San Francisco Chronicle - Sunday, July 7, 2002
Sabin Russell, Chronicle Medical Writer

Recapturing the immediacy of the 2000 conference -- situated in the center of an AIDS hot zone -- will be next to impossible in this prosperous European hub, in a country where the adult HIV infection rate is 0.5 percent. The contrast is stark, almost embarrassing.

"I'm disappointed that the Barcelona conference is not in a developing country. It would have had maximum impact if it was close to the front line," said Richard Feachem, head of the Global Fund to Fight AIDS, Tuberculosis and Malaria.

The Global Fund, which was conceived of last year by U.N. Secretary-General Kofi Annan, is one of the tangible byproducts of Durban -- although international pledges of $2 billion to fund it fall far short of the $7 billion to $10 billion that Annan said is needed to turn the tide.

A goal of both the Barcelona conference and the new Global Fund will be to "scale up" existing prevention and treatment programs to a level commensurate with the size of the problem.

So far, the worldwide AIDS catastrophe has claimed an estimated 20 million lives -- and threatens 40 million people who are currently infected with HIV, the virus that causes AIDS.

Desmond Johns, director of the New York office of the Joint U.N. Program on HIV/AIDS, known as UNAIDS, summed up one of the main challenges of the Barcelona conference: "There are more than enough good programs to absorb whatever money is available. The challenge is to increase those resources."

Durban put a spotlight on the immensity of the AIDS problem in Africa and prompted a continuing debate over how much wealthy nations should do to help poor countries cope.

"If Durban was an awakening, what we're seeing now are the first steps toward answering that challenge," said Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. "After two years of consciousness-raising since Durban, there is movement."

This time, officials will be able to measure progress against the Declaration of Commitment -- a measure ratified a year ago by a special U.N. session that set specific goals, such as rolling back the infection rate among young people by 25 percent.

Indeed, the success of the Barcelona conference will be assessed by how well the gathering ultimately converts rhetoric into action.

"This conference aims to hold all governments accountable to their Declaration of Commitment," said Stefano Vella, president of the International AIDS Society, which sponsors the international gatherings.

Already there has been controversy.

Reports that dozens of delegates from developing nations were unable to get Spanish visas to attend the conference threaten to mar the week's proceedings and highlight the divisions between haves and have-nots. The full scope of the visa problem won't be clear until the empty seats are counted.

The conference will provide a major forum for critics of the relatively modest amounts of financial assistance wealthy nations have provided. But because there nevertheless has been a substantial increase in international AIDS spending, policymakers will hotly debate how the money should be allocated: to prevention, treatment or a combination of the two.

For the anticipated 15,000 registrants, the Barcelona conference promises a rich array of scientific research and political theater. As the conference opens today, a march for Worldwide AIDS Treatment will mass before the Font Magica (Magic Fountain), one of the city's visual jewels.

Scientists will present data from hundreds of studies. Key topics include research on the toxicity of current antiretroviral drugs; studies of newer drugs that may be safer and more powerful than the current generation; and the latest information on potential AIDS vaccines.

Epidemiologists will continue to probe the origins of AIDS and attempt to predict its deadly path.

"The most important story will be China," said UCSF researcher Andrew Moss. Although Africa remains the continent most stricken by AIDS, with an estimated 28.5 million HIV infections, researchers are growing increasingly alarmed that the two most populous nations on Earth, India and China, are showing signs of a breakout.

Last week, a UNAIDS group in Beijing released a study warning that an "HIV/AIDS epidemic of proportions beyond belief" was already unfolding in China, a nation of 1.3 billion. An estimated 3.9 million of India's 1 billion people are already infected.

Among the issues to be raised in Barcelona are which prevention measures should be taken in poor countries to limit further spread of the disease. In the British journal the Lancet, researchers on Thursday wrote that an aggressive program of fully funded prevention programs could spare the world 29 million new infections by 2010.

While investigators debate which, if any, vaccine candidate is most promising for future control of the disease, other prevention measures will be explored.

There will be more discussion about male circumcision -- an inexpensive, one-time, permanent medical intervention -- which studies suggest may reduce transmission by 50 percent, the same level of protection as a modestly effective vaccine.

Reports about microbicide gels and diaphragms -- so-called female- controlled HIV prevention measures that kill or block HIV -- will also be aired. The Durban conference closed two years ago with a powerful speech by former South African President Nelson Mandela.

"In the face of the grave threat posed by HIV/AIDS, we have to rise above our differences and combine our efforts to save our people," Mandela said at the time. "History will judge us harshly if we fail to do so, and do so now." On Friday, Mandela will be returning to the podium to deliver the closing remarks, and perhaps, history's first judgment.

E-mail Sabin Russell at srussell@sfchronicle.com.
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