It’s been four years since the International AIDS Conference was first held in the developing world, in Durban, South Africa, where the activist 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: Even a year afterward, in 2001, US government officials still insisted that Africa’s healthcare infrastructure was too primitive to support the prescription of HIV therapies and, more despicably, that Africans couldn’t successfully take antiretroviral combinations 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 last week in Bangkok, the political winds had so shifted that the official conference theme was “Access for All.” 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 major new AIDS initiatives, worth billions of dollars, each of which emphasize treatment. The 2001 Doha Declaration opened the door for the off-patent production of life-saving drugs, and since then the cost for generic combination pills has dropped to as little as $140 a year. And the World Health Organization (WHO) set an ambitious goal: to treat 3 million of those who are ill enough to require therapy–about half of the global need–by the end of 2005. By the time some 19,000 AIDS researchers, government leaders, UN officials and AIDS advocates gathered in Bangkok last week, the question was no longer whether to treat, but how.

If a dark cloud hung over the proceedings, it was because actual progress has been so slim. Millions have died of AIDS worldwide since Durban, and, with only eighteen months remaining to meet the WHO’s “3×5” goal, a mere 440,000 people in the developing world have been put on antiretrovirals. “By measures of human life, the ones that really matter,” said Jim Kim, the WHO’s AIDS director, during one morning plenary, “we have failed and we have failed miserably.” He urged those in attendance not to give up on 3×5, but to identify the obstacles to meeting that goal, and to overcome them.

At Bangkok, these obstacles were the subject of frustrated and angry debate–in the conference rooms, in hallways and in the streets: The devastating brain drain of doctors and nurses, recruited for better-paying jobs in the North. The persistent denial on the part of political leaders, in depressing display on the final day when Sonia Gandhi, facing a potential AIDS explosion in India, insisted that her government–now treating fewer than a thousand of its five million HIV-positive citizens–had the problem under control. The devastation of healthcare infrastructure caused by IMF austerity programs and the prioritization of guns over butter. And above all, the vagaries of donors, each with their specially earmarked funds and idiosyncratic reporting requirements that thwart efforts to scale up treatment. On this front, Annan’s Global Fund to Fight AIDS, TB, and Malaria, with its hands-off policy of funding–it funds any nationally coordinated AIDS proposal that its technical experts favorably review–received widespread praise at Bangkok, while Bush’s emergency AIDS plan, with its morality-based restrictions on prevention and its patent-bound rules on drug purchasing, came up for constant and ferocious criticism. Yet again, the United States’ stubborn unilateralism left it without allies on the world stage.

At a plenary session, 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 Bush’s plan refuses to fund needle exchange 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 only be used to buy brand-name drugs, which would quintuple her costs. Mozambique’s health commissioner, the director of Malawi’s National AIDS Commission and countless other representatives of “recipient” nations complained that Bush’s restrictions force them to design funding requests that don’t relate to national needs or follow scientifically proven approaches. And everyone from a World Bank official to an Indian women with HIV excoriated Bush’s “ABC” policy, which emphasizes abstinence and being faithful over condoms, as brutally irrelevant to the millions of faithful women infected by their husbands. The General Accounting Office, a US oversight agency (which has just changed its name to Government Accountability Office), released a report at Bangkok on Bush’s initiative that echoed these concerns. In interviews with twenty-eight USAID officials involved in implementing the plan, twenty-five identified US program constraints–especially limits on the purchase of generic drugs–as primary obstacles to the program’s success.

Though Bush trumpets his commitment to the global AIDS fight, the delegation he sent to Bangkok was rather anemic; Health Secretary Tommy Thompson, booed off the stage at the last AIDS conference in Barcelona, discovered a scheduling conflict this time around. And their behavior only served to increase their isolation. When treatment activists from as far afield as South Africa, Kenya, Thailand and Britain held a march on opening day to put some urgency into the “access for all” rhetoric, Jim Kim of the WHO, UNAIDS head Peter Piot and Global Fund director Richard Feachem all joined the protesters to accept their written demands, but US global AIDS head Randall Tobias refused to face his critics–and then canceled three scheduled appearances over the coming days, leaving a surrogate to defend Bush’s refusal to fund WHO-approved generics as a “safety” measure. Tobias finally agreed to speak only after securing a platform to appear solo, in a special lunchtime lecture, and then nearly stomped from the podium after being met by protesters. Afterward, he used his time with reporters to snipe at the Global Fund, claiming it was dysfunctional and saying that his boss’s $200 million suggested contribution was sufficient. (Feachem says he needs $1.2 billion from the United States in 2005, and even Congressional Republicans are considering $500 million.)

At one point, I got into a conversation with Abner Mason, a Republican activist who sits on Bush’s presidential AIDS council. “Just once,” he told me, “I would like to hear someone say ‘Thank you’ for what the President has done on AIDS.” The words of Zackie Achmat, an HIV-positive leader of the Treatment Action Campaign who has risked jail to bring generics into South Africa in a challenge to his own intransigent government, offer an effective rejoinder. When he spoke at a press conference on the final day, a reporter asked about the “America bashing” that had taken place in Bangkok. “America bashing?” he replied. “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 are now living with HIV worldwide, 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 as well.

The United States’ go-it-alone war on Iraq has cost at least 11,000 lives so far. But its go-it-alone strategy on AIDS promises to cost far more.