In June, 2006, UN member states at the General Assembly High Level Meeting on AIDS ambitiously committed themselves to provide "universal access to comprehensive prevention programmes, treatment, care, and support by 2010". The XVI International AIDS Conference, held last week in Toronto, provided the first opportunity to draft a strategy to meet that goal.
What werethe highlightsof this meeting? Fresh science brought attention to a new class of antiviral agent, the integrase inbibitors. An extremely drug-resistant (XDR) strain of tuberculosis (TB) was described. A visible shift took place in the terms of engagement with HIV-from treatment to prevention.1 Male circumcision, preexposure prophylaxis with antiretrovirals, microbicides, and vaccines were all discussed vigorously. Women were centre stage. Routine testing for HIV provoked furious debate, with proponents arguing that it was one of the few practicable ways to expand treatment. Opponents said it would undermine essential liberties. In sum, there was much to reflect on: narrowly defined, a success.
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But the opportunity to produce a roadmap to reach the 2010 target of universal access was squandered. Rarely has there been a meeting that felt so disengaged from a global predicament of such historic proportions. The agenda in Toronto was unfocused, giving prime air time to celebrities, such as Bill Gates and Bill Clinton, while largely ignoring Africa. Africa bears the greatest burden of AIDS today-24-5 million of 38-6 million people with HIV. Yet no African representative spoke at the opening of this meeting. Instead, non-Africans were nominated to speak on behalf of Africa. This surprising marginalisation sent an incredibly negative signal to the conference's 30 000 attendees. It suggested that Africa lacked leadership on HIV-AIDS and that its peoples paid the disease far too little attention. A leadership vacuum does exist in one country-South Africa. But in its anger over South Africa's shameful handling of the AIDS epidemic, the International AIDS Society inadvertently silenced the voice of a great continent.
Away from the star-studded plenaries, Africans and many others from countries most affected by AIDS had a troubling message. Global action to defeat this pandemic has stalled. A veneer of achievement-1-6 million people taking antiretroviral drugs, together with the existence of powerful financing mechanisms, such as the Global Fund, the President's Emergency Plan for AIDS Relief (PEPFAR), and the Gates Foundation-has bred complacency. Those who lead the AIDS community should be asking difficult questions if they wish to turn back the tide of HIV. Here are ten questions that failed to get the answers they deserved last week.
1 Why do we refuse to admit that there is still no genuine global commitment to scale up our response to AIDSP There remains a massive funding gap in the effort to control HIV. 2005 saw the world's AIDS budget reach USS8-3 billion. But $30 billion will be needed by 2010 to achieve the goal of universal access. The Global Fund is already several billion dollars short of what it needs for 2006-0/ And G8 countries continue to renege on their past financial pledges.
2 Why are the wider health, economic, social, and cultural contexts of AIDS still being ignored? There are catastrophic weaknesses in health systems and human resources for health. But AIDS is a human crisis, as well as a health crisis. In particular, AIDS is a crisis for women, driven as it is by vast gender inequalities that stubbornly persist in the world today. Somehow, the international commitments made in Cairo in 1994 to the rights of women to reproductive health services have been forgotten. Reproductive health has become divorced from the response to AIDS, a mistake of impossibly large proportions.
3 Why does our definition of science still seem to include only the laboratory experiment and the clinical trial? Social and ethnographic approaches to HIV treatment and prevention research are yielding important warnings about current AIDS strategies. HIV programmes can foster conflict and resentment,3 they often ignore sensitive cultural dynamics,4 and they can marginalise the influence of violence, crime, and alcohol on the way public health messages are transmitted and received.5 Unless we broaden the meaning of HIV science, AIDS campaigns will fail.
4 Why do we see biology, medicine, epidemiology, social science, and policy making as parallel, mutually exclusive "tracks" at the International AIDS Conference? Why do we reinforce these disciplinary divisions, instead of creating new alliances between them? The International AIDS Society would likely plead that rigid separation of communities is the only way to handle the huge number of submitted abstracts. But if the Society truly wants to foster science and social change, it should not buckle in the face of scholarly boundaries. It has to devise and promote different ways of working.
5 After 25years of AIDS, why are children still largely ignored? 2-3 million children under 15-2 million in sub-Saharan Africa alone-live with HIV. Yet fewer than 5% of these children receive the treatment they need. The worst shortfalls are in paediatric care, prevention of motherto-child-transmission, primary prevention, and the protection and support of children affected by AIDS, notably the 12 million children in Africa who have lost one or both parents to AIDS." HIV is an exquisitely acute child killer, yet children are barely mentioned in our strategies to defeat this disease.
6 Why do health agencies and programmes still base their prevention messages on the outdated and scientifically corrupt idea of abstinence? As studies in Africa show all too clearly, abstinence programmes do not and will not work. Abstinence alone is simply incompatible with most African cultures. Sex is bound up with traditions and practices that cannot be terminated by the moralistic injunction of one donor government. As the AIDS activist, Beatrice Were, argued in Toronto, abstinence is not only not protecting women, it is also hastening stigma and fuelling the African epidemic by making it harder to talk about sex, rape, and intimate partner violence.
