Battle against HIV must be waged on medical and political fronts

By CHARLES ARTHUR


It would be hard enough if HIV - human immunodeficiency virus - was all that people were fighting against.

For as Lisa Price, policy manager for the Terence Higgins Trust, the best-known British Aids charity, says, it is hard to resist thinking of it as an intelligent and calculating enemy: "This is one of the smartest viruses that people have ever seen. It changes all the time."

In the time it took to read that paragraph, three more people somewhere in the world became infected with HIV. The virus' spread is not slowing.

Both deaths and new infections reached a record last year, at 3 million and 5 million, respectively, more than 20 years after it was first identified, and there is still no sign of either a cure or a vaccine.

Instead, because HIV is so tough to combat medically, and because it exploits the tiniest weakness in the body's own defences, and mutates to confound attempts to kill it, it has set the First and Third World Governments at odds over the anti-retroviral drugs needed to treat it. But every time it seems it is understood how to tackle it, the world's scientists and politicians discover that it is more complicated still.

To begin with, some people thought that HIV affected only homosexuals - they were wrong. Some scientists suggested that HIV did not cause Aids. They were wrong, too, though some people have stuck to the same line - most recently the South African President Thabo Mbeki, who insists he has never known anyone who has died of Aids.

In a sense he is right. Just as nobody ever dies of old age, instead, it is the opportunistic infections that HIV enables which kill you. In fact, most people with Aids finally die of pneumonia.

It has even prompted a split within the Catholic Church over the Vatican's insistence that condoms spread, rather than restrict, the spread of HIV.

For such a deadly virus, it's surprisingly divisive.

While the World Health Organisation yesterday unveiled a scheme for the annual World Aids Day that it dubs "3 in 5" - to provide the latest anti-retroviral drugs to 3 million people by the end of 2005 - United Nations Secretary-General Kofi Annan has spoken of his frustration at trying to get help to the sick.

More than 42 million people are infected with HIV worldwide, of whom 26.6 million live in sub-Saharan Africa.

The largest number of infections is in South Africa, where about five million, or one in ten citizens, are HIV-positive. And a combination of unprotected sex, and drug abuse, is fuelling an explosion of the epidemic around the world - in India, China, Indonesia, Papua New Guinea, Vietnam, Russia, Ukraine, Estonia and Latvia.

Since you started reading this article, 20 people have become infected with HIV.

Yet in the West, being HIV-positive is no longer the death sentence that it was in, say, 1983, when there was little chance of preventing the infection turning into Aids, at which point a patient would typically live for less than a year before dying.

Now, although there is still neither cure nor vaccine, new drugs mean HIV has become a disease that one can live with.

The drugs bring unpleasant side-effects, such as nausea, occasional hallucinations, and in some cases a strange redistribution of fat around the body. But you can live with them - perhaps indefinitely.

In Africa, however, those treatments have been too rarely available. The WHO estimates that 4.2 million people need anti-retrovirals in sub-Saharan Africa, but only 50,000 get supplies.

Annan thinks many political leaders still do not care enough to fight the disease, which has killed 28 million people since it was first reported among homosexual men in the United States in 1981.

"I am not winning the war because I don't think the leaders of the world are engaged enough," he said. "I feel angry, I feel distressed, I feel helpless ... to live in a world where we have the means ... to be able to help all these patients, what is lacking is the political will."

And the problem is that only one thing, the use of condoms, dramatically reduces the spread of HIV. Needle swapping programmes for intravenous drug users also work, but on a smaller scale.

And only one thing - the use of modern drugs such as anti-retroviral therapy (often called "triple-therapy cocktails") - makes it possible to live with HIV without the disease progressing.

Given those facts, you might think that the world's leaders would focus on them both, and support their spread to everyone who could be affected. You'd be wrong. And since you started reading this article, 30 people have become infected with HIV.

The Catholic Church, which has millions of followers around the world in Aids-hit countries, came under fire from its own ranks at the weekend when a pressure group called Catholics for a Free Choice said it would begin an advertising campaign saying "Good Catholics Use Condoms" as "a direct challenge to the cardinals and bishops who have recently claimed that condoms were helping to spread HIV/Aids".

The Vatican supported this bizarre claim in October, saying that condoms had tiny holes which allowed the virus to pass through - and so to use them would encourage its spread. The WHO angrily called the advice "incorrect" and "dangerous". Catholics for a Free Choice called the Vatican's policy "a disaster".

The lack of availability of treatments for those who are infected could be called a disaster, too - though that has not resulted from any dogma. Instead, it grows from a fundamental dispute between the giant pharmaceuticals companies, which are the only organisations able to fund rapid and effective research to produce new therapies, and the Governments of the countries which need them. Western Governments have tried to please both sides, and generally failed.

The pharmaceuticals companies want to price the drugs to fund the increasingly expensive research to develop the next generation - and perhaps find a crucial chink in HIV's armour that might lead to a vaccine, or a cure.

But African countries especially cannot afford those prices, and have sought ways around the companies' patents, to make "generic" versions of the drugs - exactly the same chemicals, but without the brand name. That led to threats of trade wars.

In October former US President Bill Clinton set up a deal for four drugs makers in South Africa and India to make generic versions of anti-retroviral treatments, for about a quarter of the price of the patented version, and nearly half of the previous lower price.

Dr Bernard Pecoul of the medical charity Medecins Sans Frontieres' Access to Essential Medicines campaign welcomed the deal.

"One pill, twice a day at this reduced price is exactly what is needed to rapidly expand the numbers of people receiving anti-retroviral treatment in developing countries," he said. "With this announcement, the WHO's '3 by 5' objective becomes much more feasible."

Feasible, yes. The larger questions are whether it will happen.

Beyond that debate, the search for better treatments goes on. "We've been saying that a vaccine is five to ten years away for 15 years," said Price. "But it is looking more realistic that we will [have one] in the next five years."

Surely then the arguments may begin anew over who should fund the vaccine's provision. And since you began reading this article, more than 40 people have been infected with HIV and more than 20 others have died from Aids.


- INDEPENDENT