• Cold Feet and Timid Steps Forward
• $100 Million for India
• Tenofovir? You're Soaking in It!

Cold Feet and Timid Steps Forward

The World Health Organization announced a goal of treating three million people in the developing world with antiretroviral therapy by 2005. As 2002 comes to a close, plans for reaching this goal proceed at a snail's pace. Sometime in December the UN agencies and their partners will announce the formation of The International HIV Treatment Access Coalition (ITAC), which is supposed to be the vehicle for coordinating the effort to expand access to ART. GMHC and others have been pushing the UN agencies working on scaling-up ART to do more and come up with a "roadmap" for scale-up for World AIDS Day 2002. This roadmap would have several main features:

1. A discussion of the international infrastructures needed for scale-up and a commitment to fund and create these components. If we are to scale-up treatment, we cannot expect procurement, human resources development, resource mobilization, technical assistance, laboratory testing, monitoring and evaluation, to be done on a laissez-faire, country-by-country basis. The Global Fund is realizing this fact for its own grantee countries and starting to think about some trans-national mechanisms to facilitate and coordinate some of these activities.

2. A discussion of some standardized planning, budgeting and implementation tools for national ART programs and a commitment to creating these tools. These could include training manuals, operational, technical, planning and budgeting guidelines, and templates for setting up recording and reporting systems.

3. A timeline and milestones for accomplishment of these international and national level components.

The establishment of ITAC is not a substitute for developing this roadmap as soon as possible. Right now, the main obstacle to hammering out a plan for scale-up is a failure of nerve and leadership by all involved, from the UN organizations, to development agencies and governments in the North, to the mainstream NGOs. Once there is a real plan for scale-up, these institutions will have no excuse but to move forward with expanding access to ART, with all its risks and challenges. It's as if they've been chased to the edge of a cliff and have suddenly frozen in fear of the leap they have to make to get safely to the other side. No one denies the true enormity of what is being proposed or the difficulties facing us, but the true risk here is for the millions of people living with HIV around the world who face certain death unless action begins now.

$100 Million for India

The Melinda and Bill Gates Foundation announced a new initiative to slow the transmission of HIV in India, raise awareness and fight stigma. In particular, the program will focus on mobile populations such as truck drivers and migrant laborers who are considered to be at higher risk of acquiring and spreading HIV/AIDS. The grant, however, makes no provision for treating the estimated 4 million people in India already infected.

Focusing on "containment" of HIV within targeted communities, some critics say, implies a lack of concern for the people of those communities. They fear that this persistent blind spot means that such prevention-only approaches are doomed to fail.

The proposals to address stigma in India have met a better reception. In a country where discrimination is a way of life, breaking through the fear and denial will be a major challenge.

Tenofovir? You're Soaking in It!

In a separate announcement, the Gates Foundation said it will fund a proposed multinational clinical trial to evaluate the use of tenofovir as a novel approach to HIV prevention in sexually active adults in resource-poor countries with high HIV incidence. The study will assess the acceptability of, and adherence to, a regimen of one tenofovir tablet taken once daily as prophylaxis. If shown to be safe and effective in this setting, tenofovir could be adopted as an HIV prevention method equally accessible by men or women.

The ethical implications of providing antiretroviral drug to uninfected people while dying people go without and the impact of pre-exposure prophylaxis on the behavior of trial participants deserve further discussion.