AIDS Lines

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To participate in last week's World AIDS Congress in Toronto you had to enjoy walking. It was a huge conference (25,000-plus people) in a massive conference centre. So, we all trudged, session to session, from the South Tower to the North Tower to the Media centre to the Global Village and back again. Wherever you went there were two columns comprising a substantial portion of the world HIV/AIDS action community, moving in well-ordered, opposing directions.

The strategic focus of the Congress had the same features.

The dominant and official line at the Toronto AIDS Congress was on medical technology prevention. The big plenaries, high-profile and famous speakers and media releases had a piece of technology somewhere - microbicidal gels, the circumcision cutting device (whatever that is) and the increased supply of ARVs (anti-retro virals). Even this list was limited with little focus on two other technologies, one basic, the other complicated, the condom and the vaccine - one too "values loaded" and the other perhaps too close to a very distant horizon. In this technology approach HIV/AIDS is a distinct and separate, technical and apolitical issue.

Now everyone loves a simple solution to a very complex problem. The AIDS pandemic is complex no matter from which angle it is dissected. A sex partner controlled gel that neutralises transmission would be a very simple solution. Likewise ARVs for all would be great. And, if only we could, as was cited as a possibility based on some initial data, reduce transmission by mass cirumcision. The well heeled line in Toronto - those who put up big chunks of money, run big agencies and have senior United Nations roles - voiced this remarkably coherent agenda.

The barefoot line in Toronto knew differently. People working on the ground in Africa, Asia, Caribbean, Latin America, Eastern Europe, the Pacific and significant communities in Europe and North America voiced and debated their analysis, ideas and experiences in the margins of the Congress within satellite, informal and poster sessions, and in chats in the Global Village, corridors and other more convivial venues.

Given the AIDS numbers and trends - deaths and infections - the "barefooters" understand the severe time barriers to the "simple" solutions being proposed. A microbicidal gel is at minimum 5 years away. The realities of a supply side approach to ARVs, with the need of 60 billion dollars over 10 years [The Economist] and very low coverage rates to date stare the barefoot line up right between their eyes every day of every week. When mass circumcision is posited as a possible simple solution the cultural "challenges" are all too clear from the barefoot perspective. This line knows that HIV/AIDS is a political issue inextricably sourced in and linked to poverty, gender, education, human rights, culture, governance, other core development issues and political priorities and resources.

Because the starting point for this AIDS line with its feet on the ground is the people and communities directly affected by HIV/AIDS - not the medical fields, the immediate - not the far off, and the complex - not the simple. They work up close to this vicious social and political disease, in their different countries and communities, trying to increase dialogue and debate on HIV; campaign for increased drugs and better services; increase condom use; reduce stigma; prioritise HIV/AIDS for attention within their national and local institutions; better organise their responses; seek and maintain higher information, knowledge and awareness levels; empower women and encourage more respectful men; influence public policy; and ensure people are both aware of the possible personal preventive actions they can take and are encouraged and supported to take those actions. They seek these important changes through a full smorgasbord of context-relevant actions and strategies - from health system strengthening, radio entertainment, needle exchanges, condom promotion and supply to people living with HIV/AIDS groups, legal challenges against pharmaceutical companies, music lyrics and school curricula (to mention just a few).

The barefooters are getting increasingly tired and worn feet pursuing this path. Which is strange as it was the set of actions outlined above that were so apparently successful in addressing HIV/AIDS in Uganda, Thailand and the gay communities in the first decade of the epidemic as well as more recently opening up the generic drug possibilites. But now the global emphasis has moved very significantly to the medical technology approach. This has had two effects. The dreams around special gels, ARVs, vaccines and now circumcision can undermine the realities of the local responses. When the big agencies not only prioritise their voice for the global technology approach but also prioritise their high-profile funding in the same direction then this momentum away from local and national action to global science and technology is further compounded. And the shoeless here know that even should the technologies be developed, ARVs be universally available and gels, circumcision and maybe vaccines work and be available in 5 to 10 years, then issues of culture, social norms, behaviours, stigma, poverty, gender and education will present considerable barriers to their application.

We all have to hope, in the two years between now and the next World AIDS Congress in Mexico City in 2008, that a much better balanced strategic and funding line is drawn between the well heeled and the barefoot, the social and the technical, medical and communication interventions. Perhaps then, in Mexico City, we can all walk in one productive line. We certainly need to.

Warren Feek

wfeek@comminit.com