Toronto AIDS conference: calm surface deceptive?

For Web sites on this conference, see http://www.connotea.org/group/aids-2006

About 25,000 people came to the XVI International AIDS Conference (August 13-18 in Toronto), making it the largest AIDS meeting ever. This conference, which happens in the summer of every even-numbered year, is unlike any other medical meeting in any field. Almost 10,000 abstracts on medicine, science, prevention, and other aspects of AIDS were published the day before the conference started (much too late for people to use them in planning their time). Important new research was released, but the defining character of this conference is the many diverse groups and voices from around the world who gather to present and compare information, and coordinate their work and communication. For a short overview of the event, see Altman's report in The New York Times [1].

In Toronto the different AIDS groups around the world seemed to be on the same page, with little disagreement--on the surface at least. This conference was mostly about prevention, and treatment activists did not question that emphasis. Basically everyone agrees that treatment is essential in its own right and is a major part of prevention, but that treatment alone cannot stop the epidemic. One controversy was the dispute between advocates of more routine HIV testing, vs. standard pre-test counseling and informed-consent procedures.

Major speakers delivered a number of messages that as far as we know were well in tune with the 25,000. These include the huge and growing problem of tuberculosis (which kills more people with AIDS than any other disease), the lack of healthcare personnel in poor countries (in large part due to failure of policies and practices in rich countries), the huge problem of AIDS orphans and the heroic work of grandmothers who are raising them and need help, the fact that the scientific debate on harm reduction is over (clearly it works), and a higher profile for woman-controlled means of protection including microbicides and pre-exposure prophylaxis (highlighted by Bill and Melinda Gates in the opening session on Sunday).

The leadership is very concerned that the necessary funding for global AIDS control may not be available in the future, although total funding has been increasing substantially. And AIDS stigma remains a huge problem, which still blocks global control of the infection.

The feeling on when AIDS should remain "exceptional" and when it should be handled more like other diseases does not seem to have entirely jelled.

One could easily come away with the impression that the AIDS world is basically doing well, except for the clearly mixed commitment of many other individuals and institutions whose cooperation is needed but not always there.

A Deeper Look

Gregg Gonsalves (now with AIDS and Rights Alliance for Southern Africa, Cape Town, South Africa) noted that AIDS killed more people in 2005 than in any previous year, and outlined some of the problems [2]. He explained "AIDS is essentially a crisis of governance, of what governments do and do not do to and for their people." More controversially, he cited "the often misdirected energies and efforts, and the paralyzing effects, of the international AIDS bureaucracy"--which often promotes remote, Western approaches over local ones.

Also, Lancet editor Richard Horton commented on the Toronto meeting, "The opportunity to produce a roadmap to reach the 2010 target of universal access was squandered. Rarely has there been a meeting that felt so disengaged from a global predicament of such historic proportions....

"Away from the star-studded plenaries, Africans and many others from countries most affected by AIDS had a troubling message. Global action to defeat this pandemic has stalled.... Those who lead the AIDS community should be asking difficult questions if they wish to turn back the tide of HIV [3].

Dr. Horton's last two of ten questions were:

"Why do so many of those committed to defeating AIDS prefer to lecture one another about what each is doing wrong, instead of working harder to find meeting points of dialogue and partnership? Part of the answer is that there are few places where such constructive collaborations can be formed and nurtured. This is perhaps the chief challenge facing the global AIDS architecture.

"All of which leads, finally, to the most damning question of all: why is the world's response to AIDS failing?" [3].

Comment: Supporting a Global Movement for Health

The ongoing difficulty of getting political support to control a worldwide epidemic, one that kills almost 3,000,000 people every year, shows the need to get more people involved. And today it is often hard for non-specialists to get involved, especially in poor countries; often they would have to come up with money, and then hope to be allowed to participate in remote, bureaucratic meetings, far from the action of actually helping people in their communities.

One fear of alliance with other health movements is that it costs so much more to save the life of someone with HIV (including the cost of antiretroviral treatment probably for life, and the medical management necessary), than to save a life by treating other conditions that kill many people in poor countries (such as diarrheal disease that may need only a short course of inexpensive treatment). Could this mean that based on cost-effectiveness, all the public money available will go to other conditions, and no one in most poor countries will get HIV treatment unless they can pay for it privately? That would mean that in HIV, people could not organize successfully for themselves and their communities--a formula for making nothing happen. A better strategy is to get wider political support, bringing more money into health. The total needed to achieve most goals worldwide is far less than what countries now spend on wars.

To get people involved, a health movement must be able to deliver, including money for community projects, expert advice, and material support. It could publish guidelines on projects that communities could do to improve their health (from installing a pump for clean water, to tuberculosis or malaria control, to HIV prevention or treatment), and obtain the government commitment and funding, and other necessary resources. Most hiring would be local.

One model of organization is the U.S. Marshall Plan in Europe after World War II, combining local initiative within guidelines, and lots of outside money. But here there would be multiple sources of funding, probably resulting in multiple guidelines--by political necessity, but maybe also a benefit since nobody knows for sure what will work best.

Probably the biggest obstacle to broader alliances between AIDS and other groups has been that people are too busy with their own work to devote serious time to such coordination. Perhaps communication, alliances, and coalitions among diverse organizations should be recognized as its own professional and activist specialty.

References

[1.] "Bright Spots, Lost Chances on AIDS," Lawrence K. Altman, The New York Times, September 12, 2006.

[2.] "25 Years of AIDS--Reflecting Back and Looking Forward," speech by Gregg Gonsalves, available at http://www.timetodeliver.org/?p=241

[3.] Horton R. A Prescription for AIDS. Lancet. August 26, 2006; volume 368, number 9537, page 716, available at

http://www.microbicide.org/publications/show_story.html?NewsID=909