Forward from World Aids day

Friday December 1, 2006

Sarah Boseley

In the end it was a display of garlic, beetroot, lemons and African potatoes that changed the policies of a government and may yet save the lives of thousands of people with HIV/Aids. South Africa's health minister, Manto Tshabalala-Msimang, has been sidelined from her country?s treatment programme after an outcry from the 20,000 scientists, health workers and campaigners at the International Aids Conference in Toronto last summer. South Africa?s exhibition stand featured the dietary remedies that Tshabalala-Msimang advocates for people with HIV instead of the life-prolonging drugs that most Aids-hit countries are striving to roll out to their populations.

The apparent U-turn in South Africa?s Aids policies that followed the condemnation from abroad and demonstrations at home is considered by many experts to be the most hopeful development in the fight against Aids in some time.

South Africa has an estimated 5.4 million people infected with HIV, which is about one in 10 of the population. Its foot-dragging on the provision of drugs was one of the main reasons the World Health Organisation (WHO) failed to reach its target of providing anti-retroviral treatment for 3 million HIV-positive people ? half those who are thought to be in urgent need ? in developing countries by the end of 2005.

A change in attitudes

If a recent speech in Cape Town by the deputy health minister, Nozizwe Madlala-Routledge, is anything to go by, all is changed. She spoke of two of her cousins who had died of Aids because they did not get drugs in time. Aids had not just a human cost, she said, but a huge economic cost that governments needed to be helped to understand. ?In the final analysis, the cost of not treating HIV and Aids far outweighs the cost of treatment,? she said.

Craig McClure, executive director of the International Aids Society, which organises the conference, says the policy shift is the most dramatic outcome of Toronto. ?Clearly the South African government has moved to scale up more quickly on anti-retroviral therapy and move away from the frankly embarrassing approaches to HIV treatment,? he said.

The biennial International Aids Conference ? a vast, noisy campaigning forum masquerading as a scientific meeting ? has a tendency to trigger political shifts. In Durban in 2000 the cry went up for drug treatment for poor countries and the clamour began for low prices to allow that to happen.

Now more than a million people in sub-Saharan Africa are on the triple-drug combinations that used to cost $10,000 a year per person; they have been driven down to less than $150. Taking in middle- as well as low-income countries, 1.65 million are on treatment, WHO?s head of HIV/Aids, Kevin De Cock, told the Toronto conference.

Road to freedom

The G8 has endorsed a target of universal access by 2010, but De Cock admitted that it would be ?hard going?. Children have been left behind in the drive to treatment, and pregnant women with HIV are not receiving the drugs that could stop them passing it to their baby at birth.

But as the numbers of people infected with HIV climb relentlessly ? last month?s UN Aids report shows 4.3 million more infected this year, which means 39.5 million people are living with HIV ? a new drive on prevention has begun.

Many people put their hope in the sort of technological solutions beloved of the Bill and Melissa Gates Foundation, which is funding trials of microbicides ? gels or creams that women can use before sex to kill or block the virus ? and vaccines, which have proved problematic and which everybody agrees are decades away.

Circumlocutions

In Toronto, Bill Clinton called on the world to start figuring out how to bring circumcision to men in cultures where the issue could be tricky. In India, Muslims are circumcised but Hindus are not. Early trials have shown that circumcision can protect men against HIV. Next summer, if the results of further trials confirm this finding (and they may also show that the women who sleep with circumcised men are protected as well), ?we will have a big job to do . . .? said Clinton. ?It is important that as we leave here, we all be prepared for a green light that could have a staggering impact on the male population but that will be frankly a lot of trouble to get done.?

Technology is not the final answer, though, or the spread of HIV would have been prevented by universal condom use. Condoms have been around for a long time, but they are still not available in much of Africa or are simply not worn. Clinton is among those who have begun to talk more urgently about universal testing. If people know they have HIV ? and most do not ? they will not only seek treatment, but may take precautions to protect their partners.

The obstacles

Exactly how this is to be done is problematic in practical terms and an ethical minefield in countries where people have few enough human rights. Nobody denies the stigma still associated with HIV infection. But Clinton said that the climate has changed from the early days of the epidemic when his friends were dying in California. He gave his backing to the universal ?opt-out? testing scheme being introduced in Lesotho, the tiny state bordered on all sides by South Africa. ?If it is done right, Lesotho?s infection will plummet and more people will live,? he said.

However, it is not proving as easy in Lesotho as many experts had hoped. Systems and procedures have to be set up to ensure that people understand the implications of a test and give informed consent, and that they then get treatment if they are positive. This is sophisticated stuff. It involves training and costs money. Promises of funds were plentiful in Toronto, but they have not all been fulfilled. And in Botswana, where progress has been faster, the government has had to pass a law to prevent people whose tests are positive from losing their jobs.

McClure says there is recognition of ?the inextricable link between treatment and prevention?, which was a strong message from Toronto ? and that prevention is ?more than just condoms and abstinence and faithfulness?. There is no simple solution to HIV. Even if a vaccine is developed, more likely than not it will protect some people and not others. There is now a more realistic understanding that we need a whole range of tools, from education to condoms to microbicides and to drugs.

Disappointment after Doha

The drug war has not yet been won. Five years after the Doha declaration at the World Trade Organisation gave poor countries an explicit right to bypass drug company patents and buy cheap copies of expensive medicines, Medecins sans Frontieres, Oxfam, the Stop Aids campaign and others say the situation is worse than before.

?Rich countries have broken the spirit of the Doha declaration,? says Celine Charveriat, head of Oxfam?s Make Trade Fair campaign. ?The declaration said the right things but needed political action to work, and that hasn?t happened. In fact we?ve actually gone backwards. Many people are dying or suffering needlessly.?

An Oxfam report says that since the signing of the Doha declaration in 2001, ?rich countries have failed to honour their promises. Their record ranges from apathy and inaction to dogged determination to undermine the declaration?s spirit and intent. The US, at the behest of the pharmaceutical industry, is uniquely guilty of seeking ever higher levels of intellectual property protection in developing countries.?

Washington has pursued its own free-trade agreements with developing countries, tying them into much tighter observance of patent rights than had been expected at Doha. ?The USA has also pressured countries for greater patent protection through threats of trade sanctions,? the report says.

Turning to the British government

The Stop Aids campaign, a coalition of 90 NGOs, is calling for the British government to champion the issue at the G8 summit next year. Three-quarters of HIV drugs are still under monopoly production and unaffordable in poor countries, it says. More than 75% of those who need HIV treatment urgently are still not getting it. Only 8% of children with the virus are on drugs, which cost four times more than those for adults.

?Sadly, promising words have not translated into life-saving treatments and five years is too long to wait when the stakes are so high,? says Steve Cockburn, the campaign coordinator.

The US government and drug companies are pressuring countries not to buy cheap copies. They are leaning particularly hard on India not to make copies. Today?s cheap Aids drugs will be useless to many people with HIV in poor countries in a few years, because the virus becomes resistant and new medicines are needed. Those are prohibitively expensive. The next international Aids conference, in Mexico in two years? time, could be tempestuous.

 

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