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Of elephants and AIDS

BANGKOK, Thailand
THE INTERNATIONAL AIDS conference in this Asian capital last week mobilized scientists, drug salesmen, activists, politicians, actors, statesmen, medical doctors, and spin doctors to deal with a disease that is killing 8,000 people a day. Then one non-AIDS death caught the attention of the 20,000 delegates: A Bangkok man was stomped to death by an elephant. First reports identified the guilty elephant as one of 20 who had performed in an opening day parade at the conference center, but it was later found to have been a different beast. With AIDS, there is no mistaking what is killing millions.

More than two decades into the worst pandemic in 600 years, nothing better demonstrates how the virus still has the upper hand than the "3 by 5" goal of the World Health Organization -- 3 million patients under treatment with AIDS drugs in developing countries by 2005. With just 400,000 people now being treated, there is little chance the goal will be reached. Even if it were, it would be more than matched by the 5 million new infections every year, including 40,000 in the United States.

AIDS is winning, and it is just getting started in India, China, and Russia.

As bleak as the figures are, delegates here pointed to hopeful developments since the last AIDS conference in Barcelona in 2002. Late last year the premier of China, Wen Jiabao, shook hands with an AIDS patient in a move to bring the disease out of the shadows in that country. Earlier in 2003, President Bush pledged $15 billion over five years for international AIDS assistance.

That single act would have made the president a hero here if he had sent much of the money to the Global Fund for AIDS, Malaria, and Tuberculosis. Instead, most US AIDS money last year went to bilateral programs in 15 African, Caribbean, and Asian countries.

Credit to Congress
Last year Bush proposed just $200 million for the Global Fund, a fraction of Europe's contribution. Congress, to its credit, appropriated $550 million for it, roughly one-third of its total receipts. For 2005, Bush has again called for just $200 million. Congress should at least match last year's total.

The Bush administration has also been criticized for trying to negotiate bilateral trade deals that stop countries from developing generic versions of the next generation of antiretroviral drugs produced by brand-name pharmaceutical companies to replace ones that the virus becomes resistant to. US officials also lose some of the good will that $15 billion should yield by periodically minimizing the importance of condoms -- for example, suggesting that condoms are supportable only for prostitutes or women forced into sex trafficking. Since the United States is by far the biggest single donor of condoms to developing countries -- it will hand out 550 million this year, far more than the highest number under President Clinton -- this is mostly rhetoric to appease Bush's right-wing base, which would like to see the United States supporting just abstinence or, in married couples, fidelity.

In an interview last week, Bush's AIDS coordinator, Randall Tobias, said, "We're trying to use every tool that's available." He meant there is a role for all elements of the "ABC approach" to AIDS prevention first popularized in Uganda: abstinence, being faithful, and condoms.

Abstinence is not a realistic option for a young woman in sub-Saharan Africa who has been married off to an older man who engages in risky sex practices. But UN Secretary General Kofi Annan in his opening-day address used the word abstain in calling on men to be more responsible in their sexual behavior and to free themselves of cultural stereotypes and expectations about female subordination in the home.

Dr. Ernest Darkoh, manager of Botswana's AIDS program, also talked about the failure of health officials to take on men's role in transmitting the virus. "I don't hear people saying, 'Do something about the men,' " he said.

More freedom for women
Even the ABC approach is too limited for a virus as frustratingly invulnerable to a vaccine as HIV has proven itself. The word vaccine was not even mentioned during the official opening speeches. Scientists are said to be five to seven years away from developing a vaginal microbicide that women could use to protect themselves from men who don't heed the message of sexual responsibility and refuse to use condoms. Beyond that line of defense, women -- and society at large -- would benefit if more resources were invested in their education. This would free them from the economic imperative of early marriage to older, prosperous men or prostitution, with the great risk that it carries of HIV infection.

During the conference, these and other issues were debated against a backdrop of the parading elephants, young Thai women modeling dresses made of condoms, and Nelson Mandela speaking eloquently of the TB that afflicted him in prison. He called for more funds for treatment of TB, an opportunistic infection that flourishes when HIV patients' immune systems are weakened. In the same exhibition hall where drug maker Roche touted the virtues of its $16,000-to-$20,000 per year Fuzeon treatment for failing AIDS patients who have run out of options, a 16-foot motorized condom blimp floated overhead, advertising an HIV prevention measure that costs pennies to manufacture.

There is talk of ending or scaling down the biennial AIDS conferences. This would be a mistake. World leaders long ignored this deeply stigmatized disease, which in its initial stages lies so quietly that many are unaware they carry the virus and could be infecting others. There is much to be gained from so many victims and fighters of AIDS meeting in loud, and sometimes rude, circus-like gatherings to confront a disease that owes much of its lethality to silence.

DONALD MacGILLIS
 

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