose theme is "Access for All". Many attending will be looking for answers as to why so few people in high-prevalence countries have affordable access to life-saving drugs. Denis McClean reports from Bangkok
More than 60 million people have been infected with HIV since the beginning of the pandemic, and 20 million adults and children have died from AIDS, including three million last year. This is by far the biggest public health crisis ever to hit the planet. The most frightening thing is that we are still in the early stages of the pandemic, according to UNAIDS chief Dr Peter Piot.
The real explosion in AIDS will happen in the world's most populous region, Asia. This will be weighing on many people's minds as the first international AIDS conference to take place in the region opens tomorrow in a country fighting the area's first nationwide epidemic fuelled by elements as diverse as injecting drug use and sex tourism.
India and China are experiencing rapid growth of HIV in certain population groups. As the statistics lag behind the reality, India may already have overtaken South Africa as the country with the largest number living with HIV/AIDS.
"Nobody is being held accountable. There is a huge gap between the rhetoric and what's not happening on the ground," said Mr Stuart Flavell, international co-ordinator for the Global Network of People Living with HIV/AIDS (GNP+), which represents people living with the virus in more than 100 countries.
As infections grow at the rate of 14,000 per day, it is estimated that at least six million people need to be on anti-retroviral therapy (ART), drugs which slow the reproduction of HIV. Only about 400,000 people in developing countries are on ART, including a miserly 60,000 people in sub-Saharan Africa, the pandemic's epicentre where more than 25 million adults and children are infected. Lack of access to treatment, in addition to the stigma and discrimination suffered by people living with HIV/AIDS, are two powerful reasons why most of those people don't even know they are HIV-positive.
The prospect of achieving the WHO target of three million people on ART by 2005 - the much-vaunted "three-by-five initiative" - seems daunting, even if $20.5 billion is estimated to be available to support the effort, mainly through the two-year-old Global Fund to Fight AIDS, TB and Malaria.
Global Fund executive director Dr Richard Feachem will be making a joint appeal in Bangkok with the UN Secretary General, Mr Kofi Annan, for greater donor support.
Dr Feachem told The Irish Times: "The key issue is accelerated implementation. We have the low-price drugs. We have greatly increased political commitment. From the Global Fund and other sources we have a lot of new money on the table. So a key issue is moving ahead rapidly with prevention and treatment."
Last year was the Global Fund's first full calendar year of operations, and the four funding rounds approved so far are enough to fund treatment for 1.6 million people. The sustainability of this is still a crucial issue, as a minimum of $3.6 billion will be needed next year to continue existing programmes. The Global Fund's ideal funding level, seen as required to make a significant impact on the global death toll from AIDS, is $7 billion to $10 billion annually.
By 2007 it is estimated that $20 billion will be needed every year to fight the pandemic.
Complementing the Global Fund is the US President's Emergency Plan for AIDS Relief (PEPFAR), which is supposed to make $15 billion available over five years to fight AIDS in Africa and the Caribbean. But as much as one-third of this money is earmarked for the promotion of sexual abstinence programmes. Much of the rest will be spent on buying expensive-brand drugs as opposed to cheap WHO-approved generic drugs.
The most recent US contribution to the Global Fund was $200 million, which pales by comparison with US expenditures in Iraq and Afghanistan.
"The only possible explanation we can imagine for the Bush administration's current position on procurement of quality-assured generic medicines is that it is more interested in protecting the interests of the pharmaceutical industry than it is in expanding anti-retroviral treatment to the largest possible number of people," said Ms Ellen 't Hoen of Médecins Sans Frontières' Geneva-based campaign for access to essential medicines.
Another subject that will draw much debate in Bangkok is the expansion of routine testing for HIV infection, which is strongly endorsed by Richard Holbrooke, president of the Global Business Coalition on HIV/AIDS. He has argued that new technologies, such as a cheap and reliable saliva swab-test, should be widely promoted, with public education programmes stressing the importance of testing.
However, many veteran health workers, such as Bernard Gardiner, HIV/AIDS programme manager with the International Red Cross and Red Crescent, oppose routine testing.
"We have to appreciate the impact of a positive test on the individual, psychologically and emotionally. People have been killed because of their positive status; they can lose their jobs. People need to be counselled before they take such a test, as there is nothing routine about the impact it can have on their lives," said Mr Gardiner, who has worked for several years on AIDS prevention programmes in Asia.
He is supported by people like Mr Flavell of GNP+. Mr Flavell also sees the recruitment by Western countries of scarce, qualified health staff from the developing world as a critical issue for discussion in Bangkok.
In Africa, WHO estimates that 100,000 health workers have either died from AIDS or left for better-paid jobs. Mr Flavell is critical of countries like the UK and Canada which recruit heavily from developing countries.
"Recruiters for the NHS are taking out full-page ads in African newspapers and at the same time you have critical shortages of health workers," he said.
He also would like to see progress made at Bangkok in improving the understanding of the relationship between TB and HIV. "We are still treating the two diseases separately. There is widespread recognition that many people living with AIDS also have extra-pulmonary TB, which is not treated. The best prophylaxis for TB is getting ART. I only know that because I am one of those people who was on TB prophylaxis before going on ART. It has a significant impact on the quality of life and boosts the immune system."
Dr Feachem said the many activists from non-governmental and community-based organisations who will attend the conference can expect good news from a report to be launched by the Global Fund.
"Early indications are that where NGOs are principal recipients of grants, they are performing better than in cases where governments are the principal recipients," he said.