Time to Deliver: Report on the Toronto AIDS Conference by Heidi Larson
Twenty-five years after the HIV virus was identified, and 16 international conferences later, the prevailing sentiment at the XVI International AIDS Conference, held in Toronto, was that the resources and technologies that have been mobilized are facing social and structural obstacles.
The theme of this year's conference, "Time to Deliver," was as much about the need for social change as it was about the need for vaccines, new prevention tools and improved treatment.
The need for increased access to anti-retroviral drugs and new "tools""particularly for prevention"were certainly in the headlines and addressed in a number of sessions, but there was a sobering consensus that drugs and "tools" alone would not address underlying structural barriers to AIDS prevention and treatment that need a much longer-term approach.
While acknowledging some significant achievements in the global response to AIDS, Dr. Peter Piot, executive director of UNAIDS, sent a strong message to the conference crowd that, "tragically, the end of AIDS is nowhere in sight." He stressed in his opening address to the conference that, despite some gains in research, "an AIDS response that is not as embedded in advancing social justice as in advancing science is doomed to failure."
The overall mood of this year's International AIDS conference was different.
For one thing, the spectacle was not activism: The centre-stage events were dominated by Bill Gates and Bill Clinton. It was a strange irony that two white, wealthy, powerful men took the spotlight, given the growing acknowledgement that gender, race and economic inequities are posing significant obstacles to defeating the AIDS pandemic.
As one panellist said angrily at a session on 25 years of community responses, "one single individual should not have $500 million (and more) to be giving away," referring to the donation the Gates Foundation recently gave to the Global Fund for AIDS, TB and Malaria. Such inequities, he argued, are a big part of the problem.
Gregg Gonsalves, coordinator of the regional treatment literacy and advocacy program at the AIDS and Rights Alliance of South Africa, spoke out at the plenary session on "25 Years of AIDS: Reflecting Back and Looking Forward," pointing to what he perceived as a negative trend in the global response.
"I think we've created a vast infrastructure," he said, "privileging generalised international responsibility instead of specific, local political accountability, privileging technical experience and skills over local knowledge, and promoting development or assistance instead of social change."
"It's no coincidence", Gonsalves said, capturing a sentiment that swelled across the various sessions and events around the conference, "that these multiple epidemics exist among marginalised communities around the globe: among the poor, women, drug users, sex workers, gay men, prisoners, migrants. The social, economic and political policies that create this marginalisation in the first place also push us into the path of oncoming epidemics. Yet we place our hopes in programs that narrowly construct risk around individual behaviour or in some new technology that will save us."
Bill Gates, lent a different sobering thought, pointing to the fact that even with the increasing availability of more affordable combination drugs, there is not enough money to pay for the millions who will be needing them in the future at the rate the pandemic is growing. While his focus remains on new technologies, he prioritised prevention technologies, calling for acceleration in research and development for prevention "tools" such as vaccines, microbicides and oral prevention drugs.
Gates noted that the Foundation has made stopping AIDS their top priority and acknowledged the importance of involving women in the AIDS response, making a strong call for microbicide development to "put the power to prevent HIV in the hands of women."
As Gates stressed, "No matter where she lives, who she is, or what she does, a woman should never need her partner's permission to save her own life."
Positive or Negative Social Change?
The Consortium defines "social change" as a shift chosen by the people involved"or that is catalysed by the needs of a community"that alters normative and structural elements of their community with long-term impact across many groups.
When social change is positive, it is a fundamental and continual reshuffling of power relationships that helps all the members of a community voice their views, access resources, make decisions, improve their lives and strengthen the community's ability to change and renew itself.
At the conference, in hallways and in sessions, there was an angry sense that some of the social change occurring is negative and obstructing realisation of the years of knowledge and resources that have been mobilised.
Particular frustration was boiling around growing neoconservatism and the Bush administration's criteria for AIDS funding, perceived by many as an entry point to push Christian fundamentalist values at the expense of the AIDS pandemic.
The "ABC"""Abstinence, Be faithful, use a Condom" approach to AIDS prevention was particularly under attack, with sharp criticism of the United States government's perceived overemphasis on abstinence alone and the purse strings attached to it. Some debates were around whether the ABC approach started in the United States or in Africa and how much PEPFAR funding is truly tied to abstinence only education. The whole notion of abstinence education seemed ludicrous to many conference participants and speakers.
In a plenary on "Taking Stock: Current Changes in the Global Response," Canadian activist Louise Binder called for comprehensive prevention strategies, including targeted education, availability of adequate and affordable male and female condoms, harm reduction programs for drug users, decriminalisation of the sex trade, an end to violence against women and girls, and microbicide research. While she called for a "comprehensive" prevention strategy, she saw no room for the U.S.-promoted ABC approach. "What a prevention strategy absolutely cannot include is the ill-conceived, counterproductive and dangerous policy of ABC.
"To my mind," she continued, "this is the most blatant example of policymaking by men who know nothing of the context and reality of the lived experience of women and girls."
"While we are grateful for prevention funding," Binder said, "donors including PEPFAR must remove all strings, including the abstinence until marriage condition, from their funding approach.
"The strings are ropes around women's necks. And they are killing us."
One panel focused on "ABC in Africa: What is the Evidence?" gave little evidence to support ABC. Kevin O'Reilly from WHO reported on a joint study with Hopkins School of Public Health that found, "in general, minimal impact on abstinence" as a result of the ABC programmes.
Another study on the attempt to promote "zero grazing" in Kisumu, Kenya, spoke to the need for strategies other than abstinence-only, quoting local key informant comments such as, "Abstinence is incompatible with our local traditions. Most of our customs end with sex. Whether planting seasons or harvest, everything ends with sex."
Promoting "abstinence only" and prohibiting safe-needle exchange programs for drug users are two of the many examples of actions against the evidence. As activists chanted when scientist Tony Fauci took the podium at one of the Conference plenaries, "Tony, tell George the evidence can't be ignored. Condoms, needles and the rest, we need more than just a test. Tony, tell George the evidence can't be ignored."
The frustration around social and political obstacles to using proven interventions was pervasive. When Lancet editor Richard Horton, moderating a plenary, asked Peter Piot "What keeps you awake at night?" Piot responded, "It's only AIDS that keeps me awake at night". What keeps me also awake at night and what keeps me angry is that where we have evidence that's not being used. That goes from harm-reduction programs to promotion of condoms.
"And what also keeps me up at night is the fact that we're blind to the drivers of this epidemic. If we're not going to deal with the gender issues"some of the social injustice and inequality issues, we have no chance of stopping this epidemic even with a vaccine, because the vaccine will not go where it's needed."
The need for social change was clear at many levels, whether addressing gender inequality, overcoming judgment and providing proven interventions such as needle exchange programs to marginalized populations, or talking straight about sex.
Despite such renewed or new attention at this AIDS conference to prevention " along with the recognition that the structural and social drivers behind the AIDS pandemic must be more aggressively addressed"none of us believes the road ahead will be smooth.
While the calls for a social change approach to fighting AIDS is encouraging, we must recognise that the social and structural context in which we are working has become far more difficult during the past 25 years of the pandemic.
Hopefully by the time of the next AIDS conference--Mexico City in 2008"social change "technology" will have also advanced.