Global AIDS: Back to the Past?

Summary: The new affordability of treatment in poor countries made possible the unprecedented high level mobilization against global AIDS earlier this year, by transforming AIDS in poor regions from an unsolvable tragedy to a moral issue and chance to save lives. But then a backlash turned funders against treatment -- transforming AIDS again, from a chance to save lives to a chance to sit by and watch tens of millions die. As a result, AIDS lost some political support and momentum -- not only for treatment, but for prevention as well. If treatment is a key to mobilization, we need to recognize that.

Just weeks ago, governments of rich and poor countries alike seemed more likely than ever before to mobilize serious commitment to controlling the global AIDS epidemic. There was growing consensus that 7 to 10 billion dollars per year -- the amount proposed by United Nations Secretary General Kofi Annan, about 1% of world military spending -- would be enough to greatly reduce the spread of AIDS, treat many of those who are ill, do operational research to make sure the programs are effective, speed the development of vaccines and new treatments, and greatly reduce the burden of tuberculosis, malaria, and other infectious diseases.

But suddenly rich-country governments in the U.S. and Europe pulled back. The U.S. contributed $200,000,000 to the United Nations fund -- about 2% of the need, about a tenth of what would have been regarded as serious. European governments so far have not contributed anything. And in the recently concluded World Health Assembly, the U.S. and European governments actively blocked proposals to help poor countries buy low-cost medicines -- on behalf of the proprietary pharmaceutical industry, which seems to fear that any plan to make patented medicines permanently affordable in poor areas would threaten its patents or ability to charge high prices in the U.S. and other rich countries.

What happened?

We suspect that one key cause of the loss of momentum on global AIDS is something that has not been discussed or recognized even by the participants.

For years it was an article of faith that public money for AIDS control in poor countries should go to prevention, never to treatment. Few said otherwise, because at $10,000 per year for drugs alone (or even $2000), HIV treatment was not going to become widely available in poor areas no matter what anyone said or did.

Some prevention advocates have long feared that treatment would out-compete prevention politically (probably because it saves the lives of identifiable people, unlike prevention), resulting in resources being misdirected to treatment of the terminally ill instead of to stopping the epidemic. But in fact, treatment gives people reason to be tested, reason to mobilize to save their own lives or their family members or friends, reason to become involved in comprehensive AIDS control programs. It also motivates the fight against AIDS stigma, by transforming it from something unpleasant but only rarely life-threatening, to a direct threat to the lives of specific people. Some professionals have missed the fact that treatment access is a strategic cause to improve prevention and reduce the spread of HIV, as well as a humanitarian cause to save lives because it is the right thing to do.

These arguments had no consequences until recently, when generic pharmaceutical manufacturers started offering some modem combination antiretrovirals at under $500 per year. At this price widespread treatment in Africa became thinkable for the first time.

We believe this new possibility of treatment in poor regions fundamentally transformed world thinking about AIDS. Before, most of the public in the U.S., and probably other rich countries as well, basically saw the global epidemic as an unsolvable tragedy (or as a bottomless resource pit) in Africa. Tens of millions of people already infected were doomed, and nothing could be done to change that, nothing anyone did could make any meaningful difference.

But with drugs less than $500 per year, the perception of global AIDS changed from a hopeless cause to a moral issue and chance to save lives. Now people could get involved. The result was the first-ever move toward serious government commitment to control the epidemic, and other major infectious diseases -- not just through treatment, but through prevention, research, treatment, whatever was needed.

The "Harvard plan" -- a widely discussed analysis of how to provide treatment in developing countries, released in early April -- also helped to show it was doable, and at a cost amounting to "small change" in the global economy.

But then a backlash occurred. Some prevention experts became alarmed and upset by the new momentum behind treatment. As one "international health official who asked not to be identified" told The Washington Post:

"It's so politically incorrect to say, but we may have to sit by and just see these millions of [already infected] people die," he said, acknowledging that this was an option that would be considered unacceptable in the developed world. "Very few public health professionals are willing to take on the wrath of AIDS activists by saying that. But a whole lot of them talk about this in private." (Global AIDS Strategy May Prove Elusive: More Funds Available, but Consensus Lacking, Washington Post, April 23, 2001, page A01).

We do not know to what extent anyone went to the major funders -- the handful of key staff people involved in AIDS funding in the U.S. and European governments, and major foundations -- and soured them on treatment. AIDS activists were surprised to find unexpected lack of support in Congressional offices, and to hear international-development experts new to AIDS saying the fight was to save future generations. One Congressional bill earmarked 10% or less for treatment, vs. 70% for prevention. Overall, there was a sudden surge in official sentiment for abandoning those in poor countries who are already infected -- and the millions more who will become infected there.

One might think that pharmaceutical companies would lobby for global treatment, providing balance. If anything, the opposite was true. Widespread treatment in poor countries might threaten their patents and high prices in rich countries -- the cash cow that supports the entire industry.

Potential donor governments seem to have responded mainly not by shifting future money from treatment to prevention, but by losing interest in AIDS. Why?

We believe that what happened is that with treatment marginalized, AIDS was transformed again -- from a moral issue and chance to save lives, to a chance to sit by and let tens of millions of people die. Government officials and their staffs are people, too; and when this happened, they lost enthusiasm for the whole project of controlling global AIDS. Other world issues are always available.

Many have said (correctly, we believe) that without hope of treatment, prevention will not work well. What has been overlooked is that without hope of treatment in poor countries, it becomes very difficult to mobilize against global AIDS in rich countries. The triple track of advocating funding for research, prevention, and treatment -- long successful for U.S. domestic AIDS programs -- should be considered for international funding advocacy as well.

As one activist put it, treatment is easier to sell than condoms. Of course the point is not to substitute treatment for prevention, but to facilitate widespread mobilization to do whatever is necessary to stop the epidemic.

We suspect that hope of treatment was the key that transformed the meaning of the global epidemic, and made possible the beginnings of the unprecedented mobilization earlier this year. When this hope was removed, the movement stalled. Rich-country governments, which had never made a commitment to a properly funded campaign against global AIDS and other infectious diseases, reverted to business as usual.

This is only a theory -- that the possibility of treatment in developing countries was central to the rise and then a sudden fall in high-level interest in global AIDS. Many theories are wrong. We urge those involved to consider this one, and see if it holds true.

If hope of treatment is key to effective political mobilization against the global epidemic -- critical to involving people in rich countries even though they are not directly affected (as they already have access), as well as people in poor ones who are directly affected -- we need to recognize that fact and design comprehensive research, prevention, and treatment programs that do not abandon those already infected.