The XIV International AIDS Conference: a call for action ... now

A few weeks after I returned from the XIV International AIDS Conference in Barcelona in July 2002, I made a home visit to a dying AIDS patient who could not tolerate highly active antiretroviral therapy (HAART). His face was gaunt and his body wasted. He had lost nearly half his body weight over the past 2 months. He seemed like a relic from the pre-HAART era of the 1980s and early 1990s.

The patient's emaciation served as a grim reminder of the 94% of HIV-infected people who live in low- and middle-income countries and for whom HAART is mostly unavailable. Whether through daily protests or during highly technical scientific presentations, international activists and prominent researchers kept the HIV/AIDS catastrophe in the world's poorest countries at the forefront of the 6-day conference.

A harrowing report released by UNAIDS just before the conference heralded the theme of “knowledge and commitment for action.”1 In Botswana, Swaziland and Zimbabwe, over one-third of adults aged 15–49 years are infected with HIV. Life expectancy in the hardest-hit countries has been reduced by over 20 years. Fourteen million children had been orphaned by AIDS by the end of 2001 (a number that includes only those children still alive).1

At the opening plenary session Bernhard Schwartländer, an epidemiologist from the World Health Organization (WHO), could barely conceal his distress as he reported on the unimaginable devastation wrought on the world's poorest people by the AIDS epidemic.2 Schwartländer declared that just 10 years ago he would not have believed the figures now being reported. In 7 countries HIV prevalence rates are greater than 20%. Schwartländer estimated that, failing drastic intervention, 25% of the workforce in some countries will have died of AIDS by 2020. Every component of social organization, including health, education, employment, family structures, law enforcement and the military, is on the brink of ruin. According to Schwartländer, who appeared almost desperate, a comprehensive response fully implemented by 2005 could avert 29 million new infections in low- and middle-income countries over the next 8 years.2

Providing access to medications is a crucial part of that comprehensive response. Access to HAART in developing countries is seriously limited: fewer than 30 000 of the 28.5 million people with HIV infection in sub-Saharan Africa had been treated with antiretroviral medications by the end of 2001.1 At the Barcelona conference, Dr. Papa Salif Sow of Senegal outlined clinical and laboratory criteria for the initiation of HAART in HIV-infected people living in developing countries.3 His proposal is remarkably similar to the guidelines of the International AIDS Society—USA,4 released the day after Sow's presentation: in contrast with earlier recommendations,5^,6 these guidelines no longer require a baseline plasma viral load as an independent indicator for initiating therapy (although the IAS—USA recommends that HAART should be considered in any person with a viral load greater than 50 000–100 000 copies/mL). Further, the ideal CD4+ cell count or “golden moment” at which to initiate antiretroviral therapy in asymptomatic patients has moved from 500 to 200 ´ 10⁶/L — a far more conservative recommendation than in earlier guidelines.5^,6^,7^,8 Later treatment means fewer people receiving HAART, and hence lower drug costs.

The hope that early initiation of HAART could eradicate HIV was quashed by reports that latently infected CD4+ cells have a half-life of 6–44 months. At that rate of decay, even with 100% treatment compliance, it would take a patient over 70 years of treatment to fully eradicate HIV. The new treatment guidelines, emphasizing long-term control and deferral of treatment until it is immunologically necessary, reflect the harsh reality that in 2002 eradication or cure does not seem possible.

Canada did not fare well at the Barcelona AIDS conference. Irene Fernandez, a migrant workers' rights activist from Malaysia, opened the formal conference program with the second Jonathan Mann Memorial Lecture (named after the former head of the WHO Global Programme on AIDS who died in the Swissair crash at Peggy's Cove in 1998). She singled out Canada's failure to meet the United Nations target of giving 0.70% of gross domestic product in official development assistance. Canada ranks behind 14 other countries with a contribution of about 0.25% of gross domestic product for the year 2000.1 Two days later AIDS activists raided Health Canada's exhibition booth and plastered the walls with stickers asking “Where is the $10 billion?,” referring to the money required annually for HIV/AIDS treatment and prevention in developing countries.

During the conference Canada's Minister for International Cooperation, Susan Whelan, announced that Canada would spend $53.3 million to fight HIV/AIDS in developing countries. But this funding was not new; it had already been allocated to the Canadian International Development Agency in the federal budget in December 2001.

At an evening reception held by Whelan, I decided to engage her on the subject of Canada's dismal foreign aid record and informed her of Irene Fernandez' comments. The minister said Fernandez was wrong. I told the minister that the highly respected Canadian, Stephen Lewis, United Nations Special Envoy on AIDS in Africa, says that $10 billion annually is needed for HIV/AIDS in developing countries. She was even more dismissive of Lewis while defending Canada's record in the global fight against HIV/AIDS. She admonished me to lobby, write letters and protest. By way of this commentary, I am following the minister's advice.

During the closing ceremony of the conference 2 former heads of state, Nelson Mandela of South Africa and Bill Clinton of the United States, challenged the world's political leaders to confront HIV/AIDS with the same commitment they have shown in the fight against terrorism. Clinton proposed that the world's poorest countries should determine what they can afford to spend on HIV/AIDS and then send us — the rich countries — the bill for the rest. It is time for Canada to pay up.

𝛃 See related articles pages 481, 485 and 526