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“The Vancouver of Implementation Science” meets the “Fund the Fund” Demonstration at the Cape Town AIDS Conference

By Mark Harrington

The Difference of a Decade

For anyone who had been at the Durban, South Africa, AIDS Conference in mid- 2000, when virtually no one with HIV in developing countries was receiving antiretroviral therapy (ART), the Fifth International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention, held in Cape Town, South Africa, on July 19–22, 2009, showed the breathtaking progress that has been made in the past nine years—and the daunting challenges still ahead.

In 2000, then South African president Thabo Mbeki opened the conference with a long and rambling defense of his policy of refusing to provide ART for either the prevention of mother-to-child transmission or the nation’s estimated five million people then living with HIV.

In 2009, after a historic, unprecedented, and exhausting campaign by the Treatment Action Campaign, South Africa now has the world’s largest HIV treatment program, with over 600,000 South Africans receiving ART. The program has now been so effective that in some places—such as the township called Gugulethu just outside of Cape Town—HIV-associated tuberculosis (TB) rates, which have increased fivefold since the advent of HIV, were shown to decrease by up to 80% after the introduction of ART. This showed that HIV treatment, when combined with a decent TB program, can reverse the toll taken by HIV-associated TB disease. (A recent report from the World Health Organization indicates that TB kills at least 25% of people with AIDS globally.)

Another study, from Uganda and Zimbabwe, similarly showed that HIV treatment reduced malaria incidence among ART recipients by 75%. And a host of studies have shown that treating pregnant women with triple antiretroviral therapy during pregnancy and through breastfeeding could reduce the transmission of HIV to 1% or less.

These studies all demonstrate that the scaleup of ART—which now is reaching four million people around the world, according to the World Health Organization and the Joint United Nations Program On HIV/ AIDS—is bringing benefits across the continent of Africa, particularly among mothers and their infants; ART is saving lives and reducing diseases such as TB and malaria.

Scientific Progress, but a Grim Outlook for Future Funding

The implementation science at Cape Town was as breathtaking in its way as was the therapeutic revolution that marked the International AIDS Conference in Vancouver, British Columbia, in 1996, when highly active antiretroviral therapy (HAART) was dramatically presented at an international meeting.

However, the mood in Cape Town among activists and some policy leaders was grim. Activists held a meeting with Dr. Michael Kazatchkine, executive director of the Global Fund to Fight AIDS, TB, and Malaria, who noted that in the coming year 2010 the Global Fund was likely to face a gap of at least US$3 billion between the needs identified by recipient countries and the amounts likely to be available from donors. The global economic crisis has taken its toll, but other pressures have also become acute, such as a backlash among donors, development “intellectuals,” and even some high-burden countries, where the momentum of the past seven years of ART scale-up is beginning to flag. Global HIV activists held a demonstration on the conference’s last day demanding that the world “Fund the Fund” and “Fill the $3 Billion Gap.” A brilliant campaign by the AIDS and Rights Alliance of Southern Africa (ARASA) pointed out the amounts that could be spent on saving lives if only African leaders and donor countries such as the United States had the right priorities. For example:

  • the US$686 billion spent on the war in Iraq is more than 140 times the money needed to close the Global Fund’s funding gap for HIV and TB
  • the US$48 million spent by Ugandan president Yoweri Museveni on a new private jet would provide 229,524 person-years of ART
  • the US$500,000 spent by Swaziland’s king Mswati III on a new luxury vehicle could subsidize 21,000 treatment courses for his subjects suffering from TB
  • the US$250,000 spent by Zimbabwe’s president Robert Mugabe on his 85th birthday party would cover TB treatment for 10,501 Zimbabweans with tuberculosis

Activists from south and north united in a campaign to show the human costs of the current economic crisis, and the consequences for people living with HIV if we fail to achieve universal access to HIV, TB, and malaria prevention, treatment, and control by the end of the year 2010.

Policy makers have often told AIDS activists that our goals are unrealistic. The track record of the past three decades show that what is held to be unrealistic in one decade becomes reality in the next. In the 1980s, HIV was untreatable; in the 1990s HAART became available. In the 1990s, AIDS treatment was considered too expensive; in the first decade of this new century, over four million people received it. To turn the epidemic around, in the next decade, we must make history by achieving the goals of universal access while expanding and intensifying research to discover a cure and a vaccine.

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