June 24, 2001

U.N. Hopes AIDS Summit Will Turn Talk Into Action

By MAGGIE FARLEY from the Los Angeles Times



UNITED NATIONS - Two years ago, many leaders of the nations hardest hit by AIDS didn't even want to admit that the disease existed in their countries. Now, as the fight against the epidemic gathers momentum, not only are they willing to talk, but they also finally may be poised to act.

This week's three-day global conference on AIDS and HIV, which will bring 3,000 dignitaries to the United Nations, could provide the opportunity.

"The magnitude of the crisis is finally beginning to sink in," said Secretary-General Kofi Annan, who recently declared the issue of AIDS "a personal priority."

"At no time in the past 20 years in dealing with this growing catastrophe has there been such a sense of collective resolve and collective possibility," he said. "I believe this year will go down in history as the year we turned the tide."

Although U.N. summits are known more for talk than for action, the conference, which will begin Monday, caps a series of recent meaningful shifts indicating that the campaign against the disease is moving forward at a pace long hoped for by the 36 million people living today with HIV, the human immunodeficiency virus that causes AIDS.

"In the last four months, it has been startling how much has moved, almost like the dam broke," said Stephen Lewis, the new U.N. special envoy for AIDS in Africa.

In fact, 20 years after the discovery of a medical curiosity among gay American men, the disease has only recently been transformed into a global issue.

The turning points include the engagement of the United Nations and the Security Council; the creation of a multibillion-dollar Global Fund for AIDS and Health; the drop in drug prices, making once out-of-reach treatments suddenly possible; and new strategies to finance solutions that treat the AIDS battle as an investment in global stability.

When Richard Holbrooke, as U.S. ambassador to the United Nations, proposed a special Security Council session on AIDS in Africa 1 1/2 years ago, people told him that he was wasting his time. They said that it was a health issue, not a security issue, and that an international strategy to curb the spread of AIDS would interfere with nations' sovereignty. Russia, Ukraine and China threatened to boycott the session.

But after visiting AIDS treatment centers in nine African countries, Holbrooke said, it became clear to him that AIDS was more than a health crisis. The disease attacked the stability and social fabric of countries, he argued, and so it rightfully belonged in a security forum.

"It just seemed obvious that you've got to take AIDS out of the category of the disease of the moment and put it in another category," he said in a recent interview. "The fact of the matter is that AIDS is uniquely dangerous."

In typical fashion, he charged forward, eventually winning China's support and Russia's and Ukraine's grudging agreement to sit in the meeting, if not participate.

The Security Council's Jan. 10, 2000, meeting--the first session of the new century--is widely cited as a watershed moment in the globalization of the AIDS battle.

"A turning point was when it was discussed in the Security Council," said Dr. Peter Piot, the executive director of the UNAIDS agency. That debate "transformed AIDS from a medical curiosity to a global problem with implications for security," he said, and put it on the political agenda of many countries.

Suddenly, national leaders who had denied that AIDS was a problem were forced to confront it--and were offered more help to do so.

Now Holbrooke hopes to galvanize business leaders as well. After leaving the U.N. post in January, he became the president of the Global Business Council on HIV/AIDS. He aims to get multinational companies to help with prevention and treatment for their employees and their communities in the hardest-hit countries.

"Business has not done a fraction of what should be done," he said. "But they are realizing that AIDS has a direct economic cost to them and that they have a social responsibility to address it."

Annan admits that the U.N. came too late to the issue of AIDS. But as the crisis intensified and proposals to deal with it multiplied without any coordination, Annan declared in April that he would make the fight against the pandemic his "personal priority."

Now that it has his full attention, the statesman from Ghana has proved to be a symbolic leader and an important intermediary. He is perhaps the only world leader who can persuade the sometimes adversarial players--drug companies and African leaders, rich countries and needy ones--to work together to curb the AIDS crisis. His involvement has helped accelerate efforts that needed direction and backing.

The soft-spoken U.N. chief is a master at subtle pressure. In 1999, he began the long process of persuading pharmaceutical companies to provide AIDS treatments at lower prices to developing nations, adding his diplomatic gravitas to the guerrilla tactics of activist groups such as ACT UP and the moral weight of advocacy groups such as Doctors Without Borders.

