AIDS 2008 in Mexico City: New Focus on High Risk Behavior in all Countries

Mexico City, August 4, 2008: The biannual international AIDS conference opened last night with great fanfare here in the capital of one of the countries that has the greatest success in combating AIDS. To me, the biggest surprise is the noticeable increase in attention to the need to assure prevention coverage among those at highest risk, including sex workers, men who have sex with men, and other groups at high risk. Since the Stockholm conference in 1988, which was the fourth ever held, I have attended almost all of these international conferences and a substantial number of the regional conferences in between. During the early conferences, most attention was on HIV prevention with only the most specialized medical researchers and activists from the rich countries talking about treatment. Then as triple-drug therapy was developed and improved, attention turned towards extending access to poor countries. In 1997, when Martha Ainsworth and I launched our book on the economics of AIDS at the African AIDS conference in Abidjan, effective treatment still cost $20,000 or more per patient-year with only about a 50% price reduction in Thailand and Brazil. So our book's major message was that efficiency, equity and public health arguments all compellingly converged to support government action to prevent HIV infection, especially among those most likely to contract and transmit the epidemic. Our message on treatment was one of horizontal equity. Countries should subsidize AIDS treatment to the same degree they subsidized the treatment of equally expensive chronic adult illness. These two messages were and have been very unpopular. Indeed, ACTUP and other activist groups sometimes marched through the auditorium chanting hostile slogans when I was on the list of speakers. Even the World Bank turned its back on the first of our messages. Now, 20 years after I attended my first AIDS conference and 11 years after the launch of Confronting AIDS, I think I detect a movement towards both of our 1997 messages. On treatment, after worldwide efforts have substantially lowered treatment costs and expanded access, there are now calls (including here at the Mexico conference) for horizontal equity between AIDS and other diseases within developing country health sectors, but the more dramatic change is on prevention.At a satellite meeting yesterday here before the conference opening, the Gates-funded Avahan project session presented their marked expansion over the last four years of prevention services to millions of sex workers in India. This is the country where a decade ago a Minister of Health declared that "in India AIDS is not sexually transmitted." Since then the Government of India has significantly expanded access to prevention for millions of sex workers. The Avahan project builds on and greatly intensifies the government's experience, adding the management and marketing techniques from the world of business (see Sebastian Mallaby's book The World's Banker for part of the story of how the World Bank might have contributed to the change in India's stance). The presentation of how Avahan assures virtually 100% coverage of all sex workers in the states where they work was the most impressive presentation on prevention implementation I have seen in 20 years. A remaining frustration with the Gates-funded effort is the low priority they have placed on rigorous evaluation. Perhaps a business-orientation among Gates' and Avahan's top management has blinded them to the international public good benefits of rigorous evaluation. For whatever reason, Avahan collected no baseline data and no data on comparison districts which had not (or not yet) received their intervention. Lacking these two essential ingredients, the evaluation they promise is underway will be severely handicapped. A second sign of change was a satellite meeting entitled "Know your epidemic, Know your response" hosted jointly by the World Bank and UNAIDS' GAMET (Global Monitoring & Evaluation Team) working group. The presentation by Juliana Victor-Ahuchogu on the state of the epidemic in Western Africa contrasted dramatically with previous UNAIDS/World Bank characterizations of the epidemic and the needed response in this region which have ignored high-risk groups in favor of funding community wide efforts.A third sign of change was during this morning's plenary addresses, which opened the conference. For example, the first item on Alex Coutinho's rousing call for action was, “It is unacceptable that fewer than 10 percent of people in high risk groups in developing countries have access to prevention services." Why have economic and public health arguments finally begun to have traction after 20 years? Everyone has a theory. Mine is that the rapidly expanding number of people in poor countries with an entitlement to lifetime AIDS treatment has the decision-makers finally willing to focus on what works instead of what feels good. Since many more lives could be saved by prevention than by treatment – at much lower cost, this cause of change is indictment of the international public health decision making apparatus. One wonders if that apparatus will fail the world as badly on the next epidemic – the one of pandemic flu for example.