Who cares about AIDS?

Last November, Worldwatch staff researcher Radhika Sarin talked with former U.S. AIDS Czar Sandra Thurman, non' head of the International AIDS Trust, about the difficulties caused by widespread cultural taboos and a backward-looking or distracted Bush administration.

WORLD WATCH: With the UN's global fund [against AIDS] so under-funded by governments, who is going to step up and fill the funding gap?

Sandra Thurman: The vast majority--maybe even 99 percent--of the $10 billion needed annually to mount an effective campaign for both prevention and treatment is going to have to come from developed nations. Even the Gates Foundation, which is the largest foundation donating to these kinds of efforts at the moment, is still only giving $100 million here and $100 million there. It helps, but we need a lot more than that.

So it's going to have to be governments that give the majority of the money. Currently, of the $10 billion that we need a year, governments are only contributing about $2 billion. So, there is a huge gap.

WW: Is the current U.S. administration making it difficult?

ST: It's difficult. But they haven't been bad to work with. Secretary [Tommy] Thompson [of the U.S. Department of Health and Human Services (HHS)] is very interested in expanding HHS's involvement in global AIDS issues.... So there is some commitment in the administration, but this is not a priority for them at the moment. They have some folks who are fairly conservative [about] what constitutes national security and what doesn't. While I have a tremendous respect for many of them, quite frankly they are looking at this 21st-century challenge with 20th-century vision.

WW: What about the recent work of the National Intelligence Council addressing AIDS as a security issue, and the growing number of security people in the past two years talking about the impact of AIDS on stability--is all that going to help?

ST: It will make a huge difference. A lot of people who don't really give a damn about what the people in the health community say will hear about AIDS from their friends in the security community. I mean, these are separate cultures.

When I was at the White House, we had our first National Intelligence Council Report that talked about AIDS as a security and stability issue in 1999. And that was tremendously helpful to us in advocating in Congress and elsewhere, and beginning the conversation about what, in our modern-day world, constitutes security and stability. It's not the old Cold War model.

It's a very interesting time, with people really starting to understand that AIDS is not just a health issue, but a fundamental security issue, a fundamental development issue, and a fundamental economic issue in the countries hardest hit. So we have to have a multidisciplinary approach. We have never struggled with a problem quite like this before--a problem that requires a shift in paradigms and priorities across so many different communities. In the women's community, in education, anywhere you go, something is going to have to change if we are to turn this epidemic around. It's different from small pox, different from flu, different from polio, and different from some of our environmental challenges. There are a lot of moving parts that have to be in sync to make any progress in this epidemic.

It's also taboo. Nobody wants to talk about sex. Nobody, in any culture. It's not for discussion. Except for maybe the Scandinavian countries, no matter where you go, it's not for discussion. Here in the United States with all of our Puritan baggage, we still can't talk about sex in schools in most parts of this country. We are completely schizophrenic--we sell everything with sex, but we still can't have an honest conversation about it without everybody going apoplectic. And that's true in every other part of the world.

WW: In the United States there is a growing movement toward abstinence education. Is that going to make it harder to convince people we should allocate money for commonsense programs overseas, such as promoting condom use?

ST: Absolutely. People are taught to "just say no," but "just say no" does about as much to stop people from doing drugs or having sex as "have a nice day" does.

And that's true of gender issues, too. In Africa, girls are six times more likely than boys to become infected with HIV. In the next ten years, AIDS is going to become largely a woman's issue. But the women's community has not put HIV/AIDS at the top of their agenda. It's still at the bottom because the culture of the women's community has been dealing with family planning, reproductive health issues, and other kinds of gender issues for 100 years.

WW: There is also the real threat of a rich-poor divide. If prevention and treatment efforts are focused only on those who can afford it or have resources, AIDS will become a disease that afflicts mostly the poor.

ST: There are 28 million people infected in Africa, and fewer than 35,000 are on triple combination therapies. You don't have to go to the London School of Economics to figure out that this doesn't work.

WW: Should we be putting the limited money we're getting for this into prevention, vaccine research, or providing treatment? What are the priorities for spending?

ST: We have to do prevention and we have to do care and treatment. I have a lot of friends in the public health community who still are focused on just doing prevention. It's the old public health model. The fact is that if those people had not been asleep at the wheel at the beginning of this epidemic, we would [not] have 40 million people infected that we have to treat now.... You can't separate treatment and prevention. In places where there is no access to treatment, there is no incentive of any kind for people to go in and be tested for a disease. Where there is no treatment there is no hope. You have to connect the two. The only way that you can get people into counseling and testing in many places is if there is access to support services or treatment of some kind. Why go find out that you're going to kick the bucket if there is nothing that you can do about it? You'd rather not know. That's human nature.

People say, well, you don't want to be passing on this disease. But denial is a powerful force. And if there is nothing people can do to fix this, then they don't want to know about it. You see that in all kinds of behaviors, not just in HIV. If people don't feel that there is something they can do, they just zone our of the whole thing.

Even in funding for AIDS, when we polled focus groups, [we found that] people are overwhelmed when you tell them about how bad the epidemic is. This is among "opinion elites," you know, New York Times readers. Most of them don't grasp how big the epidemic is. Then once you tell them, they are completely overwhelmed by the numbers, and they think, "Oh, my goodness, there is nothing we can do." Then if you tell them that we know what works--that there are great programs in both prevention and treatment that have been successful in developing nations--they want to invest.