Annan used the same tactics with members of the business community, telling them that if they didn't ante up now to help fight the disease that was decimating their work force and future markets, it would cost them much more later.

And then he gave them a way to do it.

At an AIDS conference in Nigeria in April, Annan announced the creation of the global fund to intensify the attack on the disease. The world needs to spend as much as $10 billion annually, he said--five times the current amount--to effectively stem the spread of AIDS. The U.N. chief extracted commitments from African leaders to greatly increase their countries' spending on health programs and infrastructure to show donors that their money would be used effectively.

Yet the dynamic leader's biggest battle is against the bureaucratic reputation of his own organization: His personal vision, the global fund, nearly died last month because donors didn't trust the U.N. to run it.

Bernard Pecoul, a physician and director of Doctors Without Borders, couldn't stand to see any more unnecessary deaths. In developing countries, the group's patients were dying of diseases that were easily treatable in the West--malaria, pneumonia, diarrhea--because the drugs were too expensive. And increasingly, they were dying of the infections that come with AIDS.

While the Paris-based group had long pressed for access to less expensive medicines for poor countries, the AIDS epidemic made the need much more urgent. In 1999, the year Doctors Without Borders won the Nobel Peace Prize, Pecoul intensified the campaign and heightened the focus on AIDS treatments whose $10,000 yearly price tag put them out of reach of nearly all of the group's patients.

The real turning point came in February, when India's largest drug maker, Cipla, approached Doctors Without Borders with a deal. Cipla would provide anti-AIDS therapy to the group for $350 per person a year. The firm could afford to give the drugs for little more than the price it cost to make them because in India, pharmaceutical patents protect only the manufacturing process, not the actual drug.

"We said, 'Great,' " Pecoul recalled, "even though it is not our role to procure and distribute drugs. It is much more the mandate of U.N. agencies, but they had approached the U.N. for months without any feedback. So Cipla came to us."

Within a few weeks, Western pharmaceutical companies followed suit, offering drastic reductions on AIDS treatments--and, in some cases, giving them away. Critics say that the corporations are merely offering selective discounts for a limited period to prime new markets and that the price and lack of infrastructure for delivery of the medicines still leave treatment out of reach for all but about 1% of the people who need it in Africa.

Others fear that the emphasis on treatment will swing the focus away from the less expensive and more effective alternative: prevention.

But the sudden availability of even limited treatment is a psychological milestone in the AIDS battle. Because an estimated 90% of those infected don't know that they have HIV, the prospect of treatment is an important incentive for testing and thus limiting the virus' spread, experts say.

With a model that has newly energized the AIDS battle, private aid groups have found a new way to put their money where others' mouths are.

Some call it "venture philanthropy," in which aid programs are run like a business and money is considered an investment that should yield a return, not to be given, spent and forgotten. This streamlined approach has changed the language of public health: Suddenly, directors of U.N. agencies are talking like investment bankers instead of bureaucrats. And suddenly, things are getting done.

This year, Annan was searching for a way to coordinate the myriad AIDS programs and proposals--and to mobilize more money to back them--when Bill Gates dropped in. Gates and his team suggested that Annan look at the immunization program they had sponsored, the Global Alliance for Vaccines and Immunizations, or GAVI.

The program was designed by the Bill and Melinda Gates Foundation to attract money from "investors" interested in quantifiable results. GAVI has input and administrative help from U.N. agencies, but it is otherwise separate.

With its small public-private board, efficient grant-making system and in-country follow-up, GAVI has been able to roll out successful vaccine programs across Africa in less than a year.

In fact, it wasn't until the U.N. declared that GAVI was a model for Annan's Global Fund that donations began to roll in.

"We bring all the stakeholders around a table--with everyone united by a common purpose," said Gordon Perkin, the director of the global health program at the Gates Foundation and one of the creators of the model. Donors and recipients devise strategies together about how to use the grants, and if the recipients don't reach their targets, they may not receive more money.