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- AIDS in the 1980s: Overcoming Fear and Denial
- AIDS in the 1990s: Success and Complacency
- Global Mobilization at the Millennium
- Future Prospects
Since the acquired immune deficiency syndrome (AIDS) pandemic began in the early 1980s, the world has achieved great successes in education, prevention, and treatment, yet it remains threatened by growing complacency toward the most deadly plague humanity has ever faced. Since the disease was first recognized in 1981, science has learned a great deal about what it came to call AIDS. A pathologic state resulting from infection by the human immunodeficiency virus (HIV), the disease has no symptoms of its own. HIV disrupts the immune system of its host, making the host vulnerable to other diseases. Carriers of HIV are infectious long before they display symptoms. Transmission of HIV occurs through the exchange of bodily fluids, blood products (including blood itself and plasma), and congenitally or perinatally from mother to child.
When HIV first emerged as a unique and identifiable disease, it was prevalent mostly within the homosexual community, leading some to characterize it as the “gay plague.” Within a few years, however, it had spread to the heterosexual population. Heterosexual transmission predominates today, particularly in the developing world, most notably in sub-Saharan Africa but also in East and South Asia and Latin America. In sub-Saharan Africa, the spread of the disease has been aided—paradoxically—by both civil war, which displaces people, and peace, which increases commerce and worker mobility through migrant and seasonal work. The danger of disease transmission among drug users has led to the development of needle exchange programs in many locations, though opponents claim such programs encourage drug use. Lack of understanding of how the disease spread in the early years also resulted in many blood banks becoming infected, leading to disproportionate rates of HIV among hemophiliacs.
Although a cure for AIDS remains elusive, preventive measures have been effective in many circumstances. Current treatments, while costly, have made AIDS a generally chronic rather than deadly disease and have helped curb transmission in some instances. As a result, infection rates in the developed world have peaked and begun to decline. This has led to some complacency in fighting the disease, which continues to ravage the developing world even as globalization and security concerns have helped bring the issue back into the spotlight. As of 2007, almost 40 million people worldwide were infected. In short, the nature of the AIDS threat in the United States has changed fundamentally since its emergence, but it remains a critical issue for the twenty-first century.
AIDS in the 1980s: Overcoming Fear and Denial
In the early 1980s, American doctors began to notice a sudden appearance of rare cancers and strains of pneumonia with unusual frequency in young men. Normally, only the elderly succumbed to these diseases, but the immune systems of these men were too weak to fight them off. Medical researchers began working to understand the nature of the agent and how it was spread. Initially, victims were confined to the gay communities of New York, Los Angeles, and San Francisco. By 1982, however, the disease had spread to other cities and to others populations, namely drug users and women. It became clear that the infection was spread by sexual contact and through the blood. Cases also began to emerge in other countries, the first being Denmark and Haiti. Over the next few years, researchers around the globe worked to uncover the existence, structure, and behavior of HIV.
In the United States, the emergence of AIDS coincided with the Reagan administration’s budget cuts, war on drugs, and return to “family values.” Because early AIDS victims were disproportionately drawn from fringe communities, the government was slow to respond. It soon became clear AIDS could not be dismissed as a “gay plague,” but the media emphasized the at-risk groups epidemiologists darkly called the “Four-H Club”: homosexuals, Haitians, heroin addicts, and hemophiliacs (some added hookers to the list).
As medical research on the disease was accumulating, the public remained ignorant. AIDS was getting a great deal of press, but the media generally failed to inform the public about its exact nature. Hysteria and scapegoating were common. Individuals who tested positive for HIV faced overt discrimination—such as denial of access to public facilities or loss of employment—and social ostracism.
A diagnostic test was made available in 1985, but there was little incentive to be tested until a treatment with real prospects of success existed. In the meantime, patients could do little to fight the disease and risked the exposure and social stigma of being a carrier. It was not until the actor Rock Hudson died of AIDS in October 1985 that President Reagan made his first public comments on AIDS. And not until mid-1987 did Reagan make his first major speech on the disease, acknowledging its seriousness as a public health problem.
