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.