Why ‘dogmas of the quiet past’ will not work against vicious circle wreaked by the pandemic

Date: 27/11/03

South Africa launched the largest-ever AIDS treatment programme last week, and top generic drugs firms have promised to slash their prices for poor nations. Welcome moves, but rich countries must do more. David Cronin reports

SMALL victories have been notched up in the struggle against AIDS during the past 12 months.

At the time of World AIDS Day (1 December) last year, Thabo Mbeki's government was still facing accusations of being "in denial" about how South Africa has the largest absolute number of people infected with the HIV virus in the world. But last week it launched the biggest national treatment programme for antiretrovirals (ARV) - medicines which can delay the onset of AIDS - that any country has ever devised.

There has been much fanfare, meanwhile, about the recent deal brokered by the Bill Clinton Foundation with top generic drug companies to slash the price of two key ARVs for a group of poor nations, including Tanzania, Rwanda and Mozambique. A course of these drugs will now set a patient back €110 per year - half the previous price.

Naturally, the progress has been welcomed by those working at the coal face of the AIDS pandemic. Nevertheless, it pales in comparison to the scale of the associated problems. Around 95% of the 42 million with HIV in the world live in developing countries; six million of them need ARVs, some 300,000 get them.

"AIDS stands almost alone in human experience," Peter Piot, the UN's under secretary-general, said in an address to the World Bank last week. "I don't normally use such words but "exceptional" is the only word that fits.

"Many diseases and natural disasters create their own brutal equilibrium, a self-regulating mechanism that eventually enables society to cope, if not to overcome. AIDS, thus far, seems different. Virtually all its impacts serve to weaken our defences and accelerate its spread, not to limit it. By selectively killing young adults, AIDS removes the keystone of developing societies. The surviving children are less likely to be in school, well-nourished or properly socialized. This makes them more susceptible to the very situations that enables HIV to spread, and so the circle turns.

"Moreover, because it preys on the most private human behaviour and stays invisible for years, it has silenced us from acting. In short, AIDS has rewritten the rules."

He then quoted Abraham Lincoln: "The dogmas of the quiet past will not work in the turbulent future. As our cause is new, so we must think and act anew."

AIDS activists believe the disease has become so prevalent it can only be fought if there is a quantum leap in the sums that rich countries are prepared to spend in fighting against it.

So far, their contributions - including those of the EU - have, in the minds of most activists, been inadequate.

Back in 2001, UN Secretary-General Kofi Annan called for €8.5 billion per year to be allocated to tackling AIDS.

In response, the Global Fund to fight AIDS, Tuberculosis and Malaria was established in January 2002. So far the international community and a coterie of private donors have pledged €4 billion to the fund - well under half the yearly sum Annan has sought for tackling AIDS alone.

European Commission spokesman Diego de Ojeda recently pointed out that the Union is the largest financial backer of the fund. Between them, the EU's executive and the 15 member states have pledged 55% of the total amount offered to it. Yet some of the Union's governments have promised quite small sums - €84,000 and €250,000 in the case of Austria and Greece respectively.

"You can be the best and still give very little if everybody else is also giving very little," notes Louise Hilditch from ActionAid Alliance. "The big question is if the amounts given are enough to fund enough of the proposals on the table. My understanding is that they aren't."

In a new report for the European Parliament's development committee, Danish deputy Ulla Sandbæk urges that the Commission should increase its contribution to the Global Fund to €1 billion per year. This call is backed by Christian charity World Vision. "The Commission cannot afford to ignore either the causes or the symptoms of this crisis," says Jane Backhurst, director of its Brussels office. "As recent World Bank and UN reports confirm, the proportions of this disease run the risk of destroying all previous achievements in reducing global poverty, including EU-led initiatives."

Global Fund spokesman Tim Clark says higher contributions are needed if the body is to realize its objectives. In October, it joined the World Health Organization (WHO) in launching a scheme to provide three million AIDS patients with treatment by 2005. Parents would especially be targeted in a bid to prevent the numbers of children who have been orphaned due to AIDS from soaring. The world currently has some 13 million "AIDS orphans".

"We intend to reach our ambitious targets but they are out of reach at the moment," says Clark. "We are always teetering on the brink of insolvency and we will never have enough money in the bank. We do not have money to sit on. Our job is to raise funds and to spend them."

Because of the nature of the AIDS crisis, only a multi-pronged approach seems appropriate. This will have to include treatment of those already infected, ensuring the widespread use of condoms and developing an AIDS vaccine.

An ongoing problem is that condoms remain a taboo subject in many poor countries. The stance of religious leaders, especially those in the Catholic church which opposes anything that impedes sex from being linked to procreation, has been blamed as hugely damaging to efforts to control the disease.

Even though he has taken a vow of celibacy, the Vatican's spokesman on family affairs, Cardinal Alfonso Lopez Trujillo, has held himself up as an expert on sexual matters. He has controversially argued that the AIDS virus can pass through "pores" in condoms. "The AIDS virus is roughly 450 times smaller than the spermatozoon," he told BBC's Panorama programme. "The spermatozoon can easily pass through the "net" that is formed by the condom."

Meanwhile, the Archbishop of Nairobi, Raphael Ndingi Nzeki, has told his congregations not to use condoms, even though 20% of Kenya's population is estimated to be HIV positive.

Development Commissioner Poul Nielson has blamed such doctrinaire stances for the spread of AIDS. "Condoms are part of the solution," he remarked in October. "The condemnation of condoms is part of the problem."

The Commission says it has funded a dozen projects over the past 15 years which prove that condoms are the only effective barrier against AIDS. One followed more than 500 heterosexual couples, each with one partner who was diagnosed HIV positive, for stretches of up to 21 months. It found that in cases where 122 people did not use condoms regularly during intercourse, 12 cases of HIV infection occurred. But out of 123 people who made a point of using condoms while having sex, no case of the virus' transmission was registered.

The Council of Ministers approved in June a €600 million fund for research and development into AIDS, TB and malaria over a five-year period. Much of this has been earmarked for work aimed at securing vaccines for the three major killers.

Lieve Fransen, a Belgian doctor turned EU official who represents the European Commission on the Global Fund, says that while there has been much progress on providing ARV treatment and bringing the price of medicines down, "the vaccine question is the main thing I would not necessarily be that positive about".

"I don't think we are going fast enough," she adds. "I still think there is a lot of bureaucracy rather than a focus on product development. We need to be encouraging the private sector more to develop a vaccine."

Still, there may be grounds for optimism due to the first human trial of an anti-AIDS virus which is being undertaken in South Africa. (The trial began earlier this month.) Significantly, the AlphaVax replicon virus has been designed specifically to prevent the C HIV-1 subtype of the virus. This is the most commonly found strain of HIV in South Africa.

But Seco Gerard, an access to medicines campaigner with relief agency Médecins sans Frontières (MSF), says the Commission's slow reaction to the development of a new vaccine for W135 - a strain of meningitis proving to be a major killer of African children - does not inspire confidence.

She berates the EU executive for not yet heeding a call from the WHO to buy the vaccine in bulk for distribution where it is most needed.

"The EU has been completely absent on that. If it is not answering a call on a meningitis vaccine, is it going to do the same with AIDS?"

Major feature. Rich countries and pharmaceutical companies must do more to help poorer countries cope with the AIDS pandemic.

http://www.worldaidsday.org/ http://www.worldaidsday.org/

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