Michel Kazatchkine of ANRS and Joep Lange of the International AIDS Society have welcomed delegates to the opening session of the 2nd IAS Conference on HIV Pathogenesis and Treatment in Paris, France, on Sunday 13 July. The meeting is co-sponsored by the US DHHS, NIH and CDC and a number of pharmaceutical companies. A series of reports will appear on aidsmap throughout the coming week.
The meeting, two years after the first, held in Buenos Aires, Argentina, combines basic science and a focus on treatment access in developing countries, which are strongly represented among presenters and those attending. 1850 abstracts were received, of which 190 will be presented orally and 900 as posters.
The closing ceremony, on Wednesday, is due to be addressed by the French President, Jacques Chirac, and by EU Commission President Romano Prodi. It will also to be integrated with the closing ceremony of a donors' meeting for the Global Fund to fight AIDS, TB and Malaria, which is taking place in a nearby hotel on the same day.
Bertrand Delanoë, the openly gay Mayor of Paris, welcomed the conference with an acknowledgement of the hope given by Paris-based researchers to people with HIV and AIDS worldwide. However, the unequal access to the results of this research across the world was quite unacceptable. As part of the response to this, he called on the European Union to commit a billion euros a year to the Global Fund to fight AIDS, TB and Malaria.
The former Brazilian President, Fernando Henrique Cardoso, spoke on building a state-civil society alliance to fight AIDS, based on Brazil's experience. To counter stigma, it was essential that "the victims became protagonists" and the role of people with AIDS had been central to the response to this public health crisis.
The adoption as public policy since 1996 of free and universal access to "life saving ARV drugs" had been immensely important, but stemmed from earlier discussion of HIV, AIDS and human rights which had helped the Brazilian government set a national framework for policy development as early as 1988. Openness, flexibility, multisectoral work and openness to community initiatives had been underpinned by key legal rulings on questions of employment and insurance. A strong inter-party consensus had been forged around the response to AIDS to secure it against changes of regime in the country.
"The 500 million dollar annual costs of ARV treatment had been more than compensated" by the reduction in hospitalisation and the gains for the lives of the people treated. Lowering the price of the drugs had been essential, including the promotion of local production of ARVs. The case brought by the USA against Brazil at the WTO over production of generic drugs had been withdrawn in June 2001 on the opening day of the UN General Assembly Special Session on HIV/AIDS, which he had no doubt was the result of international public opinion.
In Brazil, the epidemic has not gone away, and is increasingly affecting younger people, poorer people, and women rather than men. Those affected included women whose only sexual partner was their husband, which showed the inadequacy of policies based solely on promoting sexual abstinence and faithfulness. Condom promotion remained an essential component of the response to AIDS.
In Africa, political commitment and mobilisation would be the key to getting effective international responses to the epidemic in that continent. Brazil is now helping Mozambique, in particular, and other lusophone countries in their responses to HIV and AIDS. (Mozambique has recently adopted a radical plan for large scale access to ARV treatment, with support from former US President Bill Clinton in negotiating with international donors.)
Jean-Paul Mouatti, economist working with ANRS, spoke on access to treatment in developing countries. He argued that ARV treatment can be a rational choice in developing countries, even though it is obvious that standards of care will differ in some respects with differing levels of resources.
What is not acceptable, he argued, is a double-standard of thinking, where arguments that are not accepted as ruling out treatment in the North are widely used as reasons why treatment should not be provided in the South. For example, concerns about non-adherence to treatment and the risks of HIV resistance to treatment.
The economic rationale for scaling up treatment was discussed under six headings.
Differential pricing can be obtained: marginal cost of production is relatively low, and differential pricing can be introduced without jeopardising profits in wealthier markets. Currently, this correlates with volumes sold rather than ability to pay.
Private interests in intellectual property rights must be balanced against larger concerns of public health. Patent protection is essential as an incentive for research and development but does raise prices where there are monopolies. The introduction of generic competition has been central to the reduction of prices of ARVs.
Prevention and care complementary, not alternatives to each other. Access to HAART boosts the effectiveness of prevention, rather than removing the incentives for it, although the increased life expectancy of people with HIV may increase the exposure of people to transmission.
Cost-effectiveness of treatment can be demonstrated. Those who argue that prevention is always more cost effective than treatment generally ignore the fact that in the absence of an effective prevention technology such as a vaccine, the cost-effectiveness of prevention is subject to a law of diminishing returns. There is therefore a limit to the amount of money which can be spent on prevention, before the benefit from additional spending is matched by spending on treatment.
In Brazil and other middle-income countries, the reduced cost of hospitalisation totally offset the cost of ARV treatment, however this may not apply in poorer countries. Yet, when other costs - to people with HIV and to the society as a whole - are taken properly into account, the balance shifts in favour of treatment.
In the developed world, life expectancy of a gain of a year in return for health care spending of around twice the annual national income per person is seen as something which should be introduced without argument. On this basis, ARV treatment can be justified in many more countries than it is currently provided in.
World Bank studies for India challenge the idea that ARV is unaffordable, especially if a positive impact on prevention efforts is taken into account.
The macro-economic impact of HIV had been seriously underestimated by techniques that had treated the impact merely as a loss of productive labour but ignored the role of young adults as parents and teachers in promoting the development of a whole society. A recent World Bank study of South Africa argues that without effective action, that country will turn into a low-income country (like the present-day Congo) "in four generations".
International estimates call for $8 to $10 billion dollars a year, split between international and national funds, to mount an effective global treatment access programme. There are legitimate concerns that HAART may have effect of transferring resources from the poor to the less poor. He argued that equity concerns should bias international and public funding towards providing treatment to poorer sections of society. The alternative to concerted action would be 'antiretroviral anarchy' which would benefit no-one.
A Burundian doctor, Marie-Josée Mbuzenakamwe, spoke on behalf of the global community of people affected by AIDS and HIV. Of 90,000 people in Burundi who needed treatment now, only around 1,000 were actually receiving it. The G8 countries, including the USA, France and UK, had yet to match their statements in favour of international action against HIV with resources to match.
The session concluded with a performance by the Parisian gay men's choir, in a gloriously multicoloured array of shirts, dedicated to all who had died in the course of the epidemic.