Shortly thereafter, at the Third International Conference on AIDS in Washington, D.C., Vice President George H.W. Bush was booed by the audience for defending Reagan’s HIV testing proposals, which called for the compulsory testing for all hospital patients, prison inmates, persons applying for marriage licenses, and foreigners applying for immigration visas. Protesters contended that compulsory testing was draconian and wasted resources that might be used on education and more effective preventive measures. Outside the White House, police wearing long rubber gloves arrested demonstrators. In June, the U.S. Public Health Service added AIDS to its list of diseases for which people could be barred from entering the United States on public health grounds. Then in July, the Helms Amendment (after Senate sponsor Jesse Helms, R-NC) added HIV infection to the exclusion list. It was not until May 1988, however, that the United States finally launched a coordinated HIV/AIDS education campaign. Surgeon General C. Everett Koop distributed 107 million copies of a booklet titled “Understanding AIDS.” The first direct federal assistance to community organizations was not provided until the 1990 Ryan White Comprehensive AIDS Resource Emergency (CARE) Act.
The lack of government support mobilized private resources and volunteers to establish community-based organizations to provide care for many of the early victims. It also motivated a number of groups to press for action. The gay rights movement was involved from the beginning, but with heterosexual transmission of HIV political cooperation between the AIDS activist community and the women’s movement emerged. The medical community also played a vital, if more complicated, role in the AIDS movement. In some ways, it has been argued, the medical community effectively opposed the movement. Fear of infection led to great caution among those treating HIV-positive individuals, which the AIDS movement decried as discriminatory. At the same time, gay and women’s groups had a common interest in getting the federal government to apply massive resources to education, prevention, and research toward finding a cure.
The last important group to join the movement was hemophiliacs. Early on, the AIDS movement publicized the plight of hemophiliacs to emphasize that the disease was a concern for all. A key figure in that campaign was Ryan White, a 13-year-old hemophiliac who had contracted HIV in a blood transfusion. White became the object of media attention in August 1985, when he was barred from public school in Kokomo, Indiana, out of fear he would infect other students. Although he was finally allowed to enter school in November, the case was invaluable in informing the public that everyone—not just homosexuals and drug users—was at risk of AIDS and it was a vital public health concern. White became a tireless promoter of the AIDS cause until his death in 1990.
As frustration mounted that nothing was being done to deal with the epidemic, a segment of the AIDS movement became increasingly radicalized. From its start, the AIDS Coalition to Unleash Power (ACTUP) has not shied away from disruptive and controversial tactics. Its focus on militant action conveyed the desperation of AIDS sufferers. The coalition’s membership was drawn largely from the white, middle-class gay and lesbian communities. The group formed spontaneously in March 1987 when the author and activist Larry Kramer suggested more radical tactics were needed; its first major protest was held on Wall Street against perceived profiteering by the pharmaceutical industry from AIDS drugs. Soon after the protest, the Food and Drug Administration (FDA) announced it was significantly shortening the drug approval process. ACTUP blockaded and temporarily shut down the FDA in 1988, occupied various stock exchanges on a number of occasions, and disrupted Catholic Church services to highlight the Church’s positions on AIDS-related issues. In January 1991, ACTUP held a “Day of Desperation” in New York City, staging protests at government buildings and Wall Street and occupying Grand Central Station and the newsrooms of the Public Broadcasting Service and CBS.ACTUP also worked to establish and maintain links with other movements. From May 1 to 9, 1988, the group organized protests in more than fifty cities to focus public attention on links between AIDS and homophobia, women, people of color, and drug use. ACTUP consistently focused on economic impediments to access, corporate greed, the inadequate government response, and discrimination. Other groups around the world would adopt the same focus in the years to come.
