Once, AIDS was the global leveller. Now, those from affluent countries are being treated while prevention is the only real hope of the poor. Laurice Taitz reports from the 13th International AIDS Conference in Durban THE world came to Africa this week, and for the first time in the history of the AIDS epidemic, the developing countries took centre stage. Instead of the mind-boggling statistics and abstract scientific rallies between First-World Ivy-leaguers that have characterised previous AIDS conferences, the agenda was shaped by the needs of the developing world and the voices of those who have been most affected by this modern plague. "For the first time ever there is massive world attention on the conference and AIDS in Africa, because it is being held here in South Africa," said Dr Peter Piot, the Belgian head of UNAIDS, the umbrella AIDS agency based in Geneva. In many ways the 13th International AIDS Conference, held in Durban, was a collision of two worlds - the world where scientific advances are geared to making HIV/AIDS a chronic but treatable condition and the other, where it's a wasting disease that brings untold suffering and certain death. At venues across the city, people from around the globe spoke of a disease that has taken hold of people's lives. "At the clinic they often say there is nothing we can do," said Mzokhana Mdevu, a 29year-old man from northern KwaZulu-Natal who is HIV-positive and whose story features in a photographic exhibition, Positive Lives. "It's not fair. I am unhappy that people overseas can get better treatment while here in South Africa we have to die." At a meeting on treatment access, Dr Daniel Berman from the Nobel prize-winning organisation Medecins Sans Frontieres, which provides medical care in developing countries, said: "Our physicians are enraged. They are becoming hospice workers because there are no drugs to treat people." In short, the drugs are where the disease is not. It was not always this way. Addressing the opening session on Monday, Ronald Bayer, of Columbia University, New York, spoke of the global inequalities that made infectious diseases treatable in the richest countries and untreatable in the poorest. "No longer was it the limits of medicine that defined the situation. Rather, it was the inability to afford treatments because of resources," he said. From the strident calls of activists on the steps of Durban's city hall to the restrained scientific proceedings in the International Conference Centre, the same things were being said. "Morally, the state of affairs is unacceptable. It constitutes an outrage against the most basic conceptions of international justice, of human dignity, against the very idea of human solidarity," said Bayer. The message was clear. For a long time, developed countries have paid scant attention to the needs of their less fortunate counterparts. And when they have, their own priorities have shaped their response, rather than the priorities of those they seek to assist. This has often undermined the ability of the world's poorest nations to take control of their fate. In many ways, the recent offers of free drugs by some pharmaceutical companies are part of this way of thinking, because they delay access to sustainable cheaper drugs. For instance, Pfizer's recent offer to the SA government of a free drug called fluconazole came with strings attached - it was restricted to use for just one HIV-related infection, which affects only 8% of sufferers. Other "free" drug offers come with time limits that would mean people being turned away in mid-treatment. Until now, the world's governments have accepted that treatment is the preserve of the wealthy while prevention is the only chance of the poor. Piot said: "This conference has made it irreversible that prevention and care have to be combined." People living with AIDS in countries like South Africa have been robbed of hope and dignity by governments who have resigned themselves to focusing only on the uninfected. Nevertheless, a shift has started to take place. During the week, many deals were struck and partnerships announced. Handshakes sealed promises of millions of dollars for AIDS research and developing treatment and care in Africa. Under the glare of the spotlight, tricky political decisions had to be made about what is needed and what is at stake - and where. For the Botswana government, which accepted a partnership agreement to improve the provision of treatment and care with the multinational drug company Merck and the Bill and Melinda Gates Foundation (worth 50-million, or around R350-million, over five years), the answer is clear. Unlike South Africa, pride has not stood in the way of Botswana, one of the wealthiest developing nations, declaring an emergency and accepting outside assistance. But even scientists can be political opportunists, as Piot indicated when he cautioned that the deals struck were positive but not without problems. "Everyone knows there are hundreds of journalists here so that is also, I guess, the reason why some of the top scientists in the world have come. Before this, when did the AIDS conference make the front pages of the New York Times and Washington Post?" As the week drew on, the call for improved access to drugs became the defining issue of the conference - from the march organised by the Treatment Action Campaign on Sunday to the heartfelt plea made by HIV-positive 11-year-old Nkosi Johnson and to High Court Judge Edwin Cameron, who received rapturous applause when he spoke of the gulf between rich and poor. "I speak of the gap not as an observer or as a commentator, but with intimate personal knowledge. I am an African. "I am living with AIDS. I therefore count as one among the forbidding statistics of AIDS in Africa. "Amid the poverty of Africa, I stand before you because I am able to purchase health and vigour. I am here because I can afford to pay for life itself." "Frankly," said Piot, "the issue of access to care and treatment was not on the agenda before." In many ways it had been a landmark event, said Dr Ayanda Ntsaluba, the Director General of the South African Department of Health. "It has been evident even in the scientific presentations where options for developing countries to deal with these inequalities have been a focus. "We knew when we bid to host this event that we weren't only offering South Africa as a physical change of venue." On the walls of the Durban Art Gallery hung quilts made to commemorate the lives of those who have died of AIDS. On one was stitched the words "We cared for you", over a background of 64 small panels containing the names and ages -- mostly between 25 and 35 -- of the dead: M. Ntshaba, N. Ntshaba, T. Mabaso, S. Mzolo . . . The pressure is mounting from those already infected for governments and the world to take action. Ugandan Winnie SsanyaSseruma, who was diagnosed as HIV positive 13 years ago and now lives in Europe, where she has access to drug treatment, knows that the drugs offer no cure. What they do offer is options. "I cannot tell you I have come to terms with HIV," she said. "What I can tell you is that I have learned to live with it." Amid the medical breakthroughs, hype and the excitement of 12 000 people gathered in one place, there was the everpresent reminder of the real reason for this mega-meeting: with every hesitation, someone is dying.
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