Global AIDS Strategy May Prove Elusive 

After a string of victories in the long battle for lower-priced AIDS drugs in poor countries, health care experts, AIDS activists and major donors are facing what might be an even tougher challenge -- agreeing on a unified strategy to fight the pandemic.

"Now is when the hard part starts," said Jonathan Quick, head of the essential medicines division of the Geneva-based World Health Organization.

One debate among health experts and activists concerns whether to concentrate new resources on sophisticated treatment -- even at newly reduced prices -- to improve and prolong the lives of those in advanced stages of the disease, or on AIDS prevention, less expensive treatment of AIDS-related diseases and basic health programs aimed at stopping the disease's spread. More than 36 million people worldwide, the vast majority of them in sub-Saharan Africa, are infected with the human immunodeficiency virus (HIV), which causes AIDS.

Resolving this and other differences has taken on new urgency as donors have indicated willingness to provide substantial new funds for a global AIDS campaign. Uneasy about a lack of coordination, some donors, led by Britain's Department for International Development, this month issued what some described as an ultimatum to UNAIDS -- the consortium of U.N. agencies and the World Bank that oversees international AIDS efforts.
"They told us they want something put on the table," said a senior representative of a UNAIDS member. "They challenged us to have a common view."

At a meeting in London today, members of UNAIDS are scheduled to present a broad proposal for an international AIDS trust fund administered by both contributing and recipient countries. Participating in the meeting will be delegates from the United States, Britain and other members of the Group of 8; the Scandinavian countries and the Netherlands; and major private donors, including the Gates Foundation. Questions about how to spend the money would be decided by a joint governing committee formed of donors and aid recipients.

Getting various organizations and countries in line for a common approach has not been easy. The United Nations was thrown into an uproar late last month when Carol Bellamy, executive director of the U.N. Children's Fund, declared in a New York Times op-ed article that "UNICEF is prepared to step forward as the lead United Nations agency in the procurement of anti-retroviral drugs on behalf of individual countries."

That offer, reportedly not cleared with U.N. Secretary General Kofi Annan, upset WHO Director General Gro Harlem Brundtland, who saw it as a premature policy proposal, as well as a public challenge to WHO's primacy on AIDS. U.N. agencies in charge of development and population, among others, voiced disapproval, even as they, too, clamored to claim a share of money that is not yet available.

"They are sort of like sharks when there's blood in the water," said one close observer of the U.N. process. "There is money in the air."
Apart from the United Nations, others have proposed uses for new funding. Early this month, Harvard economist Jeffrey Sachs proposed establishment of a massive global AIDS fund to purchase anti-retroviral drugs for Africa. AIDS activists criticized the proposal, which would involve patent-holding pharmaceutical companies, for not favoring generic producers who have offered even cheaper prices.

Two days later, Microsoft founder Bill Gates called a news conference to warn that the treatment emphasis risked undermining prevention efforts. Gates's family foundation has given hundreds of millions of dollars to the international fight against AIDS -- the most of any single donor.
After years of being shamed by international pressure, the major pharmaceutical companies are now offering the three-drug anti-retroviral AIDS "cocktail" to some poor countries for less than a tenth of the developed world's $10,000 per patient per year starting price. Patent-busting generic producers have offered even lower prices.
Nongovernmental activists riding high after humbling the pharmaceutical industry on the price issue are calling on African governments to immediately start positioning themselves to provide the drugs. They point to Brazil, whose government produces its own anti-retrovirals and distributes them for free.

"I think the big decisions are not with the co-opted northern bureaucrats," said James Love of the Washington-based Consumer Project on Technology, a Ralph Nader-affiliated group that analyzes drug pricing. Love, who along with other activists advocates bypassing the big companies and going straight into import and production of generic drugs, called on African governments to "have the guts" to move forward with new authorizing laws.

But some have warned that such a strategy is ultimately counterproductive. They point out that Africa has neither the health infrastructure nor the personnel to support widespread use of the complicated treatment regime. There are currently 14 anti-retroviral drugs, patented by a handful of major companies, used in various combinations to compose the three-drug cocktail. New drugs will be needed as existing compounds become less effective, and many companies are involved in the search for a vaccine. 

The companies have argued that generic producers do not pay for research and development, and unless the world trade system can guarantee that future patents will be protected, research funds will be diminished.
Many Africans say they don't want to be pushed. "We wouldn't like any further delay" in caring for South Africa's more than 4 million HIV-infected people, Foreign Minister Nkosazana Dlamini-Zuma said last week as the major pharmaceutical companies withdrew from a three-year lawsuit to prevent her government from authorizing import and production of generic drugs. "But regulations have to be done before any laws can be implemented. We'll do what we can, not because of pressure, but because we think it's right."

Other Africans seemed caught between their desire to get to the front of the line for new funding and early resentment of the expected new onslaught of advice and dictates from developed countries. "A Ugandan colleague told me that the biggest epidemic lately is the epidemic of initiatives," one European aid official said.

The proposal that was to be outlined today in London leaves open the question of how much should be spent on drugs. UNAIDS has estimated that a minimum of $3 billion a year is needed to establish basic HIV prevention and non-anti-retroviral treatment in sub-Saharan Africa alone. Adding the anti-retroviral drugs, even at bargain-basement prices, would bring that total to about $10 billion.

International contributions currently total less than $1 billion a year. According to a General Accounting Office report released last month, Africa expenditures in the fight against HIV/AIDS in fiscal 2000 by the U.S. Agency for International Development -- the largest national donor -- totaled $114 million. The GAO report noted that amount "translated into per capita expenditures for 23 sub-Saharan African countries" ranging from $0.78 in Zambia to $0.03 in the Democratic Republic of Congo.

In its budget resolution passed this month, the Senate voted to increase total international AIDS spending to $1 billion over the next two years, although President Bush's budget proposes only a small fraction of that amount.
The European Union, as well as its individual members, and Japan have said they are prepared to provide major new funds. 

But nobody believes that $10 billion is a realistic expectation for the near or middle term, and choices will have to be made.

"The exclusive focus on the issue of patent rights and prices of drugs really has overridden the much more fundamental question of how you actually get these services out and how you blunt the epidemic itself," said one international health official who asked not to be identified. "If all of these resources go to treating the terminally ill, then we can in fact see this process turn into one that's really negative for the development of effective prevention programs.

"It's so politically incorrect to say, but we may have to sit by and just see these millions of [already infected] people die," he said, acknowledging that this was an option that would be considered unacceptable in the developed world. "Very few public health professionals are willing to take on the wrath of AIDS activists by saying that. But a whole lot of them talk about this in private."