AIDS Alert International

Wealthy nations called on to boost support efforts

Five-year plan estimated to cost $9.2 billion

Using the 20-year mark in the history of AIDS as a catalyst, the United Nations and other international organizations have called on the world’s wealthier nations to increase attention, support, and funding to HIV/AIDS prevention and treatment efforts. This call to action included a series of meetings with business and political leaders and culminated in the first United Nations General Assembly Special Session on HIV/AIDS (UNGASS), held in June.

"Only through a truly global alliance will AIDS be defeated," said United Nations Secretary-General Kofi Annan in remarks addressed to the United States Chamber of Commerce on June 1 at a meeting in Washington, DC. "And in our shrinking world, all of us need to be involved in the solution because, one way or the other, sooner or later, all of us will be involved in the problem," Annan added.

Annan went on to ask the U.S. chamber for its support in the campaign against HIV/AIDS, explaining that American businesses need to start becoming involved in the campaign because the pandemic affects business through expanded costs and shrinking markets as 42% of U.S. exports go to markets in the developing world. "AIDS is uniquely disruptive to economies, because it kills people in the prime of their lives," Annan noted. "More than four out of five people dying of AIDS are in their 20s, 30s, or 40s."

Annan’s recent speeches and the Joint UN Programme on HIV/AIDS (UNAIDS) have followed a strategy of urging private-sector businesses to join in partnerships with governments in fighting the spread of HIV infection. UNAIDS estimates that AIDS prevention and care costs will need to rise by $7 billion to $10 billion a year in low- and middle-income countries. Current spending totals $1.8 billion, and projected costs through 2005 amount to $9.2 billion if enough money is spent to reverse the spread of the disease, according to UNAIDS estimates.

"We are in the middle of development, creation of a global fund, which will only be one of several mechanisms to make sure necessary money will be there," says Peter Piot, executive director of UNAIDS. "There is no way that the epidemic can be stopped and that people can have access to treatment without additional resources," Piot adds. "If we do this right, this fund should be more efficient to provide the money to where it matters on the community level."

The appeal appeared to be working in late June as some companies announced donations to the U.N. Global AIDS and Health Fund.

The $9.2 billion figure includes the money that nations such as Brazil are themselves spending on providing antiretroviral drugs to their HIV-infected citizens, says Bernhard Schwartlander MD, chief epidemiologist for UNAIDS.

However, in the nations of sub-Saharan Africa, about 80% of the funding for antiretroviral treatment must be raised by the international community, and that means billions of dollars, Piot says. "The $200 million from the United States is like a down payment, a start-up for this year for this fund," Piot says.

While Annan and UNAIDS have publicly applauded the United States’ recent pledge to the international AIDS cause, not everyone is pleased with the $200 million commitment. The international medical aid organization Doctors Without Borders (Medecins Sans Frontieres) recently held a teleconference in which physician advisors and coordinators criticized the lack of support from wealthier nations.

For example, the U.S. pledge of $200 million is a fraction of what is needed and nowhere near the sort of contribution the United States typically makes to international crises, says Daniel Berman, coordinator of the MSF Access to Essential Medicines Campaign.

The United States had an opportunity to lead the rest of the world in turning this global AIDS fund into the powerhouse it needs to be, and instead one of the richest nations in the world gave the fund a drop in the bucket, says Paul Davis, a member of the Health GAP Coalition and ACT UP Philadelphia. Davis, who was among the protesters at UNGASS, says the United States’ contribution should be closer to $2 billion than $200 million.

Secretary of State Colin Powell criticized contributions to the fund made by the European Union, saying the $582 million raised early on was little more than a good start. However, Powell’s criticism of his neighbors is ironic, because England, France, and Canada were only following the United States’ lead, Davis says. "When President Bush announced the $200 million contribution, he derailed momentum on the fund," Davis says. "He appeared to be a leader, but he set the rung so low that other contributors accepted this, and it decreased expected contributions from wealthy donors."

By the end of UNGASS, Powell had announced that the United States would provide more money to the global fund and said the $200 million was only seed money.

Berman also criticized some governments for causing delays in implementing antiretroviral treatment in developing nations. "Let’s be honest, the policy of the South African government is unacceptable," Berman says. "A lot more is possible, and if they are not willing to talk about that policy and to say that they can begin treating patients now on a national basis, at least starting pilots, then there’s something wrong there."

Doctors Without Borders officials also addressed the need for lower costs and greater access to antiretroviral treatment in Africa and other places where very few people have access to the life-prolonging drugs. The organization launched a campaign to coincide with UNGASS in which the word "decimation" was printed inside the outline of a pill capsule with a trademark symbol representing a patented prescription drug. The image is printed on a black background on t-shirts, postcards, and posters. Above the image are printed the words: "8000 people died today from AIDS because treating them is not cost effective.’"

Despite poor health system infrastructures throughout much of the developing world, these countries should be able to offer antiretroviral treatment to many of the people infected with HIV, says Anne-Valerie Kaninda, MD, medical advisor to MSF’s Access to Essential Medicines Campaign. "Today in almost all of the capital and urban cities in sub-Saharan Africa, you could at least start some pilot programs and start treating people," Kaninda says. "I think that in South Africa, for instance, at least 52% of the people infected with the virus live in urban areas, and that means they can have access to clinics and medical centers."

Also, so long as antiretroviral treatment is unaffordable or simply not offered to the vast majority of sub-Saharan Africans, then they have no incentive to be tested for the virus, and this in turn hampers prevention efforts, says Chris Ouma, MD, of Action Aid Kenya. Ouma treats AIDS patients in the slums of Nairobi and is an outspoken critic of international trade agreements that have kept antiretrovirals out of the reach of many people in Kenya and other developing countries.

HIV prevention remains the most effective strategy in fighting the epidemic, but it won’t work well without treatment, and what has happened in Africa is an example of this fact, Ouma adds. "The number of people coming in for testing is quite low because nothing will come of knowing their status."

Kaninda and Ouma also point out that there is no reason why the short-course regimens to prevent mother-to-child transmission of HIV cannot be offered routinely in all developing nations. In 2000, when some pharmaceutical companies announced they would offer these short-course drugs at little or no cost to some of the poorest nations, there still were more than 540,000 infants who acquired HIV from their mothers.

Prevention efforts face an obstacle of fear’

In Eastern Europe, which in terms of medical infrastructure more closely resembles the developing world than Western Europe, there is a lesson to be learned about the limits of HIV prevention messages, notes Konstantin Lezhentsev, MD, who works with MSF’s HIV treatment program for mothers and children in Ukraine. "There have been huge prevention activities, and during the past 10 years the main prevention message of changing behavior has been met with an obstacle of fear," Lezhentsev says.

Since Eastern Europeans who are infected have very little or no access to antiretrovirals, they equate HIV infection with death and therefore are afraid of being tested or even of facing the possibility that they could become infected through their own actions, he adds. "By providing HIV treatment, you reduce the fear of the death penalty," Lezhentsev says. "And that’s the main goal and how the prevention message could be effective."

Besides the problem of limited access to antiretroviral drugs, sub-Saharan African and Eastern European nations also have problems with obtaining prophylaxis medications and other drugs to prevent or treat opportunistic infections, the MSF physicians say. These drugs have generic versions, but there is so little competition in selling these to the developing world that the prices remain too high, Lezhentsev says.

In Kenya and East Africa, there is adequate access to drugs for respiratory tract infections, but there is a limited supply of medications for the more serious infections, Ouma notes. Also, even if prophylaxis drugs were readily available, they would not be used by enough HIV-infected people because so many of those who are infected do not know they are at risk since they haven’t been tested, Ouma adds.