At the 16th International Aids Conference in Toronto, participants were treated to a video portraying a world without Aids. In this hypothetical 2031, a man fuels his luxury car with water, a surgeon conducts non-invasive surgery with magnets, and a bored-looking nurse sits at the end of an empty corridor with nothing to do.
”Don’t Let There Be a 50th Anniversary of Aids,” pleads the video. But when the lights came up on more than 24 000 researchers, doctors, nurses and activists, the first keynote speaker swiftly punctured that fantasy.
Frika Chia Iskander, a 25-year-old Indonesian woman infected with HIV in her late teens, said she wouldn’t still be alive without access to highly activated retroviral treatment. She served as a stand-in, in a sense, for nearly 40-million people around the world infected with the virus, and 1,6-million people in the developing world whose lives have been extended by medical progress.
Iskander sketched some of the reasons so many delegates were in scant mood to celebrate. Access to medication is still unevenly and inadequately spread. Only one in four people who need treatment receive it. Many of those who suffer from the illness face the kind of discrimination that kills. Governments around the world regularly fail to address the chief causes of HIV’s spread: unsafe sex and intravenous drug use.
What’s more, the swiftly mutating nature of the virus — one researcher referred to it as ”Machiavellian,” as if HIV has a personality and a strategy — means that those on treatment now will eventually need access to newer, more expensive second and third-line treatments. ”I don’t know for how long I will be taking these medications. Ten years? Twenty years? Or even 50 years?” Iskander said dolefully. ”Is there hope for a cure? Is there still hope for a vaccine?”
Those were the kinds of questions delegates took up in a sprawling series of sessions focused on hundreds of studies. There were bracing signs of hope, among them a stream of reports confirming the relative effectiveness of anti-retroviral treatment and suggestions that earlier intervention with medication both improves the prospects for patients and makes it less likely they’ll pass it on.
Delegates learned that dozens of clinical trials on vaccine candidates are well under way in 21 countries, many of them in Africa. ”The quest for a vaccine is the most important quest on the face of the planet,” declared Stephen Lewis, United Nations Envoy for HIV/Aids in Africa. However, none of the researchers involved in the trials predicted a proven vaccine within the next decade.
Against this backdrop, researchers rubbished the idea that the conventional ABC mantra (abstain, be faithful, condomise) — would ever succeed. Gita Ramjee, director of the South African Medical Research Council’s HIV Prevention Unit, earned a rousing ovation for suggesting that policymakers add to their alphabets: ”C for circumcision, D for diaphragm, E for exposure prophylaxis, F for female-controlled microbicides, G for genital tract infection control, H for HSV-2 repressive treatment, I for immunity (a vaccine).”
Ramjee highlighted the need for action on all fronts. Initial results of a series of studies, in South Africa and elsewhere, show that a broad campaign of male circumcision could significantly cut the risk of transmission of the virus to men. She also emphasised the importance of accelerated research on microbicidal gels that could place more control of HIV prevention in the hands of women.
For many delegates, the trajectory of the disease in South Africa served as an object lesson for how the pandemic might one day tip as wildly out of control in India, China, Southeast Asia, Russia and Latin America, where HIV prevalence is far lower. Why the disease spread so quickly in Africa remains a topic of debate. But undisputed now are horrific numbers — that South Africa has the second-highest number of people infected with the virus in the world (5,3-million). The epidemic in South Africa is also considered ”unstable” meaning that it is still expanding .
Stephen Lewis, the UN envoy, was just one in a series of speakers cheered by the audience when he scored the South African government for an ”obtuse, dilatory and negligent approach,” to Aids, and criticised Health Minister Manto Tshabalala-Msimang for holding views ”more worthy of a lunatic fringe than of a concerned and compassionate state.” Tshabalala-Msimang, unlike other African health officials, wasn’t on the programme. But she served as the conference’s chief whipping girl, widely derided for the slick station set up under her direction in the conference exhibit hall.
By the end of the event, a stream of criticism of the South African government had become a torrent. Tshabalala-Msimang took a seat directly in front of Mark Heywood of the Treatment Action Campaign (TAC) and the AIDS Law Project, as he told a plenary meeting that the course of the epidemic in South Africa ”was predictable and to some measure preventable”, driven by a set of social factors that were understood as early as 1990. For good measure, he quoted assassinated African National Congress and South African Communist Party leader Chris Hani as having raised a warning about it.
When two dozen protestors carrying signs that read ”Fire Manto!” filed silently onstage, Tshabalala-Msimang bobbled up and down in her chair as if overtaken by laughter. When I approached her as the session ended, she waved me off: ”I will debate this at home,” she said, leading an entourage out of the hall within spitting distance of her critics. ”There is nobody who can fire me from here. I don’t belong to Toronto.”
Sibani Mngadi, the minister’s spokesman, complained that Tshabalala-Msimang had been attacked merely for choosing ”a different path that wasn’t emphasised at UN meetings”, one focused on underlying causes of the spread of Aids, like poverty and lack of nutrition. ”We’re only three years into the government plan,” he added. ”I don’t think people are being fair.”
One after another, researchers scored other governments around the world for putting politics ahead of science, particularly in programmes involving men who have sex with men, commercial sex workers and drug users.
At a press conference, TAC general secretary Sipho Mthathi denounced pharmaceutical companies, among them sponsors of the Toronto conference, for pressing patent protections to try to block India and Brazil from producing cheaper versions of needed medications.
The urgency of the need for more success in prevention efforts as well as care was driven home when Peter Piot, the head of the UN Aids Programme, rubbed elbows with Hydreia Broadbent, a young African-American living with HIV. She strode to the podium, in fashionably spiked hair and sandals, to tell a hushed auditorium how she’d been diagnosed with HIV at 3 years of age, and was granted a second chance at life because of the treatment she’d received. ”I’m 22 now. I’m in college. I date, and I plan on marrying and having kids,” she said with defiance.
Her situation reminded me of the group of teenagers I met a year ago at Harriet Shezi Children’s Clinic in Johannesburg. Those teenagers also receive excellent care, but they’re the lucky few, a small fraction of HIV-positive children born in South Africa each year, most of whom die before the age of two. By contrast, in the United States and much of Europe, mother-to-child transmission of HIV has been nearly eliminated.
Broadbent’s story also called to mind a group of boys I met at a rally for Jacob Zuma in Limpopo earlier this year. They were pre-teen guys — smart, loose-limbed, wisecracking, lively, full of hope, and just beginning their active sex lives. One of them asked me if I knew Eminem personally. But none seemed to have the faintest clue about how to protect themselves or their partners against the virus.
They represent the majority of Africa’s young people, who haven’t yet been reached by effective prevention messages and don’t have access to treatment when they fall ill. Up to 70% of the world’s unmet need for treatment is in Africa, 95% of all those living with the virus are now in the developing world, and an estimated 90% of them don’t know they’re infected.
Perhaps the uncertain future of such large numbers of people was on Piot’s mind when the moderator asked him what keeps him awake at night these days. ”I wonder how can we can make sure that 10, 20, 30 years from now there will be access of treatment,” he replied. ”That’s what keeps me awake at night — and it also makes me angry.”
Piot’s plea for a doubling of efforts to create a sustained programme proved less lofty than the fantasy that water might one day fuel our cars — or the hope that Aids can be vanquished by 2031. Aids poses exceptional challenges for successive generations, nowhere on a greater scale or more poignantly than in Africa. After all the evidence had been culled from six days of reports, Piot’s more prosaic hope for an exceptional response seemed plenty ambitious enough.
Douglas Foster is associate professor at the Medill School of Journalism, Northwestern University, Illinois