Beyond Barcelona _ The Global Response to HIV

"We cannot lose the war on AIDS and win our battles to reduce poverty, promote stability, advance democracy and increase peace and prosperity," former US president Clinton said at the closing ceremony.
There is a striking contrast between the countries where people are dying from AIDS and the countries where they are receiving effective therapy. In Western nations, there were 25,000 deaths from AIDS in 2001, and about 500,000 people were using antiretroviral drugs against human immunodeficiency virus (HIV) infection. In sub-Saharan Africa, however, there were 2.2 million deaths, and only about 25,000 people were receiving antiretroviral treatment. If there was a single message from this summer's 14th International AIDS Conference in Barcelona, Spain, it was that this situation must change, and change quickly. "Treatment is technically feasible in every part of the world," Dr. Peter Piot, the executive director of the Joint United Nations Program on HIV/AIDS (UNAIDS), said at the opening ceremony. "I don't know a single place in the world where the real reason AIDS treatment is unavailable is that the health infrastructure has exhausted its capacity to deliver it. It's not knowledge that's the barrier. It's political will." The emphasis on improved access to antiretroviral drugs throughout the world has been catalyzed by the development of effective medications and by sharp price reductions. It also reflects a growing recognition of global interdependence and the devastating impact of the AIDS pandemic. Of the 40 million adults and children living with HIV infection at the end of 2001, roughly 95 percent were in developing countries (see Table). HIV infection is spreading rapidly in many areas, including parts of China, eastern Europe, and central Asia. There are now seven African countries (Botswana, Lesotho, Namibia, South Africa, Swaziland, Zambia, and Zimbabwe) where more than 1 in 5 people between the ages of 15 and 49 years are infected with HIV, and another six countries where more than 1 in 10 are infected. By 2010, orphans (children under the age of 15 whose mothers, fathers, or both have died) will account for 15 to 25 percent or more of all children in 12 sub-Saharan African countries; most of these children will have lost both their parents to AIDS. Also by 2010, the U.S. Census Bureau projects that life expectancy in some countries in sub-Saharan Africa will fall to near 30 years, levels not seen since the end of the 19th century. Without AIDS, life expectancy in Botswana would be 74 years in 2010; with AIDS it is projected to be 27 years. The International AIDS Conference is a unique forum that brings together diverse groups, including researchers, practicing physicians, government officials, activists and the news media. While researchers presented their findings, Piot and other prominent leaders, such as Nelson Mandela and Bill Clinton, used the conference as a platform from which to galvanize support for more rapid and concerted action. "We cannot lose the war on AIDS and win our battles to reduce poverty, promote stability, advance democracy, and increase peace and prosperity," Clinton said at the closing ceremony. Ten billion dollars a year is required for a "minimum credible response to the epidemic," according to Piot. The $10 billion annual figure is more than three times the $2.8 billion that is currently available from governments, foundations, businesses, and other sources. Another $3 billion a year is required for treatment and prevention of malaria and tuberculosis. As the Global Fund commits itself to raising and distributing billions of dollars, the number of people in developing countries who receive antiretroviral therapy should increase substantially.
According to Clinton, "the wealthy nations should determine what each's share of the $10 billion a year" is and "should pay it." There are various possible formulas. Under the United Nations system, the United States pays about 22 percent of the costs, followed by Japan, Germany, France, the United Kingdom, and Italy. The $10 trillion U.S. economy represents about 40 percent of the $25 trillion economy of the industrialized world. According to the economist Jeffrey D. Sachs, an advisor to United Nations Secretary-General Kofi Annan, the United States should be spending about $3.5 billion internationally for AIDS, tuberculosis, and malaria in fiscal year 2003. This would represent about a third of the $10 billion global expenditure for the three diseases that Sachs believes is necessary in the next fiscal year. The total expenditure should increase to $13 billion or more in the following years. Of the $3.5 billion from the United States, Sachs recommends that $2.5 billion go to the Global Fund to Fight AIDS, Tuberculosis, and Malaria and $1 billion to bilateral programs. According to figures released at the conference, the Bush administration has requested about $16 billion for spending on HIV and AIDS in fiscal year 2003 _ about $15 billion for domestic programs and $1 billion (some for research) for international programs. For the nations with the world's largest economies, $10 billion a year is not a lot of money. There is serious concern, however, about whether funds for HIV programs will be spent effectively. The issues include the design of treatment and prevention programs, the cost of antiretroviral drugs, and the likelihood of misuse of funds and diversion of resources. There are inevitable tensions between accountability for the efficient use of resources and unreasonable requirements of proof that programs are changing the course of the epidemic before they can be adequately funded. The Global Fund to Fight AIDS, Tuberculosis, and Malaria is an independent, nongovernmental organization based in Geneva that accepts donations from governments and other sources. It should quickly become the largest financing mechanism for HIV programs in the developing world. The next several months are critical. Before the end of October, the Global Fund, in conjunction with the World Health Organization and the United Nations, is expected to finalize its financing plans and make public a plan of action. Governments and private donors will then have to decide whether they accept it and are willing to contribute accordingly. It is not clear that the action plan will become the actual plan. As the Global Fund commits itself to raising and distributing billions of dollars, the number of people in developing countries who receive antiretroviral therapy should increase substantially. Among the critical needs are outfitting and enlarging both treatment and prevention programs, training physicians and community-based health workers to care for people with HIV infection, and continuing to reduce the prices of effective antiretroviral medications. At the end of 2001, some generic combinations of medications were available for about $350 per person per year. If the annual cost of antiretroviral therapy could be reduced to no more than $100 per person per year, treatment would be affordable in many more countries and donations would have a far greater effect. Millions of people throughout the world are treated each year for tuberculosis, malaria and other serious infections. By July 2004, when the 15th International AIDS Conference begins in Bangkok, Thailand, it will be clear whether or not millions of people are receiving effective treatments for HIV infection as well. Robert Steinbrook, M.D.