San Francisco Chronicle - Sunday, July 14, 2002
Sabin Russell, Chronicle Medical Writer

Twenty-one years into the epidemic, AIDS has become a banker's tale: Developing nations needs $10 billion a year from the rich to stop this epidemic. At best, they are getting $3 billion.

The numbers, whether billions of unavailable dollars or millions of projected deaths, are simply mind-numbing, and the lofty calls for action, repeated at these gatherings every two years, are growing shopworn.

Nelson Mandela, an icon of hope, hobbled on stage for the closing ceremonies to deliver the wisest line of the conference: "Unless we are able to follow what we say by doing something practical, our eloquence is worse than useless."

There were no scientific breakthroughs here, though none was expected. There were horrific tales of a plague spinning out of control, but the stories have been heard before.

The crucial questions are these: Is the rest of the world really paying attention to the warnings coming out of Barcelona? Or are those who came here living in a bubble of compassion and commitment that will pop once their jets depart from Spain?

Former President Bill Clinton touched on the surreal quality of the AIDS catastrophe. "How could we explain to someone from outer space," he asked, "that the world is being consumed by a disease that is preventable?"

Everyone's long-term hope for an AIDS vaccine is hampered by technical hurdles, a maddeningly elusive virus and the agonizingly long time it will take for a clinical trial to prove if a vaccine will work or not.

For Americans, some of the most frightening and vexing data were released at the start of the conference. A federal Centers for Disease Control and Prevention study of young gay men in six cities found that 3 out of 4 newly diagnosed with HIV had no idea they'd been infected. That included 90 percent of newly infected gay black men, 70 percent of newly infected Latinos and 60 percent of newly infected whites. For all racial groups, 60 percent of those surprised by the diagnosis perceived themselves to be "at low or very low risk of being infected."

Consequently, the face of the epidemic in the United States is changing. More than half of new infections are among blacks, who represent only 12 percent of the population. Although in the United States the disease remains primarily one of gay men, there are indications that the heterosexual spread of HIV is occurring among African Americans living in impoverished pockets of the Deep South.

Outside the United States and Western Europe, AIDS is overwhelmingly a disease spread by heterosexual contact, with young women and girls bearing a grossly disproportionate share of infections.

"This pandemic has become a war on women," said Stephen Lewis, United Nations special envoy for Africa.

There was some good news at this conference. A new AIDS drug called T-20 is proving safe and effective. It is the first of a new class of molecules called "fusion inhibitors" that block infection by interfering with the virus' ability to slip through pores on a blood cell's surface.

The problem is that T-20 is made of tiny, fragile proteins called peptides, which are expensive to make and must be injected with a needle, like insulin. Its high cost probably rules out T-20 as a drug for poor countries. U.S. doctors will probably reserve it for patients who have failed all other therapies.

Drugmaker Merck announced at the conference that early trials on humans are now under way for another new class of AIDS drug, known as an integrase inhibitor.

New AIDS drugs will almost certainly be ruinously expensive. But in the two years since the Durban, South Africa, conference, enormous strides have been made by those who seek cheaper versions of the older AIDS drugs for Africa and the developing world.

If the rhetoric of helping poor nations cope with AIDS is turned into action, it will require large-scale production of generic versions with high potency, so fewer pills must be taken per day. A huge increase in pill distribution and patient monitoring is also essential.

At Durban, reports of numerous pilot projects from Haiti to Malawi proved it can be done. The World Health Organization has set a goal of treating 3 million of the estimated 6 million needing antiviral drugs by 2005.

Similarly, proven AIDS prevention plans can be scaled up to change sexual behavior, provide condoms and distribute clean needles to drug addicts.

"The key is taking what we know works and taking it to scale," said Dr. Helene Gayle, director of HIV programs for the Bill and Melinda Gates Foundation, which released a blueprint at the conference of a plan to spend $4. 8 billion a year to avert 29 million infections.

The conference marked the public debut of the Global Fund to Fight AIDS, Tuberculosis and Malaria. Its goal is to raise $10 billion, primarily from rich countries, and distribute it for prevention and treatment programs in the developing world.

Two years from now, at the 15th International AIDS Conference in Bangkok, it will be abundantly clear whether there is real progress to report -- or whether the eloquence at Durban and Barcelona was "worse than useless."

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