Time to Deliver? Musings from the XVI International AIDS Conference, Toronto

by Chikwe Ihekweazu

The HIV/AIDS ‘community’, an odd mixture of scientists, youth, community workers, activists, politicians, and various others gathered again in Toronto, Canada for what was described as the largest AIDS conference ever. “More youth than ever before!” it was repeatedly proclaimed…a hundred grandmothers from Africa! In the sweltering heat of a late-summers week, we came to share with each other the challenges and successes in the fight against this pandemic. 25 years on, with close to 40 million people infected, mostly resident on our continent, it was impossible not to feel guilty on how it had all come to this. A few weeks later, I reflect on what the legacy of this conference will be.

As I watched Bill and Melinda Gates at the opening ceremony, I truly believed that in front of us was a man in the process of redefining his legacy. Having recently given up day-to-day running of Microsoft, a company that has revolutionized our way of life, I could not help but think; in 10 years time Bill Gates might be remembered less for his role in the growth of information technology but for the public health issues he has chosen to dedicate the rest of his life to. Perhaps I am being overly optimistic and many of my colleagues will say I am, but I hope not. Often as workers in public health, with our self gratifying altruistic attitude, we are all too quick to condemn and question the motivation of people like Bill Gates. I choose to remain optimistic, and believe in this man’s intentions. He spoke at the conference, not about vague sentiments of saving the world, but with great insight into this rather difficult area. He had obviously done his homework. He is clearly giving this new project as much time and attention as he gave to Microsoft. If he does come even close to his prior successes, then we have a lot to look forward to.

“I abstained before marriage, I was faithful in marriage and still I became infected with HIV – Ugandan Lady”. It became obvious to many during the conference that the ABC strategy of “Abstain, Be Faithful and Use a condom” is failing African women. Regretfully, we have come to the painful realisation that men cannot be relied on to take the decision to “abstain”, “be faithful” or “use a condom. Women are bearing the brunt of this epidemic, getting infected earlier, caring for the sick and elderly. If the money and effort Mr. Gates is putting into microbicide research does produce the preventive tool we all hope for; then Voila! Microsoft will be but a footnote in the man’s legacy. Within the vast array of possibilities in the HIV/AIDS arena, Bill Gates has chosen microbicides to invest most of his time, money and advocacy. Until recently microbicides have struggled to stay on the agenda, now it is being hailed as the next big thing. Microbicides are chemicals that are placed in the vagina before sexual intercourse that could prevent the virus crossing into the body. Why are microbicides so exciting? Maybe because unlike most other methods available we have at present, it puts the power of prevention in the hands of women.

As usual, in the midst of despair, there were some success stories and ground for careful optimism. Botswana went against the norm and introduced universal testing in 2004. This policy requires that each person who attends a hospital to be tested for HIV unless he/she actively opts out. Botswana’s argument was that the requirement for extensive counseling prior to testing, a legacy from the era when treatment was inaccessible to most of those infected was now an impediment for universal access to treatment. Many in the ‘international community’ remained skeptical. In 2 years, this new policy led to an increase from 18 to 25% of people who are aware of their HIV status in Botswana. As of February 2006, more than 58,000 patients (of whom over 51,000 are already on ARV therapy) have enrolled in Botswana ‘s National ARV Program at 32 operating sites. In addition, another 8,300 patients from the private sector have begun ARV therapy. In a satellite session dedicated to Botswana, a nurse summarised her emotions as follows; “I cannot continue burying my friends while we insist on voluntary counseling before testing, if I wanted to be an undertaker, I would not have trained as a nurse”. Botwsana’s stand can best be encapsulated in Peter Piot’s remarks during the opening ceremony; “in an exceptional crisis, we must learn to act in exceptional ways”.

One of the most interesting sessions at the conference held on the Wednesday afternoon, titled “25 years of AIDS reflecting back, looking forward”. The panel included Antony Fauci and Peter Piot and was chaired by Richard Horton, the Editor of the pre-eminent medical journal, “The Lancet”.Most of us Nigerians were in our bi-annual, mid-conference moaning session, a meeting of sorts where we all come to cry our eyes out to the leaders of the official delegation. I knew it would be a difficult call to miss this session, but patriotic instincts can be so strong. Anyway, thanks to the marvels of modern day technology, I quickly rushed to the net to catch the webcast as soon as it became available. Richards opening remarks were poignant and profound. I felt like my country and I were being addressed directly. He asked “Why are we not using these meetings as a global accountability mechanism for country progress, to hold everyone of us accountable for what we have done in the previous 2 years, and set specific, measurable objectives for the next 2?”

On ARVs and the hope it offers for Africa, Kevin DeCock, director of the WHO Department of HIV/AIDS warned “We cannot treat our way out of this epidemic, continuing at the present pace, there will be 450,000 new cases on treatment each year yet there’ll are 4 million new infections”. Treatment without prevention is obviously not sustainable. Prevention will continue to be multi-dimensional. While sex education, abstinence, faithfulness to a partner all remain important, so does the hope for biological methods such as microbicides, ARVs and a vaccine. There will not be a magic bullet, at least not with what we know now. Results from a few studies suggest that there may be hope for finding an additional preventive tool in male circumcision, yet there is every reason to remain cautious.Even if proven to be effective, there remain huge cultural barriers to its use as a preventive health measure.

Many scientists will moan at the lack of scientific rigor in many of the sessions, and the role of “lesser mortals” in a scientific conference. I will argue that it is just as important that this conference is open to a wide variety of people from all backgrounds. I remember vividly my introduction to the HIV/AIDS field at the ‘Break the Silence’ conference in Durban, in 2002. The motivation to dedicate a substantial part of my professional career to this field was motivated less by the over-whelming science than by the inspiration of people like Zachy Achmat of the Treatment Action Campaign. At the time it was considered almost insane to imagine that ARVs, then costing about $10,000 per person per year would ever be available to treat people living in Africa. Yet Zachy and his group believed and convinced us that it was possible. Today we have seen that it is possible, with treatment costing as low as $130.00 in some cases. This was not achieved by science! History will not judge us by our scientific advances but what we do with them.

Where will we be in 25 years time? A quick death from pandemic influenza or a slow one from HIV/AIDS? Hopefully, none of the above will come to pass. Like Peter Piot, the Director of UNAIDS repeatedly says, “we know what works”. In 2 years time we will meet again in Mexico to take stock on the promises we have made. Most of all, I will look forward to the biannual meeting of the Nigerian community at the AIDS conferences. We love a good moan!

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