WW: What are some of the success stories that you talk about?

ST: Uganda. This little country, a burgeoning democracy, came out of a struggle, and was the epicenter of the epidemic. And in a decade the country cut its infection rates in half, with good leadership from the executive branch all the way down to the community level, and a constant influx of resources. This is not rocket science.

The same is true in Senegal, which was very aggressive very early and kept infection rates very low. Thailand, by targeting prostitutes, was able to stop the epidemic in Bangkok dead in its tracks. They've still got a horrible epidemic, but it isn't going anywhere. It's stabilized. Zambia is doing aggressive work with youth. Their rates of infections are starting to go down, when they were skyrocketing five years ago.

Look at Soweto, South Africa. It has incredible programs even under the specter of a president who has not been exactly supportive. And you see these great programs all around that are working. People always ask about [president] Mbeke. I tell them that in the United States, we were seven years into the epidemic before a U.S. president ever said the word "AIDS" in public.

WW: The Centers for Disease Control has been warning about a resurgence of syphilis due to unsafe sex. With access to ARV drugs now--in the United States, at least--people don't seem to be thinking of AIDS as the fatal disease that it is. There is this problem now with increased risky behavior that we weren' t seeing just five years ago.

ST: I think that is due to several things. First, we really let up on educating young people, especially young gay men, and young gay men of color, about the risk of HIV infection. People come of age every day, so you can't let up. Second, people have been completely burned out. People--I think in the gay community in particular--were just exhausted by the impact of so many of their community dying in the '80s, and just got numb. And the young gay men coming of age think it's an old gay man's disease and that this is now a chronic disease--if I get infected it can be treated. If you look in magazines, you see these advertisements for AIDS drugs that show these gorgeous men with the body of Adonis crawling up some mountain with a pick and rope. That's the image of AIDS that we're selling.

WW: In southern Africa now, some companies are pledging to provide treatment drugs to employees, or to cover some amount of the cost because they are recognizing that governments just can't meet the need. Do you think that this is going to work, and should it be heralded as a good thing?

ST: Absolutely, especially for the multinationals. These companies should be providing care to people who are infected and their families. I recognize that this will be expensive, but it's also expensive to retrain an employee every time you turn around.

WW: It seems like the more a government sees AIDS as an issue of security, the more likely it is to act. We've seen the UN Security Council take up AIDS as an issue. Who is leading the way in that charge, and how likely is it that more countries will come on board?

ST: The Secretary General is leading the charge for the UN. This is very close to his heart, and I think it helps that he's African. But then again, he does get distracted. Like, we're about to have a big war, and few other things like that.

WW: The Bush administration, taking a cue from conservative Christians, has cut family planning funding. How will that affect AIDS funding?

ST: It's a double-edged sword. On the one hand, the fact that the Christian right has taken its own initiative is important. They have a huge constituency, they've got money, they're incredibly organized. But the challenge is that they're going to focus on treatment and on orphans. And they may focus some on the prevention of mother-to-child transmissions. So that's the good news.

The bad news is that they don't support any kind of family planning. They focus on abstinence-only based education. If you say "condom," they just get apoplectic. That's how my poor successor just got run off from his job and shipped off to Health and Human Services, because, as conservative as he is, when he started talking about condoms in public, the right wing went over to the White House and pitched a fit. Just for talking about condoms. This guy is a Republican--a very conservative Catholic. So the fact that they would remove him over that tells you that we have huge problems over there.

WW: There is currently no AIDS office in the White House?

ST: There is, but it's not much of an office. There are two people and a telephone. Good people, but they don't report to the president, they are not part of the senior staff, they're stuck under the Domestic Policy Council someplace. Their access to the president is minimal.

WW: ARV drug prices have come down 90 percent or so, but they are still too expensive for the majority of people with AIDS. Do you think it's realistic to expect these drug prices to come down even more?

ST: I think they will come down even more. But they are still going to be so far out of reach for the majority of people who need them that we're going to have to look at other alternatives. We're going to have to look at bulk purchasing, at generics, maybe at tax credits for drug companies that make donations. Like Merck decided to donate Mectizan to help control river blindness in Africa. They've never made a penny on it, they've only donated it.

But even if we cut drug prices in half again, they're going to be $500 or $300 a month. For countries that spend $5 or $10 a month per capita on health care across the board, it's just not doable. As much as some people hate it, if we're going to have any kind of impact, we're going to have to come up with some middle ground here. Developing countries are going to have to spend a little more. Developed countries are going to have to spend a lot more. Drug companies are going to have to feel a little bit of a squeeze, and not get quite so cranky when folks do generics.

WW: How did The International AIDS Trust get started?

ST: When I was at the White House--when Clinton was president--there were lots of domestic organizations doing really good advocacy policy that we could call on the outside to bring pressure to bear on the inside. There were plenty of people that we could do that with on the domestic side. But there weren't organizations that could get the chief of staff of the president on the phone on the international side. So when we were at the end of the administration, we thought it would be important to put together a group to focus specifically on the international epidemic--on policy, pragmatic solutions, and resource mobilization--that had some political savvy and the leadership of folks like Bill Clinton and Nelson Mandela. They had a conversation about funding it, and they thought it was a good idea too. So with that we started the organization, and it's small, but we 're in a very good position to get people focused on issues that are sensitive. And to really bang on folks and get their attention, even in the mi dst of all of the chaos that we see in the world today.