As the 19th AIDS conference drew to a close last week, I left Washington DC with mixed feelings of hope and despair. Advances in science gave me hope for the day we can cure HIV, yet pharmaceutical companies’ fierce fight for control over existing and emerging technologies remind me of the battles ahead. I was optimistic about the commitments made by Jim Kim, the new president of the World Bank, to invest in health systems that work for the poor, but worried that declines in donor funding will slow down progress. Above all, I was energised by the activists in the North and South who have for decades demanded action. Yet I felt frustrated at the lack of high-level commitment to address prejudice, stigma and discrimination. Here I reflect on my three greatest hopes and the three battles in the struggle to end AIDS.
REASONS FOR HOPE
1. THE SCIENCE IS MOVING TOWARDS ENDING AIDS
Great strides have been made by the scientific community and the goalposts have clearly shifted – instead of “fighting AIDS” we now talk about “ending AIDS”. Scientific advances in prevention and treatment have saved lives and turned the deadly disease into a chronic condition. Medicines for those who develop resistance or side effects are more effective than ever before and scientists are on track to find a cure. There are new lab techniques to test and closely monitor people living with HIV in order to improve treatment. The evidence is clear that treatment is an effective method of prevention and new studies show that early treatment results in far better health outcomes. Therefore, there is a strong recommendation to start treatment as soon as a person is diagnosed.
2. BOLD COMMITMENT FROM THE WORLD BANK
In his opening remarks, the new World Bank President Jim Yong Kim stated that the World Bank would play a pivotal role in ending AIDS by focusing on what it does best: building health systems. I strongly believe that investing in health systems (including infrastructure, health workers, drug supply chains, and health information systems) is a critical prerequisite to ending AIDS. To achieve Jim Kim’s vision I hope that the World Bank will increase its support to developing countries (with help from other donors) to invest in free public health care and support community-based care. Access to free treatment has been critical in the struggle against HIV and we must learn from this lesson.
3. THE POWER OF ADVOCATES
In his speech Jim Kim reminded delegates that at every point in the history of the epidemic, it was the HIV activists who have led the way – putting pressure on politicians and drug companies to act. The 2012 conference brought together the veteran fighters who broke the silence on HIV decades ago and the young activists who are driving the movement today, demanding their rights and creating new societal norms in difficult contexts, such as the Middle East.
THE THREE BATTLES
1. PHARMA: THE DE JA VU PHENOMENON
As new medicines come on stream, there are signs that pharmaceutical companies are taking the same path they took decades ago when the first ARVs became available and advocates fought tirelessly to demand access to new treatment. Now as then, the pharmaceutical companies want to control of the Intellectual Property for these medicines in order to maintain absolute control of the market. For example, companies such as Johnson & Johnson and Merck are refusing to license their medicines to mechanisms like the Medicine Patent Pool (MPP), an initiative which would enable widespread generic competition and hence expand access to medicines. Some companies have cynically claimed that they are refusing to work with the MPP because they want to ensure patient adherence – as if a patent monopoly would allow them to monitor every patient! Others claim that the market for their products is so small that it cannot bear more than 2 to 3 producers: the company itself and those it decides to provide voluntary licenses. Such licenses tend to have very limited geographical coverage and their standards are not open for public scrutiny (unlike the MPP license which has transparent policy and is mandated to negotiate wide geographical coverage). Besides, generics companies, which understand the dynamics of the generics market, are best placed to determine whether it is worth producing a generic version after the entry of 2 or 3 generics producers.
2. DECREASED FUNDING
There is no doubt that donor funding for HIV and health is decreasing. The global financial crisis has been blamed for this decrease. Yet it is not possible to end AIDS without investment in massive scale-up of prevention and treatment efforts, especially via the Global Fund. Last year, the Global Fund cancelled Round 11 causing difficulties in programmes in a number of countries such as Malawi and the Democratic Republic of Congo.
This year the Global Fund is discussing a new funding model to replace the Round system. We activists are concerned that the “financial crisis” will dictate a model that dampens country demand. Allocating budgets to countries, as has been proposed at the Global Fund, will induce “self-censorship” whereby countries go for what they can buy with their allocated funds rather than what they actually need. I hope that the Global Fund board rejects such top-down approaches and maintains the principle that it prides itself on: country ownership. To enable the serious work to end AIDS to continue donors will also need to fulfil their funding commitments.
3. WOMEN AND VULNERABLE GROUPS
The initiative to have a HIV free generation via stopping mother-to-child transmission is to be applauded. Yet the lack of commitment of donors and governments to treating women before and after birth is appalling. Also, the lack of high-level political commitment from country leaders to tackle prejudice, stigma and discrimination threatens to undermine the goal of ending AIDS.
In a nutshell, the science, the advocates, and the new World Bank give me reason for hope. It’s now time for pharma, donors, and governments to play their part. Activists will not wait for long to act!
Mohga M Kamal-Yanni works for Oxfam as a Senior Health & HIV Policy Advisor