The global Aids campaign: a generation's struggle

Alex de Waal
21 August 2006

The global Aids industry put on its sixteenth bi-annual show in Toronto from 13-18 August 2006. The conference theme was "Time to Deliver" – with reference to the ever-more ambitious pledges to tackle the Aids pandemic made by world leaders, culminating in the G8 commitment at Gleneagles in 2005 to provide universal Aids treatment by 2010.

But for the 30,000 participants who thronged Toronto's Metro Convention Centre, the speeches and debates were less important than the chance to meet and network. The crowded stalls set up by the activist groups in the "Global Village" and the sleek suites of the pharmaceutical companies in the main exhibition hall showed the breadth of the constituency mobilised by the virus barely twenty-five years since the first Aids cases were diagnosed. This was as much global trade fair as scientific conference.

Indeed, Aids is a global industry. International aid for Aids topped $8 billion in 2005, more than twenty times what it commanded ten years ago. By volume, that still makes it a small business in comparison to the other products that warrant such international gatherings. If world leaders indeed recognise Aids as one of the greatest catastrophies of our time, that recognition is still largely rhetoric, in comparison to what is spent on arms or oil. Far, far more is spent on domestic healthcare in developed nations; more on cosmetics. But the Aids industry is now big enough and influential enough for us to legitimately ask, what are the products that it manufactures?

Alex de Waal is a fellow of the Global Equity Initiative at Harvard University, and a director of Justice Africa

Alex de Waal's latest book is AIDS and Power: Why there is no political crisis – yet (Zed Press, August 2006):

"HIV/AIDS, Africa's greatest human tragedy for over a century, is an immense challenge to democrats and activists. This book looks at whether governments can survive an epidemic that has cut life expectancy in half, further burdened fragile economies, and created millions of orphans. It explores why, twenty years into the crisis, democratic governments are performing so poorly in tackling the disease. It argues that existing approaches to the epidemic are driven by interests and frameworks that fail to engage with African resilience and creativity. Already, African communities have confounded some of the worst predictions of disaster, and if adequately supported, can find ways of sustaining development and democracy in the midst of HIV/AIDS"

Also by Alex de Waal in openDemocracy:

"The African state and global governance"
(30 May 2003)

"Darfur's fragile peace" (5 July 2006)

A double achievement

The Aids industry has had two great successes. The first – and biggest – is medicines. The international Aids conferences began as a forum where scientists could meet together to compare notes about a frightening new disease. Since the early 1980s, more has been learned about the human immunodeficiency virus than about any other pathogen in history. Anti-retroviral therapy can, properly administered, make HIV infection a chronic and treatable condition rather than a death sentence. The fact that anti-retrovirals are now accepted as a normal regimen in developed countries, available to all, shows how sky-high are the expectations of the drugs industry.

In any other age, such progress would be have been regarded as miraculous. The pace of roll-out in poor countries is lagging, but is still far faster than was dreamed of even in 2001, when western governments and United Nations agencies were still debating whether any Aids treatment would ever be possible in sub-Saharan Africa.

The world's, and Aids professionals', expectations are still stellar. Virologists have long been warning that the extraordinary capacity of HIV to mutate and evade the normal evolutionary pressures towards lower virulence mean that we must continually develop new lines of drugs to cope with the drug resistant strains of HIV that are sure to evolve. In 2005 there was a scare over drug-resistant HIV in New York, and resistant cases emerge regularly in other parts of the world. Meanwhile, scientific opinion is still divided over whether a vaccine will be possible, ever.

The Aids industry's second great success is the unprecedented way in which a fatal, sexually-transmitted infection has not been an occasion for repression and control. Historically, public-health emergencies have led to crackdowns on civil liberties, and early indications were that sex workers, migrants, gay men and drug-users would all feel the full force of the repressive state. Give governments a free hand, and we see the coercive apparatus out in force.

For example, all African armies which have the capacity to enforce compulsory HIV testing of soldiers, do so, and most of them automatically discharge any soldier found to by HIV-positive. Many governments admire Cuba's highly repressive – and so far, effective – approach to controlling Aids, through population testing and the isolation of the infected. Some public health professionals regret the way in which Aids has been "exceptional".

For example, they argue that the individual's right to privacy has been sanctified, overriding the rights of that individual's sexual partners to knowing his or her HIV status. Better, they assert, to have obligatory testing and partner-tracing, sacrificing some confidentiality and risking the stigmatisation of those identified as HIV-positive, in order to help stop onward transmission.

