San Francisco Chronicle - Friday, August 18, 2006
Sabin Russell, Chronicle Medical Writer

This week, as he quietly strode the hallways at the 16th International AIDS Conference here in another Canadian city, the number of people in low- and middle-income nations taking those drugs approaches 1.7 million.

After a week of watching passionate speeches, angry demonstrations and the dry display of thousands of scientific slides, delegates to this AIDS conference will depart today having marked great gains against the epidemic. Today, nearly a quarter of the people in the world who need these antiviral drugs to survive are getting them.

But activists like Sawyer still see the glass as three-quarters empty, and they worry about the challenges to come. "Sustaining what progress we've made is unlikely," he said. The battle against AIDS is still short of cash, short of a cure.

"Many people living with AIDS (still) can't get access when they need it," Sawyer said. Despite a $500 million gift from the Bill & Melinda Gates Foundation, he noted, the Global Fund to Fight AIDS, Tuberculosis and Malaria is half a billion dollars short of the $3 billion it needs by November to fully fund existing programs and pay for a new round of grants.

Breathtaking strides have been made against the epidemic in the past decade, but this conference is haunted by the same question Sawyer raises: whether the progress and commitment can continue.

"Sustainability is key," said Dr. Mark Wainberg, director of the McGill University AIDS center in Montreal and co-director of the weeklong conference, which drew 24,000 delegates from around the world. "We need to sustain the political pressure, and sustain the rollout of drugs."

It was Bill Gates, on the opening day of the conference, who first raised the question, with what he called the "harsh mathematics of this epidemic." There are nearly 40 million people in the world who are living with HIV and will eventually need the medications. Nearly 5 million people are newly infected each year. "Treatment without prevention," Gates said, "is unsustainable."

Dr. Richard Feachem, executive director of the Global Fund, acknowledged in an interview that the organization will need $500 million by its November board meeting to meet its goals. "As always, I am cautiously optimistic," said Feachem, who will leave the Global Fund in March.

Feachem noted that it was the industrialized nations themselves that set the goal of universal access to AIDS drugs by 2010. "They know that, without a fully funded Global Fund, universal access is pie in the sky," he said.

Dr. Kevin DeCock, recently named director of HIV/AIDS programs for the World Health Organization, likened the recent progress in expanding access to antiviral drugs as harvesting low-hanging fruit. "The fragile health system is not limitlessly going to be able to take on more cases," he said.

DeCock is disturbed that children have been shortchanged in the current distribution of drugs. An estimated 800,000 children under 15 need AIDS drugs, but fewer than 100,000 of them are receiving therapy. "We must conclude that scale-up has so far left children behind," he said.

The task ahead for expanding coverage of AIDS drugs is similarly limited by the weaknesses of the global health system meant to deliver them. Throughout the conference, demonstrators repeatedly disrupted speeches to highlight the mounting human resource crisis in poor countries.

"AIDS thrives where there are no health care providers," said Dr. Jennifer Cohn of Health GAP, which called on the United States to pump $650 million into a new initiative to train and retain health care workers in Africa. According to the World Health Organization, sub-Saharan Africa alone is short 1.5 million doctors, nurses, midwives and community health workers.

AIDS itself contributes to the health care worker shortage. In South Africa, 1 in 6 health care workers are HIV-positive.

Dr. Mark Dybul, newly named as Global AIDS Coordinator and director of President Bush's overseas AIDS program, said health care worker training is a crucial part of the administration's initiative, accounting for 30 percent of spending -- with a goal of getting 1.7 million new workers in place.

Another issue that threatens the sustainability of the current commitment to treat the world's poorest AIDS patients is the limitations of the drugs themselves. The French medical charity Doctors without Borders, which has been treating large numbers of patients in South Africa for six years, found that 16 percent of patients needed to switch medications to more expensive "second-line therapies" within four years. But the newer branded drugs can cost seven times as much as the older medicines, which are now largely produced by generic pharmaceutical companies in India and China.

The French group contends that the key to keeping second-line treatments affordable will be to enforce international agreements that allow countries to sidestep patents and produce low-cost generic copies -- the same strategy that made the older AIDS drugs affordable.

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