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The XVII International AIDS Conference (AIDS 2008)
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XVII International AIDS Conference Mexico City Notebook: Day One

An Interview With Science Magazine Correspondent Jon Cohen

August 1, 2008

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Jackie Judd: Jon Cohen, a correspondent for Science magazine, I am so happy to have you back.

Jon Cohen: Thrilled to be back.

Jackie Judd: You always are with us at these conferences. So, what are your expectations from this one?

Jon Cohen: Well, I think that the world has come to a point not where it recognizes that all of the effort that has gone into making treatment available to people has overshadowed prevention. This is the point in time where prevention is going to move into the spotlight.

Jackie Judd: In what ways?

Jon Cohen: Well, the world has made great progress on getting anti-HIV drugs to people who are in need of them and also to pregnant women who are infected, but it has not made great progress in preventing new infections. I think there is going to be a lot of soul searching about what has not worked. In part, it will be about, here are things we know work that are not being applied. Then part of it is going to be, what should we be testing to see if these possibilities might work? But when you look around the world, there are not a lot of places that can jump up and down and say, boy, have we really knocked the virus back, in terms of new infection. There are a lot of places that can jump up and down and say, we have really delivered a lot of treatment and a lot of prevention to pregnant women.

Jackie Judd: As I recall, in Toronto two years ago, there was some of this same kind of discussion, the tension between prevention and treatment. Is it going to be the same set of conversations we are going to hear, or has it moved forward?

Jon Cohen: I think it has moved forward. I think it probably is the trickiest thing that people are going to wrestle with here, because a few years ago the treatment rush had really just started. It was 2006, but remember that this whole drive to get treatment out really only started in 2002 and 2003. So, it was still early days in 2006. And now what we are seeing in 2008 is that the countries at the front of this -- and I mean low and middle-income countries -- are saying, we cannot sustain this. We have too many new infections. When you have five people becoming infected for every two people who go on treatment, how can you keep it up? The bank does not have that much money. I think there is a stark realization from these countries at the front that they are in trouble.

Jackie Judd: Now, do you think we are going to be hearing this debate in the public at this conference, or are these the kinds of conversations that get played out behind closed doors between groups of people who only have this opportunity once every two years to be at the table together?

Jon Cohen: I think you are going to hear it loudly again and again and again from the leaders because everyone realizes that this is not sustainable and that as much progress as has been made -- we have gotten to 3 million people in low and middle-income countries now receiving treatment. This is up from zero. You have to celebrate that and you have to celebrate the number of babies being born to infected mothers who are not infected. But put the cork back in the champagne. The new infection rate is so high in so many places that countries that are paying attention are saying, whoa, yes, we have done a lot, but they are openly talking about it because they need new ideas, they want more funding, and they want to be able to address the things that they know work that they have not been able to address.

Jackie Judd: Are we going to hear this week, is your expectation that there will be new ideas in science? Will there be any big announcements?

Jon Cohen: This meeting has been badmouthed for so many years. It has been called a circus and people just say all these really nasty things, scientists in particular, hardcore scientists. I always learn something here that is cutting-edge science. I do not go in knowing what it is going to be because it is not obvious. The prevention stuff is obviously going to be a big topic. The science stuff -- I am going to find the really new stuff in the posters. I am going to find it when somebody goes to the microphone to challenge something that someone said. There is nothing in the program that makes me say right now, boy, that is a scientific session that is going to blow minds. But when we talk a week later, I bet I will have a laundry list of things I did not know and that I think most of the scientific community will find interesting.

Jackie Judd: Well, I will come back at you with that question as we talk every day through the conference. I want now, though, to kind of turn the corner and talk about a remarkable series of articles that you have spent many months reporting that have appeared in Science magazine. The main article was about following the money, following the money now going into HIV/AIDS. What were the big take-away messages that you got?

Jon Cohen: There has been this surge of funding that has occurred over the past decade. We have gone from about $450 million going to low and middle-income countries to $10 billion. That is over a 20-fold increase. It is an astonishing amount of money. What I wanted to look at was, number one, why did this occur? Why did people start reaching deeply into their pockets to help the low and middle-income countries, and why did those countries themselves start ponying up? How has that money been used wisely? Where has it not been used wisely? Indeed, where has there been corruption? And what are the disparities?