The truly global nature of the AIDS epidemic soon became apparent. The total number of cases reported to the World Health Organization (WHO) stood at 12,000 at the beginning of 1985 and grew to 145,000 by 1988. Until the latter part of the 1980s, there was relatively little international coordination in the effort against HIV, and the worldwide spread of the disease continued unabated throughout the decade. According to prominent AIDS researcher and activist Jonathan Mann, 1987 was the “year of global AIDS mobilization.” In October, AIDS became the first disease ever debated on the floor of the United Nations (UN) General Assembly, which resolved to mobilize the entire UN system in a worldwide struggle against AIDS, establishing the Special Programme on AIDS (later called the Global Programme on AIDS, or GPA). Throughout the late 1980s, the World Health Organization (WHO) shifted its resources to developing countries as evidence of increasing infection rates emerged. Despite the attention it received in industrialized countries, AIDS was most severe in sub-Saharan Africa in the 1980s. As of 1992, WHO estimated that some two-thirds of all cases, or 6 million people, were in Africa, making the AIDS problem an economic development issue.
WHO’s inexperience in working with development-oriented nongovernmental organizations (NGOs) limited early success. Even interagency coordination within the UN was not effective, and the flow of money soon began to dwindle. Consistent with broader trends in foreign aid, funding from the developed world declined and was increasingly directed through NGOs rather than going directly to developing country governments or the UN. Governments were often perceived as inefficient or corrupt, and in the early 1990s, the donor community was becoming increasingly uneasy over inefficiencies at the UN. In addition, the aid demands of the former USSR drew attention away from other needs. In reality, though, successful anti-HIV/AIDS strategies need to include all relevant institutions. Efforts were made to improve communication between governments, the UN, and NGOs. Beginning in 1992, the yearly international AIDS conferences effectively combined scientific and NGO programs, which helped facilitate a coherent message.
AIDS in the 1990s: Success and Complacency
In the United States, the early 1990s presented the AIDS movement with a number of opportunities, but growing complacency made it difficult to take advantage of them. At the time, the United States had more AIDS cases than the rest of the developed world combined. The election of President Bill Clinton in 1992 seemed to present the movement with a politically favorable climate. Protest activity, for example, picked up markedly in 1993. In April, organizers estimated that one million gay men and lesbians gathered in Washington, D.C., for the biggest AIDS demonstration to date. The Clinton administration, however, proved disappointing to many AIDS activists. While advocating free trade, the administration strongly supported pharmaceutical companies’ efforts to maintain intellectual property rights over their patented AIDS drugs, keeping them too expensive for many in the developing world. The perceived conflict between Clinton administration rhetoric and actions mobilized the Global Treatment Access Movement.
To some degree, the success of the AIDS movement in the United States had taken the wind out of its own sails. The most dramatic advance came in 1996, when triple-therapy antiretroviral (3TC) cocktails entered the U.S. market. Before federal health officials endorsed combination therapy, pessimism was rampant about ever finding an effective treatment regimen for AIDS patients. The clearest evidence of this was the cancellation of the 1994 International Conference because so few advances in research had emerged in the preceding year. However, with the availability of somewhat effective drugs the urgency surrounding AIDS was removed and the issue receded in industrialized countries. The 3TC treatments made the disease manageable in all but the poorest sections of the developed world.
The sense of crisis regarding AIDS was all but lost within the white, middle-class gay and lesbian communities that made up the bulk of ACTUP’s membership. The number of HIV cases in the United States was not growing as quickly as originally estimated. In fact, the numbers of both deaths and new cases have declined in the United States since 1996. The issue soon became treatment affordability, as the impact of AIDS fell more heavily on minorities who were disproportionately unable to afford treatment. AIDS was becoming a particularly acute problem within the African-American population. In 1996, the Centers for Disease Control (CDC) released statistics indicating that one-third of all deaths among black men aged 25 to 44 were AIDS related. By the early 2000s, more than half of those Americans with AIDS were either African American or Hispanic. Also, more than 50 percent of cases have been contracted through injected drug use. For American AIDS activists, the growing involvement of ethnic minorities made the movement more aware of its international dimension.
