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GLITZ, HOPE AND DESPAIR: The XVIII International AIDS Conference Unrolls

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The XVIII International AIDS Conference opened in Vienna with its 25,000 attendees and its peculiar combination of glitz, tragic desperation, and reasonable hopes.

There was Saturday's Life Ball, Europe's biggest AIDS Charity extravaganza, with an advertised celebrity roster ranging from Whoopi Goldberg to Boris Becker. There was the Sunday opening ceremony "fashion show" organized by Diane von Furstenberg, Calvin Klein and Kenneth Cole. By Monday, along with the bold name speakers now expected at this conference, of which the boldest are former President Bill Clinton and Bill Gates, we had a plenary session that finally brought forward two representatives from the hard world of frontline AIDS----Vuyiseka Dubula, General Secretary of the Treatment Action Group of South Africa and Anya Sarang, President of the Rylkov Foundation for Health and Social Justice in Moscow. If you want hard work, try being openly HIV positive in South Africa and begging for a response from a government which---until a sudden, sincere change in the past year---essentially denied that AIDS existed while millions died horribly; or try being the leading voice for sane drug policies and HIV prevention for drug users in a country where junkies are considered even lower than they are in the United States.

This unwieldy blend of Hollywood and the hardest and harshest of grass roots work, of very advanced science and fashion shows, of government bureaucrats speaking from the podium and infuriated activists relegated to yelling from the floor, has always been a disconcerting aspect of AIDS. Still, if you want to raise money---and maintain public interest---in a disease increasingly defined, wherever it goes, by its impact on the poor and outcast, a glitzy ball---dress code was tuxedos---with a plethora of celebrity "spokespeople", may be inherent to the cause.

The real question, as always, is what you do with the money and the public interest?
AIDS, through billions of funding from the Global AIDS Fund, the G-8, governments across the globe---along with helpful millions added in from private fund-raising and charities---has made enormous strides in only the past five years. Just one measure of this striking progress was the announcement by Ramatlapeng Keneiloe, Health Minister of Leostho, that the portion of pregnant, HIV-positive pregnant women in her country enrolled in the short-term anti-retroviral therapy around the time of birth which slashes HIV mother-to-infant transmission basically to zero, has soared from 15% to 80% of mothers. A small African nation is reasonably looking forward to a day when it will have eliminated babies' being infected with HIV from birth.

But hope and despair are tightly bound in AIDS. Despite the longer life for the millions of adults now using antiretrovirals in rich and poor countries alike---and despite the unexpected bonus that, by slashing viral levels in HIV-positive people, current antiretroviral treatment has a major, major impact on prevention (one study showed a 90% reduction in HIV transmission from infected men put on antiretroviral treatment to their uninfected wives and female partners!), the Conference has already seen international officials and donors increasingly declare that the "antiretroviral route" is "unsustainable". "Unsustainable", of course, is the new code word for things that governments either can't or won't pay for any longer. While it would seem unlikely---one hopes---that governments and international donors will withdraw support for people with AIDS already using antiretrovirals, in the absence of funding increases, new patients will have scant access to these drugs in the future. Already in the United States, there is a waiting list of almost 2,000 people with AIDS seeking antiretroviral treatment that their state governments now refuse to pay for. (Using the financial downturn, as some states have, as an excuse not to treat people in the United States is just heinous). Treatment "waiting lists" in poor nations could reach millions---who will wait until they die.

Are there other routes? As all who have been involved in AIDS know, despite the successes, AIDS needs a radical reorganization; it is top heavy--"too much spent on studies, reports, conferences and technical assistance," in the summary of Bill Clinton. This is doubly true in the United States; while almost 2,000 Americans languish without access to available treatment, the National Institutes of Health continues to support a number of poorly organized treatment trials which hold little prospect of producing any result except millions of dollars in government revenue for "academic" research centers.

Looking to the future, whether the focus is on emerging science for better, cheaper treatments, vaccine development, prevention that works----and, most crucial, as time goes on and on---helping communities rebuild and regroup through the shock and devastation of AIDS, we must look with new eyes at how ideas, local leaders and many forms of progress can first arise through this top heavy structure.

We'll see whether the remaining days of this Conference help launch that process.