Wall Street Journal - May 20, 2003
Michael Waldholz

This week, Congress is expected to send President Bush a historic bill unleashing $15 billion over five years to fight AIDS in 12 hard-hit African nations and two Caribbean countries. The commitment, by most reckonings, is tardy. But it comes at a critical juncture for the HIV/AIDS pandemic: There is growing evidence that public-health officials finally have developed a realistic strategy that, if adequately funded, could restrain the calamitous spread of AIDS.

By the year 2010, 45 million more people will be infected by HIV, according to the World Health Organization. But 29 million of those infections can be averted "if proven prevention strategies, used in combination, are dramatically scaled up," argues a report by a blue-chip panel of public-health experts that received modest attention when it was released two weeks ago. Funded in large part by the William and Melinda Gates Foundation and the Kaiser Family Foundation, the report, by the Global HIV Prevention Working Group, reviews the state of this disease through the developing world. Going country-by-country, it details exactly what is being done, what needs to happen and how much the changes would cost.

None of the report's specific recommendations are alone surprising or new. They include such long-established ideas as aggressively promoting the use of condoms and encouraging people to delay the onset of sexual activity and limit the number of sexual partners. Some of the recommendations are as controversial as ever, such as distributing clean needles to intravenous-drug users. And some simply make sense, such as ensuring that certain blood supplies are screened for the virus and that counseling and education programs get the funding they need to warn people about the disease and its dangers.

But for the first time, health officials from the United Nations, WHO, and numerous other respected public and private organizations have produced a document ("Access to HIV Prevention: Closing the Gap") that lays out a strategy to use these means to curtail the AIDS epidemic. Despite years of research, innumerable international meetings and previous declarations, no other report has provided such a clear roadmap for attainable success.

As recently as 2000, at the international AIDS meeting in Durban, South Africa, a unified approach seemed a distant dream. South Africa's government, which sets an important tone for others in sub-Sahara Africa, was still arguing that HIV might not be the cause of AIDS, and that expensive drug cocktails that were revolutionizing care in the U.S. and Europe would cripple their budgets. Major pharmaceutical companies countered calls for price discounts by contending that few doctors or their patients in developing countries were savvy enough to make proper use of the medicines.

But in the three years since then, a great deal has changed. Health experts can now document more than just a handful of regional success stories. Uganda has significantly curtailed its infection rate through a national program in which modes of transmission of HIV/AIDS -- and ways to avoid it -- have become an open and integral part of the national conversation.

By providing near-universal access to low-cost drugs, produced in generic form by its own drug industry, Brazil has shown that its people can adhere to difficult daily dosing regimens just as well as folks in wealthier nations. Indeed, partly in response to competition from generic drug makers in India, Brazil and elsewhere, the giant drug makers have reduced the annual cost of therapy by 90% or more in developing countries, making it possible for donors, local employers and even some governments to begin buying the life-enhancing antivirals.

For years, AIDS advocates argued that making drugs accessible was crucial to preventing new infections. Without the hope of treatment, they contended, many people infected with HIV wouldn't seek to get tested. As a result, infected mothers unwittingly spread the disease to their newborns, and HIV-positive people infected sex partners. Health experts now have produced research showing that drug availability does make people more willing to participate in prevention programs.

The new report says that scaling up prevention will be expensive. But it also provides a realistic budget showing exactly where and how new money needs to be spent. Global funding for HIV in low- and middle-income nations amounted to $1.9 billion in 2002. That's one third of the $5.7 billion needed annually by 2005. Right off, much of the money should provide drugs that prevent mother-to-child transmission of the virus, and to implement national education programs such as the one in Uganda. An additional $200 million a year is needed to buy an adequate supply of free or low-cost condoms, a prevention technique that succeeds wherever it has been implemented.

Restraining HIV/AIDS will require a prolonged financial and political commitment, a commitment that substantially dwarfs the current effort to check the spread of SARS. But what SARS illustrates is that, despite many claims to the contrary, a world-wide and concerted public-health war to control a disease can be mobilized, if the will to do so is mustered.

The medical community was able to respond to SARS quickly partly because of advances in technology and new cross-boundary networks set up to fight the flu and bio-terrorism. If the respiratory ailment had struck just a few years earlier, that same level of international cooperation or infectious-disease expertise might not have been in place. But now it is.

Between this newly established intellectual infrastructure, and all too many years of learning from AIDS, there is a growing sense that the time to battle back this disease has come. The Bush administration proposal to spend $15 billion reflects this realization.

The Working Group report notes that money alone won't slow the march of HIV/AIDS. Local governments will need to know that the money is contingent on their showing that they can use the funding effectively. But at a time when 14,000 people a day are being infected by HIV, with many countries' economies and their political stability at risk, and with little hope that the virus will be contained anytime soon by a vaccine, the Working Group report provides the best chance for slowing a disease that, more than any other contagious ailment -- including SARS -- threatens the planet's survival.

Write to Mike Waldholz at mike.waldholz@wsj.com.

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