By contrast, as the decade of the 1990s neared its end, projections of AIDS cases in the developing world painted a grim picture of the future. This stark situation was not entirely unexpected. Public health officials had recognized the potential for an epidemic in the developing world for more than a decade, but significant action has only begun in the last few years. More specifically, there is increasing recognition that HIV-infected individuals need not be written off for dead. Prevention continues to be important, but the availability of drugs that hold the disease at bay has made the issue of access extremely contentious. AIDS activists complain of high drug costs, while pharmaceutical companies claim high prices sustain research on new AIDS drugs.
Despite all efforts, the magnitude of the HIV/AIDS pandemic has become truly staggering. By the end of 2003, UNAIDS estimated almost 40 million people were infected worldwide. In the 1990s, 15 million people died of the disease; by 2003, the 1-year figure stood at 2.5 million to 3.5 million. Sub-Saharan Africa has borne the brunt of the disease thus far. AIDS is currently the number one killer in Africa, according to WHO statistics, and ranks fourth worldwide. Of the estimated 40 million infected worldwide, roughly 25 million live in Africa. UNAIDS statistics show infection rates exceed 25 percent of the adult population in four sub-Saharan African countries; seven more countries exceed 20 percent, and nine others have infection rates of over 10 percent. Given these rates of infection, the worst is far from over. The impact of HIV/AIDS on the region is only beginning to be realized. The number of dead by the early 2010s is projected to surpass that of the first 20 years of the illness. By 2010, life expectancies in southern Africa will decline to nearly 30 years of age, a figure not seen in a century.
To help combat the scourge, President George W. Bush announced in his 2003 State of the Union Address a $15 billion initiative to fight AIDS/HIV worldwide. In May, Congress passed the United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 2003, which appropriated $15 billion to fight these three diseases, with much of the money destined for sub-Saharan Africa. In early 2008, Congress voted to expand what was already the world’s largest government initiative to fight AIDS/HIV to some $50 billion, adding an extra $20 billion to the amount requested by the White House. Moreover, an element of the package as originally proposed, requiring that one-third of all prevention money be devoted to abstinence programs, was dropped from the new appropriations bill, much to the chagrin of U.S. conservatives.
While the situation in Africa has deservedly received the most attention, HIV is spreading rapidly in other areas of the world as well. Estimates indicate the AIDS crisis in Africa could be repeated, or exceeded, in South Asia and the former Soviet Union in coming years. In India, the government estimated that 4 million people were infected as of the end of 2003, but the true figure may be five times higher. Eastern Europe, particularly Russia, has seen the fastest increase in infection rates since the late 1990s. In China, where AIDS was not believed to be widespread in the early 2000s, the government has acknowledged it is a problem that needs to be addressed. As that nation continues to undergo sweeping economic and social reforms, changes in lifestyle are likely to facilitate the spread of AIDS.
The National Intelligence Council, a U.S. interagency governmental think tank reporting to the Director of Central Intelligence, has predicted five highly populated countries—China, Ethiopia, India, Nigeria, and Russia—will be ravaged by AIDS in the next decade. The number of infected individuals in these countries is anticipated to rise from 14 million to 23 million in the early 2000s to an estimated 50 million to 70 million by 2010. Because these are major regional and global powers, the problem of AIDS has begun to be seen as an issue of international security. The growth of the AIDS crisis may spark tension over spending priorities, raise health care costs, and sharpen shortages of military manpower. Countries will be less able to fulfill their peacekeeping roles, potentially resulting in civil unrest. Such instability could hamper the global economy and make weapons caches vulnerable to terrorists and crime syndicates. AIDS is thus far from being contained, and its political, economic, social, and demographic impact will be more severe than many presently realize.
