San Francisco Chronicle - Sunday, July 11, 2004
Sabin Russell, Chronicle Medical Writer

A blend of political theater, medical research and social science, these AIDS conferences focus world attention on the gravity and scope of the epidemic and help to set the course of future efforts to contain it.

"This is the biggest epidemic in human history, by any standard,'' said Dr. Peter Piot, executive director of UNAIDS, the Joint United Nations Program on HIV/AIDS in Geneva. He said it will take $12 billion a year to fight the epidemic in 2005. This year's six-day meeting is likely to be dominated by discussions -- and protests -- surrounding the question of how to bring the costly combinations of antiretroviral drugs to millions of AIDS patients in poor countries.

The theme of the Bangkok conference is "Access for All," posing a direct challenge to wealthy nations to come up with strategies to provide AIDS drugs to the poor. There are 38 million people infected with HIV, the virus that causes AIDS, and nearly all of them eventually will need antiretroviral drugs to survive.

Because of its setting in Bangkok, the conference also will highlight the problem of AIDS in Asia. An estimated 7.4 million people across the giant continent are living with HIV. There were 1.1 million new infections last year in Asia alone, according to UNAIDS.

India and China, home to 2.2 billion people, are both coping with smoldering epidemics that represent less than 1 percent of their populations but add up to millions of infected people.

The conference is drawing important Asian political leaders. Chinese Premier Wen Jiabao, Thai Prime Minister Thaksin Shinawatra and India's Congress Party leader Sonia Gandhi -- who would have been named her country's prime minister had she not turned the job down -- will address the delegates.

Newly released UNAIDS estimates put HIV infections in India at 5.1 million. According to Dr. Richard Feachem, executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, India stands at a "critical juncture" that could determine the course of the epidemic.

While most health experts doubt that HIV will explode in Asia as it did in Africa -- in sub-Saharan Africa, it's estimated that 7.5 percent of adults between the ages of 15 and 49 are HIV positive -- just a small increase in the percentage of those infected in this most populous region on Earth would create a vast human catastrophe.

Thailand itself has been a showcase for successful HIV prevention. Heavy promotion of condom use in this country's commercial sex industry has reduced annual infections to an estimated 21,000 from 140,000 in 1991. But a new report by the United Nations Development Programme warns of "a possible new wave of infections" due to growing complacency.

It found that only 20 percent of young sexually active Thais are now using condoms consistently. Half of all injection drug users are now infected, compared with 30 percent 10 years ago. Infection rates among gay men have risen to 17 percent from 4 percent in the same time frame.

"I think we have lost the momentum," said former Thailand Prime Minister Anand Panyarachun, in an interview published in the U.N. report.

That may not be the kind of attention Thailand was seeking when it agreed to host the session, but it is an example of how the conference itself can spotlight problems.

"The fact that the meeting is taking place in Asia will bring the focus once again on the developing world,'' said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases.

AIDS researchers no longer use the conferences to release their most important findings. There has been enormous progress in scientific understanding of HIV, but discoveries now tend to come in incremental steps, rather than major breakthroughs. "We've been studying this disease for a long time, and the low-hanging fruit has already been picked,'' Fauci said.

But he said the international conferences still provide a valuable opportunity for the global AIDS community to take stock of its successes and failures in fighting the epidemic.

Fauci will be leading a sharply curtailed U.S. government presence at this year's conference. Citing budget constraints, the Bush administration decided that only 50 scientists from the Department of Health and Human Services could travel to the Bangkok session. That compares with 236 who were sent to the last AIDS conference in Barcelona.

During the Barcelona conference, Health and Human Services Secretary Tommy Thompson was famously booed off the stage by rowdy AIDS activists, and critics of the Bush administration see the cutbacks as retaliation.

"It's outrageous that they would limit access to their scientific experts at such an important meeting,'' said Dr. Paul Zeitz, executive director of the Global AIDS Alliance in Washington, D.C. "They are undermining the whole global response to the epidemic.''

Bill Pierce, a spokesman for Thompson, acknowledged that many government researchers were displeased with the decision. However, he said the administration was in fact being flexible with a new policy that limits delegations to 40 government scientists at international conferences.

"It's a perfectly human reaction, but I would even call it a bit of whining on their part,'' Pierce said.

The United States spent $3.6 million on the Barcelona conference. The budget for Bangkok has been trimmed to $500,000. Randall Tobias, a former Eli Lilly executive who is heading President Bush's $15 billion overseas AIDS initiative, will play a prominent role at the Bangkok conference, with numerous speaking engagements to describe the U.S. program that will pay for AIDS drugs and prevention programs in the focus countries.

Although Bush temporarily hushed critics of his AIDS policies when he announced his plan during his State of the Union address in January 2003, the program is now under attack because of the time taken to implement it.

Opponents of the president's approach also complain that Tobias has put up barriers to purchasing the lowest-cost drugs made by Indian pharmaceutical- makers in favor of more expensive, branded products made by American and European firms.

Like a mountain that creates its own weather, the AIDS conferences, scheduled every two years, tend to generate surges of publicity about AIDS, particularly as it affects the developing world, and initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, and Bush's emergency plan, have often followed.

Although the International AIDS Conference tends to break no ground in science, the session has powerful symbolic importance, said Drew Altman, president of the Kaiser Family Foundation in Menlo Park.

"The event has a catalytic impact on groups and government organizations working in the field,'' he said. "Everyone gears up an initiative so they have something to announce there.'' Global spotlight

With a theme of "Access for All," the 15th International AIDS Conference is expected to focus attention on a couple of major problems:

-- How to provide expensive anti-retroviral drugs to millions of patients in poor countries.

-- How to stop the spread of AIDS in Asia, where 7.4 million people have the disease.

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