By Liz Highleyman

Leading up to the conference, the Treatment Action Campaign (TAC), which has pioneered treatment activism in the developing world, organized a march from Cape Town's District 6 -- a neigborhood infamous for the forced removal of 60,000 black and colored people during the apartheid era -- to the city's downtown convention center.

"Mandela's legacy is health, freedom, and dignity," said TAC General Secretary Vuyiseka Dubula, who both spoke at the rally and gave the community welcome at the conference's opening session. "Health is not in a recession. Any cut backs or slowing down [in funding] would be disaster for people on antiretroviral therapy."

At a time when wealthy countries are considering adopting a higher CD4 cell threshold for starting treatment, activists urged the World Health Organization (WHO) to raise its threshold for resource-limited settings from 200 to 350 cells/mm3. Additional demands included replacing older toxic drugs like stavudine (d4T; Zerit) with the modern choices used in the U.S. and Europe, as well as access to affordable second- and third-line regimens.

The theme was echoed at the opening plenary Sunday night, which featured South Africa's Deputy President Kgalema Motlanthe, who spent more than a decade as a political prisoner under apartheid. "Unless we redouble our efforts to conquer this disease it will define the 21st century for sub-Saharan Africa," he said. "It is clear that health outcomes are related to a range of social determinants including work opportunities, education (especially for women), housing, and clean water. As a society we need to improve social and economic situation for the poor."

According to conference co-chair Hoosen "Jerry" Coovadia, 1 in 5 people in South Africa have HIV, and among women age 15 and older, the figure is 1 in 2. "HIV is the handmaiden of tuberculosis," he emphasized, and South Africa is the epicenter of an epidemic of extremely drug-resistant TB (XDR-TB).

The International AIDS Society has urged that the 350 cells/mm3 threshold be universally adopted, IAS president and conference co-chair Julio Montaner noted. "Developing countries are stuck in a therapeutic corner," he said, with drug choice based on cost rather than safety and efficacy. "This was acceptable to jump start [antiretroviral treatment] programs, but no longer."

The G8 (the leaders of the 8 wealthiest countries) came in for criticism from several speakers for backtracking on its commitment to expand access to antiretroviral therapy (ART) by 2010.

"We must hold G8 leaders accountable for their failure to deliver on their promises," Montaner said. "The U.S. is the only one to sustain its commitment." Noting a recent study showing benefits in countries supported by PEPFAR (the President's Emergency Plan for AIDS Relief, instituted by George Bush) compared with non-PEPFAR countries, he said, "Let us have more PEPFARS rather than more empty promises."

Stephen Lewis, Professor of Global Health at McMaster University and former United Nations Special Envoy for AIDS in Africa, spoke with his characteristic passion, urging scientists to become activists. "No one should underestimate the power and influence of science when it decides to take a stand," he said.

Lewis castigated funding priorities that have given billions to Wall Street and bank bailouts while health and human needs are left wanting. He also addressed the debate about competing health funding allocations in a time of recession.

"Money must be found for every imperative," he said. "It can never be an either/or. We're talking about human lives, for God's sake, not the phoney parsing of a balance sheet."

He also decried the "ugly homophobic culture," the epidemic of sexual violence, and the oppression of women -- "the world's most poisonous curse" -- and their role in perpetuating the HIV/AIDS epidemic.

At a press conference on Monday, the day's plenary speakers took Lewis' activism exhortation to heart. Reuben Granich, who presented his mathematical model showing that annual testing and universal ART regardless of CD4 count could reduce HIV incidence by 95% in 10 years, said he has seen no evidence that investment in HIV has led to neglect of other areas. "The benefit for people with HIV is clear, but it also has benefits for the societies, families, and communities in which they exist," he said.

Wafaa El-Sadr, who presented evidence of the benefits of starting treatment above the 350 cells/mm3 threshold, noted that "the vast majority [of people with HIV in the world] are not getting treatment even at the current threshold."

Paula Akugizibwe of the AIDS and Rights Alliance of Southern Africa compared the amounts spent on corruption and extravagances -- such as African leaders' expensive cars, private jets, and lavish birthday parties -- against relatively paltry expenditures on health. "The real challenge is the longstanding moral crisis that has failed to prioritize health," she said. "If the right to health is not granted in legislative frameworks, we don't have a way to hold governments accountable."

In a special session and press conference later in the day, National Institutes of Allergy and Infectious Diseases Director Anthony Fauci and recently appointed U.S. Ambassador at Large and Global AIDS Coordinator Eric Goosby discussed U.S. domestic and global AIDS policy under the Obama administration.

With every bit of data we accumulate, Fauci said, "we move toward the realization of [the benefits of] starting HAART earlier." He said that PEPFAR would continue, but without the required emphasis on sexual abstinence of the Bush era. He also said there is a "clear cut intention on the administration's part" to remove the ban on federal funding of needle exchange programs.

Fauci explained that the recent emphasis on larger health systems would not detract from HIV/AIDS funding, but rather the two are interdependent.

TAC March (Photo: Liz Highleyman)

"What the president understands very well is you can't address diseases in a vacuum," he said. "We need a more comprehensive approach rather than focusing on a specific issue. You get an economy of scale when you put things together. It does not mean individual elements are going to suffer." With regard to NIAID, he added, "We are not going to restrict what we study to HIV, but to other diseases in the context of HIV, like TB and hepatitis...I think it's going to make it better because people with HIV are also dying of other diseases."

7/21/09

Reference
5th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention (IAS 2009). July 19-22, 2009. Cape Town, South Africa.

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