The death toll in Africa suggests what the future may hold in other regions if infection rates grow to the same proportions. These figures are even more troubling when one looks at the sections of society being disproportionately affected. HIV typically strikes people in the prime of life, who would normally be contributing to the economy, raising children, and providing national defense. The World Bank estimates the African economy will contract by 25 percent between the early 2000s and late 2010s if the disease continues on its current path. Half of the population already lives on less than one dollar a day. Lack of manpower could limit the ability to harvest crops, damaging the food supply and reducing export earnings. African countries are ill-equipped to deal with such strain, given foreign debt repayments, not to mention caring for the millions of children orphaned by AIDS.
In a number of African countries, difficult tradeoffs must be made. The cost of treating one AIDS patient would pay for a year of school for ten children. While every sector of the economy has been affected, the loss of skilled workers is felt most acutely. The economic impact extends beyond the sheer number of dead. Many communities have been unable to adequately staff schools, which will also have long-term effects on children unable to obtain a good education. Given their exposure to the disease, doctors and nurses have high rates of infection, and the resulting medical staff shortage will have dire consequences for treating the disease in the coming years. This is to say nothing of the harm to children of losing one or both parents. It is estimated there will be 40 million AIDS orphans (children under 15 years) in Africa by 2010.
A number of success stories, however, provide hope that AIDS can be contained and perhaps eventually cured. Thailand, Uganda, and Senegal show that prevention strategies can have a significant impact on the spread of infection. In Thailand and Senegal, educational and preventive programs were enacted early in the epidemic, keeping the prevalence of AIDS lower than originally forecast. In Uganda, where a large percentage of the population was already infected, effective educational campaigns have curtailed the disease’s growth. What these three cases have in common is the political leaders’ strong commitment. Many developing countries dependent on foreign investment and tourism have not been forthcoming with information on the true scope of the disease. Cultural factors also discourage many African leaders from taking stronger, more public stands against AIDS. Strong support from political leaders allows resources to be mobilized more effectively, facilitates the enactment of a multi-pronged strategy involving education, prevention, and treatment, and breaks down the social stigma associated with the disease.
The case of Brazil presents an excellent example of how effective treatment can be in developing countries, particularly when trade rules recognize health needs. Since 1996, the Brazilian government has been producing its own AIDS drugs in national laboratories. Free treatment is available to all infected individuals. Brazilian law permits local production of drugs if the patent holder does not produce drugs in the country and charges exorbitant prices in the Brazilian market. The Brazilian program basically pays for itself, as companies can market the drugs produced in the country to other developing nations. Education and prevention programs have cut transmission rates, and death rates have been cut in half. By producing its own drugs, Brazil has reduced prices by 79 percent. To help other countries, Brazil has offered to transfer technology and its experience to the Third World. Many countries, however, do not have the money, expertise, market size, or diversity of civic groups to replicate Brazil’s success. But clearly spending relatively reasonable amounts on prevention and education today would save tremendous future costs for treatment.
Global Mobilization at the Millennium
According to WHO, interest in preventing and treating AIDS in the developing world was “nowhere” at the beginning of 2000. Since then, the issue has achieved global prominence. The UN Security Council debated the crisis in January 2000, the first time a health issue had ever received that kind of attention. At the session, U.S. Vice President Gore described AIDS as “a security crisis because it threatens not just individual citizens but the very institutions that define and defend the character of a society.” In the summer of 2000, AIDS was on the agenda of the Group of Eight (G8) industrial nations’ summit, in which the richest countries committed to help developing countries reduce AIDS cases by 25 percent by 2010. In June 2001, the UN General Assembly held an unprecedented 3-day Special Session on AIDS. With demonstrations taking place outside of the 2001 G8 meeting in Genoa, Italy, smaller nations, such as Nigeria, Mali, Bangladesh, and El Salvador, were invited to discuss health, debt, and the poor. A new G8 fund to fight AIDS was formally launched at the meeting. The money was intended to buy drugs and support health care infrastructure in the developing world.
