Reflections on the 2006 IAC Conference in Toronto

Two years ago, at end of the previous International AIDS Conference in Bangkok, I left with a sense of desperation. There was not much good news, apparently years away from finding a vaccine and perhaps so far off track that research needed to go right back to basics in the hope that we might find a hook for future work. There were suggestions that on the prevention front circumcision of males and microbicides might offer some hope.

Toronto was destined to be the opportunity to see what progress had been made. The theme of the conference was ‘Time to Deliver’. With the 3-by-5 WHO campaign having failed to meet its target, and enormous gaps in funding, there was a general feeling as we arrived in Toronto that the time to deliver had passed years ago. But this was after all the 25th anniversary of the epidemic (measured of course by developed countries), and it was an opportunity to look both backwards and forwards.

So what was the flavour of Toronto compared to Bangkok? The bottom line is that there has been some slow but useful progress on many fronts. There are more HIV treatments in the pipeline. There are 27 microbicide products in development with five in phase-3 trials. There is clear evidence that circumcision in males dramatically reduces the transmission of HIV from women to men. More money than ever before has been poured into HIV, and although the 3-by-5 target was missed, last year another 650,000 people accessed ARVs in developing countries, bringing the total on treatment to 1.65 million. So the 26,000 delegates (yes, it was a zoo) might feel justified by feeling good that there has been some tangible and well needed progress.

But this was not the time for self congratulation. It was clear as speaker after speaker talked bluntly about the failures as well as the successes, that unless the world community does deliver, and soon, we are facing millions more preventable deaths.

At least the vibrant democracy that Canada is led to more blunt statements than ever before about where the failures reside. Bill Clinton said that abstinence only programs simply will not work. The French health minister, Xavier Bertrand, took a swipe at US policies which impede progress on HIV. Mark Heywood, the brilliant young activist lawyer who heads up the AIDS Law Project, the legal brains behind South Africa’s Treatment Action Campaign, called for the sacking of the South African health minister, Manto Tshabalala-Msimang, while she looked on from the front row of the audience. Anand Grover of India stated that the US was deliberately protecting the interests of pharmaceutical companies at the expense of lives.

But the prize must go to the two Canadians who spoke so eloquently and directly about the challenges facing us all. Mark Wainberg, Director of McGill University AIDS Centre, the brains behind 3TC and outgoing President of the IAS, hit out hard at the Canadian Prime Minister’s absence from the conference and the failure of the Canadian government to reconfirm the clean needle program in Vancouver.

UN special envoy Stephen Lewis, in his speech [1] at the closing ceremony, said “Abstinence-only programs don’t work … it’s an antiquated throwback to the conditionality of yesteryear to tell any government how to allocate its money for prevention. That approach has a name: it’s called neo-colonialism.”

The most harrowing truths came from the facts on treatment. The HIV/AIDS director of the World Health Organisation, Kevin de Cock, said that we are never going to be able to treat ourselves out of this epidemic. The figures he gave to support his claim are these: at the end of 2005 there were 1.3 million people in developing countries on treatment; by the end of June 2006 another 350,000 had been added to the list. A good result, one might think. But the total on treatment represents only 24 percent of those estimated to need it. And it gets worse: in the last year, while there might have been 650,000 more people on treatment than a year before, there were over 4 million new infections. Furthermore, of the 800,000 children it is estimated need treatment, less than 10 percent receive it. For those few people able to access treatment, many are now developing resistance [2]HIV which has mutated and is less susceptible to the effects of one or more anti-HIV drugs is said to be resistant. to first line therapies. Due to the policies of the pharmaceutical companies aided by the US administration, the prospects for affordable second line drugs are slim.

More dismal figures surround the issue of funding. Although there has been a significant increase in funding from $300 million in the late 1990s to $8.3 billion in 2005, the fact remains that this year we need $15 billion for an adequate response, rising to $22 billion a year by 2008. The gap is getting bigger and we are going to be many billions of dollars short on what is required by 2010 unless there is a dramatic change. The world’s rich countries, and especially the United States, need to live up to the challenge, and so far they are failing to do so.

Prevention must therefore remain the critical element in controlling this epidemic. It is good that there are two new tools that we can or might shortly be able to use. But in the hype around microbicides we must remember that there is no approved candidate yet, only possibilities in phase-3 trials. But in any case will microbicides get to the women who most need them? If we judge by the progress made with existing tools, this is very much in doubt. We already have, and have had for several years, the ability to reduce mother-to-child transmission to less than 2 percent. But fewer than 10 percent of pregnant women in developing countries have access to this treatment.

We know that male circumcision seems to reduce the sexual transmission of HIV from female to male by 60 percent. But if infant males are circumcised now it will be decades before we see the benefit. And if adult males are circumcised, who will pay for it, do we have the health services to do it, and will it lure circumcised men into the delusion that they are immune from catching HIV?

By the time the closing ceremony started, and all these issues were racing in my head, I sat in the darkened auditorium, alone among thousands of other delegates, and wondered whether it had all been worthwhile. Certainly there was far more serious GIPA (Greater Involvement of People with HIV/AIDS) content than ever before. It is true that it allowed me to ponder the value and context of the work I do. Nearly everyone was at the conference, but trying to find them among the thousands there made networking almost impossible. There were six concurrent sessions and skills building workshops all running at the same time. Between the formal program and satellites, it was almost impossible to convene a meeting at all. As is so often the case, to my frequent frustration, most of the sessions were descriptive of the current situation, with little suggestion about the way forward or what actions we need to take next. There were a few refreshing exceptions such as the study of the cohort [3]In epidemiology, a group of individuals with some characteristics in common. A cohort study is a special kind of clinical trial which looks at a treatment or treatment strategy in a cohort of people. of Kenyan sex workers who apparently resist HIV, with, it seems, higher than normal levels of a certain protein, suggesting some interesting avenues for further research.

Could the estimated $20 million spent on the conference have been spent in a better way, such as treating an extra 120,000 people for a year? It is true that the organisers managed to get excellent media coverage all over the world, apparently better in countries like the UK and South Africa than here in Australia. But will those who really are critical to influencing this epidemic take any notice? People like George W. Bush and Vladimir Putin, leaders of countries considering free trade agreements with the US, leaders of countries that have serious epidemics and inadequate responses, leaders of countries who do not understand that criminalisation of drug use, sex work and men who have sex with men serves only to drive the epidemic. Will they take on board any of this? Frankly I doubt it very much.

As I listened to the closing messages I suddenly felt terribly, awfully sad. I wondered how it could be possible that humanity, with the knowledge, the technology and the resources to deal with this epidemic, does not do so. I knew that there would be millions more of preventable deaths. The tears ran slowly down my face.

• John Rock [4] is NAPWA’s International Portfolio Convenor.