Time's Up

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 "3x5" 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.

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