Over the past several years, diverse groups recognized their common interest in fighting the disease, propelling HIV/AIDS in the developing world into the spotlight. AIDS activists, advocates for debt relief for developing nations, and groups protesting globalized free trade have been some of the most prominent in promoting the issue. Debt activist groups such as Jubilee 2000 and Drop the Debt, for example, used the millennium as an opportunity to raise the issue and call for a fresh start for heavily indebted countries. These groups argued that the debt burden of developing countries limited their ability to allot adequate resources to their health systems to deal with crises such as AIDS.
Antiglobalization and consumer groups were concerned about unequal power relations in the marketplace. They saw the multinational pharmaceutical industry favoring profit over public health needs in the allocation of research and development (R&D) funds and in calling for stronger protection of intellectual property rights that prevent pharmaceutical companies in developing countries from replicating and selling critical AIDS treatment drugs. Protests surrounding World Bank/International Monetary Fund (IMF) meetings over the past few years brought these groups together and allowed them to interact and exchange ideas. The World Bank/IMF demonstrations in Washington, D.C., in April 2001 marked the second major AIDS march in the United States; the first was a protest that March in New York of the pharmaceutical industry’s lawsuit against the South African government’s effort to replicate and sell patented AIDS drugs. The movement included creation of the Health Global Access Project (GAP) Coalition, a collection of AIDS and trade activists formed in 1999. Health GAP created the Global Treatment Access Campaign (GTAC) to produce policy papers and share information among activists.
The campaign evolved with the argument that treatment was possible but the greed of the pharmaceutical industry was the major obstacle. Those infected with the disease in Africa, it was argued, need not die any more than those in industrialized countries. The GTAC painted a stark image of intellectual property protection taking priority over African lives. Pharmaceutical companies, for their part, argued that high prices are justified to support R&D, partly because relatively few drugs in development ever reach the market. People inside the industry often point to corruption and misplaced priorities in African governments as a key reason for the dire situation. Health systems are in terrible shape because governments have spent money on weapons rather than public health.
The conflict between the pharmaceutical industry and the South African government marked a significant turning point in the global response to AIDS. In March 2001, the suit brought by 39 multinational pharmaceutical companies against the South African government over its compulsory licensing plan—requiring international pharmaceutical companies to allow South African companies to produce inexpensive versions of their patented drugs and generic producers to make anti-AIDS drugs affordable—went to trial. Although international trade rules allowed this in the event of a national emergency, the Clinton administration had long threatened developing countries with a Section 301 designation (of the U.S. Trade Act of 1974) if they did not provide sufficient intellectual property protection. The Section 301 list is a sort of warning, often a precursor to the imposition of sanctions. A leaked February 1999 memo from the U.S. State Department called for “a full court press against South Africa” to ensure that it did not seek AIDS drugs through compulsory licensing or parallel importation from countries such as Brazil that were producing copies of patented drugs.
Ultimately, electoral politics allowed the movement to pressure the administration to back off its earlier hard-line stand. At early Gore campaign events for the 2000 presidential election, protestors focused attention on the administration policy, embarrassing the candidate. Soon thereafter, the Clinton administration moved away from its prior policy, in fact declaring AIDS a national security threat. As the South African trial began, other actors were jockeying for position. Indian generic manufacturer Cipla announced it would sell a triple-drug cocktail to Doctors Without Borders for $350 (U.S.), its cost of production, even though it continued to charge African governments $600. Cipla was the second Indian company to announce it would begin manufacturing generic versions of triple-drug therapies. The resulting competition could drive down prices even further. By the time the trial in South Africa began, the industry was already in a weakened position. Parallel protests were held in Pretoria, New York, Washington, London, and Paris as the trial got underway. Aside from the barrage of bad publicity, the Bush administration announced early on that it would not change the Clinton policy of not pursuing sanctions against countries importing or producing generic versions of drugs. The lawsuit was dropped less than 2 months later.