The debate on human rights, confidentiality, stigma and testing rages on without conclusion. Some of the worst-hit countries, such as Botswana – where more than one in four adults is living with HIV – have introduced routine testing, which puts the burden on the individual patient to opt out of an HIV test, which is otherwise a routine activity. But epidemiological efficacy is not the only criterion for public-health policy. What about rights and democracy? What has been the political impact of the first-ever rights-based approach to tackling an epidemic?

A liberal dynamic

The Aids pandemic coincided with global liberalisation. Indeed, it's possible that the increased movement of people and the relaxation of state and social control systems that accompanied the end of state socialism in many parts of the world, and apartheid in South Africa, actually facilitated the transmission of HIV. But it's also clear that the rights-based approach has helped to entrench political liberalism. In almost every country, civil-society organisations are leading the way in defining the problem, setting up prevention and care programmes, and mobilising people living with HIV and Aids. It is particularly marked in Africa, where NGOs are represented on the "country coordinating mechanisms" whereby the Global Fund to Fight AIDS, TB and Malaria identifies the projects it will support.

The board of the global fund also includes people living with HIV and Aids; Peter Piot, executive director of Unaids, regularly meets with Aids activists. An African activist who is blocked from directly influencing her government through parliament or the ministry of health may have more success through the roundabout route of linking up with international Aids agencies, which can bring much more direct and powerful leverage to bear on the national government.

The global Aids industry has done superbly well in giving a platform to activists across the world. Still faced with stigmatisation and discrimination, these activists need all the help they can get. Slowly the battle for the rights of people living with HIV and Aids is being won.

Also in openDemocracy's "HIV/Aids: what policy for life? " debate:

openDemocracy, "Picturing hope: the lives of the global HIV+"
(1 December 2005)

Tim France, "The United Nations and aids: learning from failure" (30 May 2006)

Roger Tatoud, "Gendering the fight against Aids"
(21 August 2006)

A long-wave event

What is less clear is whether the fight against the virus is being won. The combination of pharmaceuticals and activists has led to some immense breakthroughs in providing treatment to the afflicted. But there is much less evidence for progress on preventing new infection and on providing care and support to the tens of millions of children affected by Aids. Although HIV prevalence rates appear to have stabilised in many African countries, there is little reason for self-congratulation – a 10% adult prevalence rate still represents an immense human tragedy. Today less than 5% of African children affected by Aids receive any support from national governments or international agencies.

Missing are organised political interests to promote HIV prevention and assistance to children. Pharmaceutical companies have clear financial incentives in developing and selling new drugs. People living with HIV and Aids have clear incentives in expanding cheaper treatment. Governments of highly affected countries need no special programmes to help them respond to the political threats posed by Aids – they have smartly if often surreptitiously made sure treatment is available for the elites.

But at the moment there's no reward to a government that cuts down the number of new HIV infections. The standard measure of HIV level in a population is prevalence – the overall number of people infected. The link between new infections and overall prevalence is a complicated one, depending on the numbers of people dying, migration rates, and technical aspects of how statistics for the prevalence rate are estimated. And if the incidence rate – new infections – begins to fall, it can take six or eight years before that registers in prevalence data.

That time delay alone is enough to switch off any politician's interest. Until recently, testing technology didn't allow for rapid and reliable tests for new infections. Now that has become possible, but it's rarely done. This means that the most important indicator of success or failure in tackling Aids is simply not being measured. If we are not measuring it, we cannot reward the policies that make a difference.

Children affected by what we are simply not measuring are the hidden face of the epidemic. Our emotions are moved by the statistic of 14 million children orphaned but their harrowing stories of distress are not a factor in governments' calculations. There is still no serious commitment by national governments in poor countries, or from international donors, to mobilise the kinds of resources needed to provide basic welfare to children in societies affected. Perhaps the time lag between action today and measurable results is simply too long to attract political leaders concerned with winning the next election.

The HIV/Aids pandemic is a long-wave event. After a quarter of a century, it has still not reached its peak. Only when political leaders are ready to act with similar generation-long time horizons, can we expect serious action to overcome it. And only when political interests are served by such long-term actions, can we expect leaders to act. The global Aids industry has come a long way: it needs to plan for its next twenty-five years.

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