It’s been four years since the International AIDS Conference was first held in the developing world, in Durban, South Africa, and activists’ demand for universal treatment access was catapulted onto the world stage. Then, the idea of treating the millions of HIV-infected people worldwide was considered farfetched: US officials still insisted in 2001 that Africa’s healthcare infrastructure was too primitive to support the prescription of HIV therapies and, more despicably, that Africans couldn’t take these medicines successfully because they couldn’t tell time. And the cost of these patented drugs was prohibitive–as high as $15,000 per year. The official policy of wealthy nations was to focus on prevention and leave the millions already infected to die.

But by the time some 19,000 AIDS researchers, government leaders, UN officials and AIDS advocates gathered in Bangkok this July, the winds had so shifted that the official conference theme was “Access for All.” The question was no longer whether to treat but how. In the intervening years, studies in Uganda and South Africa proved that poor Africans with HIV are as consistent at popping pills as their middle-class counterparts in San Francisco. The World Bank, Kofi Annan and George W. Bush all launched AIDS initiatives emphasizing treatment. The 2001 Doha Declaration greenlighted the production of cheap lifesaving drugs, and since then the cost for generic combination pills has dropped to as little as $140 a year. And the World Health Organization set an ambitious “3×5″ goal: to treat 3 million of those ill enough to require therapy–about half the global need–by the end of 2005.

In conference rooms and in the streets, the most pressing challenges came to the fore: stanching the devastating brain drain of doctors and nurses recruited for better-paying jobs in the North; rousing political leaders from their persistent denial (on depressing display when India’s Sonia Gandhi insisted that her government–now treating fewer than 1,000 of its 5 million HIV-positive citizens–has the problem under control); bolstering healthcare infrastructure starved by IMF austerity programs; and, above all, ending the vagaries of donors, whose specially earmarked funds and idiosyncratic reporting requirements thwart efforts to scale up treatment. The Global Fund to Fight AIDS, TB and Malaria, with its hands-off approach–it funds any nationally coordinated AIDS proposal that its technical experts review favorably–emerged as a model at Bangkok for how funds can dovetail with countries’ national AIDS plans. Bush’s emergency plan, on the other hand–with its morality-based restrictions on prevention, patent-bound rules on drug purchasing and preference for circumventing governments to fund handpicked NGOs–came in for ferocious criticism.

Epidemiologist Karen Stanecki noted that the accelerating epidemic in Asia is fueled largely by drug injection with dirty needles and by condomless commercial sex, yet the Bush plan won’t fund needle exchanges or prevention efforts among sex workers. Joia Mukherjee, the medical director of a successful HIV-treatment program in Haiti, said she nearly rejected US dollars outright because they can be used only to buy brand-name drugs, which would quintuple her costs. Representatives of such “recipient” nations as Mozambique complained that Bush’s restrictions undermined their national strategies or forced them to use scientifically unproven approaches. And everyone from a World Bank official to an Indian woman with HIV excoriated Bush’s “ABC” policy, which emphasizes abstinence and faithfulness over condoms, as brutally irrelevant to the millions of faithful women infected by their husbands. The US Government Accountability Office released a report at Bangkok on Bush’s initiative that closely echoed those concerns.

But the US delegation seemed to have wax in its ears. When activists held a march on opening day to put urgency into the “access for all” theme, the heads of UNAIDS and the Global Fund joined the protesters to accept their written demands. But US global AIDS head Randall Tobias refused to come out–and then canceled three scheduled appearances. Tobias finally agreed to speak only after securing an opportunity to appear solo, and then nearly fled the podium after being met by protesters. Afterward, he sniped at the Global Fund while claiming that Bush’s $200 million suggested contribution for 2005 was sufficient. (The fund says it needs $1.2 billion from the United States next year.) Abner Mason, who sits on Bush’s presidential AIDS council, captured the mood of the US squad: “Just once I would like to hear someone say thank you for what the President has done on AIDS,” he said.

Zackie Achmat, an HIV-positive leader of the Treatment Action Campaign who risked jail to bring generics into South Africa in a challenge to his own government, provided an effective rejoinder. Asked on the conference’s last day about the “America bashing” that had taken place, he replied, “America-bashing? It was not America-bashing but an understanding that the greatest threat to global public health is George W. Bush. Scaling up AIDS treatment is the biggest challenge the world has ever taken up. And it can’t be done by a superpower imposing its will and its ideological agenda.”

Nearly 38 million people worldwide now live with HIV, and more than 6 million of them, already symptomatic, can tell time quite well. If a donor as significant as the United States continues its refusal to fund generic drugs, 3×5 will fail, and their health will soon fail too. The American go-it-alone war on Iraq has cost at least 11,000 lives so far. But its go-it-alone strategy on AIDS could cost far more. Bush’s plan must be gutted and rebuilt before more time is lost.