AIDS activists have also sought to bring the broader business community into the fight. UN Secretary-General Kofi Annan tried to get the private sector to support the Global AIDS Fund. Despite significant contributions by the Gates Foundation and a few other charitable foundations, success by the early 2000s has been limited in raising money from the private sector. This is not to suggest that the business sector has not played an important role in fighting AIDS. Corporations have responded to pressure both to provide care to employees and to contribute to the broader community. Companies doing substantial business in Africa have seen their workforces devastated. Increasing numbers of workdays are being lost as employees attend funerals for family and friends who succumbed to AIDS. As a result of these high death rates, companies are hiring more than one worker per job for insurance. Corporate behavior may be less self-serving than it appears, since few companies derive substantial profits from Africa and many are engaging the broader community in their efforts.
Coca-Cola is one of the highest-profile companies targeted by activists. With about 100,000 employees, Coca- Cola is the largest private-sector employer in Africa. The company has been pressured to pay for treatment for all its infected employees. In the summer of 2001, it committed to using its infrastructure in the fight. Coca-Cola is widely seen to have the best distribution system on the continent. While its trucks are not refrigerated to permit shipping drugs, Coca-Cola distributes condoms as well as educational and prevention materials. The company also lends its marketing professional to produce educational messages.
Although momentum has been generated, the goal of overcoming HIV continues to face a number of obstacles. Contributions to the Global AIDS Fund were disappointing by the early 2000s. The United Nations has estimated that an effective campaign would cost $7 billion to $10 billion annually. Contributions had reached only $1 billion as of 2003, but the total increased dramatically once Congress passed the $15 billion United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act later that year. AIDS experts point out that effective coordination between local initiatives and national and global organizations is also vital. The importance of sharing information, they say, cannot be overestimated. Moreover, even as U.S. and international efforts are stepped up, local groups must maintain some degree of freedom. The NGO community is concerned that centralization at the international level could reduce accountability and increase the potential for inefficient use of funds.
Another issue is the mechanism of getting the anti-AIDS drugs to developing countries. WHO has suggested setting up a differential pricing system. This scheme would allow poor countries to pay less for drugs than developed countries, and the industry has long resisted such a move. Safeguards to prevent the re-export of drugs to the developed world have been put forward to assuage their concerns. Extending patent rights is another possibility. It may, however, be difficult for governments in the developed world to convince their populations to accept the two-tiered system. The price of prescription drugs is already a contentious issue in the United States.
The high cost of effective treatment has placed an ever-increasing strain on national health systems. The treatments have also led to the evolution of a growing number of mutations, many of which are drug resistant. Collapsing health infrastructure, the evolution of drug-resistant strains, and the weakened immune systems of HIV-positive individuals have made opportunistic diseases like tuberculosis once again a public health concern.
It remains to be seen whether global mobilization will ultimately be successful. The “war on terrorism” has proven to be a serious challenge, overshadowing AIDS. Before September 11, 2001, awareness and resources had been increasingly mobilized, a UN special session held, and G8 meetings had focused on AIDS for two straight years. Resources, however, have now been redirected to antiterrorism efforts. Estimates of the cost of rebuilding Afghanistan and Iraq, at several hundred billion dollars, are several times the UNAIDS estimate of the annual needs for combating AIDS in the developing world. In short, resources that might have been committed to AIDS are being redirected elsewhere.
There is reason to believe that the momentum in combating AIDS will not be lost. The issue was a major agenda item in global trade talks in November 2001. There is growing recognition within the World Trade Organization that greater flexibility is needed in enforcing intellectual property rights. The 2001 meeting of the World Trade Organization in Doha, Qatar, achieved an understanding of this need to allow developing countries to combat AIDS. In the words of one activist, “Two years ago you would never have got anything like this through the WTO.” In 2005, the WTO began to modify the 1994 Trade Related Aspects of Intellectual Property Rights Agreement (TRIPS), which requires all member states to honor intellectual property rights, so as to give them some flexibility in applying TRIPS in matters of public health. This flexibility has allowed developing countries with large generic pharmaceutical industries, most notably India, to copy patented drugs and lower the price of anti-retroviral “cocktail” therapies from roughly $12,000 a year to a far more affordable $140.
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