The New York Times - September 12, 2006
Lawrence K. Altman, M.D.

Four million people in the world became infected with H.I.V. last year, raising to 40 million the number now living with the virus that causes AIDS. Though governments, foundations and others are spending billions of dollars each year, the United Nations and AIDS experts say billions more are needed for drugs to help infected people in poor countries and for measures to prevent others from becoming infected.

With 26,000 participants, the Toronto conference was the largest ever on AIDS, and its main organizer, the International AIDS Society, is now asking participants for an evaluation.

Dr. Richard Horton, the editor of The Lancet, has already weighed in, saying in his journal that the conference was, "narrowly defined, a success." But Dr. Horton was still highly critical. The organizers wasted a superb opportunity, he said, to create "a tool to chart success and to identify catalysts of change or obstacles underlying failure."

The conference was the first major AIDS meeting since June, when United Nations member countries, in a General Assembly meeting, committed themselves to providing "universal access to comprehensive prevention programs, treatment, care and support by 2010."

Dr. Horton wrote: "But the opportunity to produce a roadmap to reach the 2010 target of universal access was squandered. Rarely has there been a meeting that felt so disengaged from a global predicament of such historic proportions."

AIDS conferences should become "a global accountability mechanism to monitor country progress, to hold all parties accountable for the part they play in defeating AIDS, and to set specific measurable objectives" for discussion at future meetings, Dr. Horton wrote. He moderated one session and attended a number of others.

The Toronto conference seemed to have created its own version of the Calgary stampede when 6,000 participants shoved their way into a hall to hear the conference's two stars, former President Bill Clinton and Bill Gates, the Microsoft chairman. Hundreds more, perhaps trying to avoid being trampled, settled for an overflow room.

To many participants, a significant conference oversight was that no African leader delivered a featured talk, even though Africa is the continent most affected by AIDS.

President Ellen Johnson Sirleaf of Liberia canceled her scheduled talk a week before the conference, organizers said. Nevertheless, they found no African backup speaker, leaving non-Africans to talk about Africa's plight.

The Stephen Lewis Foundation of Toronto showed considerable imagination. The foundation, created by Mr. Lewis, the United Nations special envoy for AIDS in Africa, conducted a highly successful grass-roots gathering of about 300 African and Canadian grandmothers over the three days before the AIDS conference. African grandmothers who have lost children to AIDS and are now caring for their grandchildren described their lives to Canadian grandmothers (very few of whom are dealing with AIDS in their immediate families).

In a "global village" section of the AIDS conference, participants could talk at booths where people from around the world displayed mats, bowls and other handicrafts as well as pamphlets on their programs for care and nutrition.

But if the conference had used imagination similar to that of the Lewis Foundation in inviting some grandmothers to speak in a plenary session, participants who have never worked in Africa might have learned from accounts of their daily lives.

The theme was also a call for the world to provide enough health workers to apply what scientists know can stop the pandemic. But I would like to have heard significant discussions of proposals like a large-scale Peace Corps for AIDS, providing tuition subsidies for students and others who work on AIDS projects in affected countries and paying doctors and other health workers reasonable salaries to work in affected areas.

The AIDS conferences, held every two years, aim to bridge science, politics and a number of other fields. The International AIDS Society's duty extends beyond holding conferences, said Dr. Pedro Cahn, an Argentine AIDS expert who is the group's new president. "We have to raise our voice," Dr. Cahn said of the scientists who are the society's leaders.

But as Dr. Mark A. Wainberg of McGill University in Montreal, a former society president, said at the closing news conference in Toronto, he and his scientific colleagues have little experience in international affairs and politics.

Dr. Wainberg, a co-chairman of the Toronto meeting, said the society's leaders had been fooled into expecting support from the South African government in return for holding the 13th conference in Durban, South Africa, in 2000.

Instead, he said, President Thabo Mbeki of South Africa "turned his back on us" by convening committees that supported Mr. Mbeki's doubts that H.I.V. causes AIDS.

"We were all completely bamboozled" and "insulted," Dr. Wainberg said.

On a positive note, the Toronto conference tried to bring prevention more in balance with treatment because of the growing recognition that the two efforts are inseparable. Treatment has gained an upper hand in recent years as prices for anti-retroviral drugs have plummeted. In part, that success has stemmed from criticisms about the inability of poor countries to pay for the drugs that many participants raised at earlier AIDS conferences.

But in the 10 years since the introduction of the highly effective drug cocktails, 20 million people have become infected, and most do not know it because they are not offered H.I.V. tests.

Simple facts underlie the need for better prevention to stop the expanding pandemic. As more people become infected, they will infect others. All will need lifetime drug therapy, escalating the costs and complexity of efforts to stop the pandemic.

Mr. Clinton and other government leaders have attended recent conferences, helping to expose scientists and health workers to politics. But there have been too few government leaders at too few AIDS conferences. Future conferences, like the next one, in Mexico City in 2008, could benefit if health ministers and other government officials from countries with a spectrum of AIDS problems, from minimal to severe, participated in meaningful discussions.

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