7 Why are civil society and NGOs still not being given the credit they deserve as vital levers in the global AIDS response? Why do we still not see the community as a means for societal change? The focus of action on AIDS ranges from international instruments (eg, the Global Fund) to individual risk interventions. Intermediatelevel mechanisms to mobilise and engage communities are rarely discussed. Yet it is these community-based responses that will have the greatest impact on the epidemic, as evidenced from work in other fields, such as maternal and child health.
8 Why is stigma-of gay men and women, indigenous peoples, migrants, refugees, internally displaced persons, drug users, sex workers, and prisoners-still not the concerted focus of the AIDS response? The greatest impediment to AIDS prevention today is the invisibilisation of large social groupings by mainstream society. Communities are erased, phobias are fermented, and human vulnerabilities are criminalised. AIDS exposes the profoundest prejudices in our society, and wo do too little to reverse their pernicious effect.
9 Why do so many of those committed to defeating AIDS prefer to lecture one another about what each is doing wrong, instead of working harder to find meeting points of dialogue and partnership? Part of the answer is that there are few places where such constructive collaborations can be formed and nurtured. This is perhaps the chief challenge facing the global AIDS architecture.
10 All of which leads, finally, to the most damning question of all: why is the world's response to AIDS failing?
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The grip of AIDS will only be broken by effective programmes at country level. The difficulty is that agencies and funders-WHO and UNAIDS; PEPFAR, the Global Fund, and World Bank-operate quasiindependently of one another. They each have their own separate missions, governance structures, staff, and comparative advantages. What never happens is an event or process to develop integrated country strategies that focus only on the country-not on the interests of the agency, funder, or constituency (academic, policy, or activist). This exclusive country focus should be the purpose of the International AIDS Society's conference-a global accountability mechanism to monitor country progress, to hold all parties responsible for the part they play in defeating AIDS, and to set specific, measurable objectives for the succeeding 2 years.
A partnership between scientists and people living with AIDS could develop a set of indicators to track HIV prevention, treatment, and care, much as has been done for child survival.8 The International AIDS Conference should identify priority countries and devote specific sessions to each country-South Africa, Botswana, China, Russia, and so on-inviting ministers, policymakers, scientists, and civil society to join together in mapping, evaluating, and planning that country's response to AIDS. This biennial gathering would then provide the necessary accountability instrument, a tool to chart success and to identify catalysts of change or obstacles underlying failure.
In Toronto, Julio Montaner, president-elect of the International AIDS Society, blamed political leaders for permitting the "genocide" that is the AIDS pandemic.9 This rhetoric attracts headlines and gives welcome publicity to a still neglected disease. But such extreme language fails to point out the responsibility of the AIDS community itself, and specifically the International AIDS Society, for providing a neutral forum for scientists, policymakers, and others to work collectively against AIDS. The International AIDS Conference is a unique event in medicine. Its remarkable and inspiring diversity provides the foundation for a step change in its purpose. The power to cause a necessary schism between future and past responses to HIV lies not in the hands of political leaders, but within the AIDS community.
The Russian writer, Aleksander Herzen, once wrote that "Man and science are two concave mirrors continually reflecting each other." In Mexico in 2008, the international AIDS community will reconvene to take stock of this unprecedented pandemic and to review progress towards the 2010 goal of universal access. The litmus test for Mexico's success will be the degree to which the conference can be transformed from a scientific meeting and global beacon for AIDS, to a coordinating mechanism to drive advances in prevention, treatment, and care at country level. Talking is easy. Doing will demand a revolution. Historically and programmatically, Mexico is a perfect place to begin.
| [Reference] |
| 1 Picard A. Gathering opens with focus on AIDS prevention. The Globe and Mail, August 14, 2001: A1. |
| 2 Editorial. To empower women in the war on AtDS. The Globe and Mail, August 17, 2006: A14. |
| 3 Gruber J, Caffrey M. HIV/AIDS and community conflict in Nigeria: implications and challenges. Soc Sci Med 2005; 60:1209-18. |
| 4 Morrow OI, Sweat MD, Morrow RH. The Mafalisi: pathway to early sexual initiation among the youth of Mpigi, Uganda. AIDS Behav 2004; 8: 365-78. |
| 5 Muturi NW. Communication for HIV/AIDS prevention in Kenya: social-cultural considerations. J Health Commun 2005; 10: 77-98. |
| 6 UNICEF, UNAIDS, PEPFAR. Africa's orphaned and vulnerable generations. New York: UNICEF, 2006. |
| 7 Manandhar DS, Osrin D, Shrestha BP, et al. Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet 2004; 364: 970-79. |
| 8 Horton. R. The coming decade for global action on child heath. Lancet 2006; 367:3-5 |
| 9 Picard A. Political leaders accused of AIDS genocide. The Globe and Mail, August 18, 2006: A7. |
| [Author Affiliation] |
| Richard Horton |
| The Lancet, London, NW1 7BY, UK |
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