One of the things I did was an analysis of the hardest hit countries in the world, 33 countries. I asked how much money they have received from the four biggest donors, and then how many HIV-infected people do they have in each country? And then looking at how many dollars they have received per HIV-infected person. I found great disparities. This goes directly against the ethos that everyone, everywhere deserves anti-HIV treatment regardless of their circumstances.

Jackie Judd: You wrote in there, what you said was this has created a new division of haves and have-nots within the developing world.

Jon Cohen: Yes, that is what surprised me the most. If you turn back the clock to 2000 to Durban, the international conference being held there in this moment, where the world realizes, hey, most of the HIV-infected people in the world do not have access to these great treatments that are working. We have to change the way we do business. And then you see that there is this shift that is remarkable toward helping these people, but it hits the wall and it hits the wall because several countries around the world are really fragile. They have bad governments, they have civil wars, they have corruption.

Jackie Judd: And so the donors will not go in.

Jon Cohen: The donors do not want to go in and in the case of the Global Fund, which is one of the biggest donors, it says to countries, you come to us and tell us what you need. They cannot write a proposal that is that compelling because they do not have the civil society or they do not have the government. They do not have all the pieces that the Global Fund needs to say, yes, this can work. Remember, the Global Fund is performance based. They give you a chunk of money, then two years later they look at you and they say, what did you do with it? These countries, like Zimbabwe, struggle with this. The Central African Republic struggles with this. The Democratic Republic of Congo struggles with it. These are all hard-hit countries that need help.

Jackie Judd: Now, in the article, you interviewed the man who created AidSpan, which is this independent watchdog group over the Global Fund, and what he talked to you about was a kind of mentoring program so that these countries that are not getting any dollars can learn how to get them. Has that idea progressed at all?

Jon Cohen: Well, Bernard Rivers is his name and he just floated the idea in April, so I think it is too new an idea to know. He is a very provocative thinker and he speaks to everyone on the ground. He really does a great job of that. I think that it is an idea that deserves serious consideration because these countries clearly need to help. What he was suggesting was, okay, you cannot go in and write the proposals for them, but you can help them to see how to put the components together and actually write a good proposal, too. The writing matters, too.

Jackie Judd: You also quoted an economist who criticized the efforts of the big funders because they have not taken the next step, he says, in figuring out how they all fit together?

Jon Cohen: It is a big problem. It is a problem of global architecture. That is the language they use in global health. There is not architecture. There is no blueprint that says, okay, you take care of the right flank and I will do the left.

Jackie Judd: So that one complements the other.

Jon Cohen: Exactly. The way they do it is they each have their own programs. They look over to the right and they look over at the left, but they do not sit down at the table and say, you know what? The Democratic Republic of Congo is in trouble. What are we going to do? There is nobody sitting on top of the globe, looking down and saying with this stentorian voice, this is what we must do. There is nobody there. There is nobody running the show. Most of the gaps get filled in. I think we have to be fair. It basically works, but when you see the number of countries -- I think I found that 10-percent of the HIV-infected people in the world live in these countries that receive very little money, very little assistance. That is a lot of people. It is nearly 4 million people.

Jackie Judd: So, after this very extensive reporting trip -- it was several months -- do you come away from it, Jon, feeling optimistic, pessimistic, depressed about what you will find when you go back out there a year from now?

Jon Cohen: I started covering HIV/AIDS seriously about 20 years ago. I have seen so much progress in ways that I never imagined that I largely end up feeling optimistic, in large part because it used to be that I would go visit a hard-hit country and just go to a hospital and see hundreds of people dying. That still exists, but I am not seeing that as much. And I am even going to countries like Botswana where they have 87-percent of the people in need of treatment receiving treatment. That is astonishing. In 2002, Botswana was the first country in Sub-Saharan Africa to offer free treatment to everyone. So, I am really optimistic about that side of it, but I am a journalist and I am a professional skeptic. The pessimism is there and it depresses me, too, when I see things that obviously could be done to help and are not being done.

Jackie Judd: Okay, thank you.

Jon Cohen: Thank you.

Jackie Judd: Jon Cohen, correspondent for Science magazine, I will talk to you again soon.

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