AIDS CONFERENCE

XVI International AIDS Conference in Toronto 2006

Aids who it affects 2006

Personal tributes

They are the names of the dead, neatly handwritten on little white flags.

The 8,000 flags arranged in a field at the south entrance of the Toronto Metro Convention Centre this week were a personal testament to lives lost to AIDS each day around the world. It took 40 people and six hours to assemble the display.

"What we wanted was to have ordinary folks who care to have their voices heard," said Lynn Thornton, the executive director of VIDEA, an agency that helped organize the installation.

Known as the Community Action on AIDS Project, the Toronto exhibition was one of eight put up across Canada.

Above the image of a crying face one caption read: AIDS Doesn't Go Away. Another flag was simply inscribed: Help.

"Some of them (are) memories of people who have died, some of them things people would like to have done here," Thornton said.

Conference Theme: Time to Deliver - 13/08/2006

The AIDS 2006 Conference theme, Time to Deliver, underscores the continued urgency in bringing effective HIV prevention and treatment strategies to communities the world over. Twenty-five years after the first reports of what was later to be known as AIDS appeared in the CDC’s Mortality and Morbidity Weekly Report, the magnitude of this epidemic demands increased accountability from all stakeholders to fulfill their commitments, be they financial, programmatic or political.

While additional resources and continued scientific research are critical to an effective global response, the theme recognises that the scientific knowledge and tools to prevent new infections and prolong life among those living with HIV/AIDS already exist, even in the poorest settings. The challenge at hand is to garner the resources and the collective will to translate that knowledge and experience into broadly available HIV treatment and prevention programs.

The International AIDS Conference exists for exactly these reasons. It is one of the most important gatherings for the release and discussion of key scientific developments in the fight against HIV/AIDS.

AIDS 2006 will bring together the movement of people responding to the HIV/AIDS epidemic to share their lessons and together stake out the road ahead. In doing this, the Conference directly affects the lives of those living with and affected by HIV/AIDS. AIDS 2006 is a catalyst for change.

In September 2003, Canada announced it would implement the WTO's decision and in May 2004 it passed the Jean Chrétien Pledge to Africa act, which has since been renamed Canada's Access to Medicines Regime. But it topped its legislation with additional requirements that made it even tougher for generic producers to get drugs out.

For instance, since negotiations over voluntary licensing between generic companies and patent holders must last at least 30 days, it is tough to discern when talks are simply stalled or have broken down. Also, the law is limited to a list of specific medicines in specific formulations. Even if a generic company makes it through all those hurdles and a compulsory licence is granted, it is valid for only two years. After that, the entire process starts again.

At the bare minimum, said Elliott, Canada needs to get rid of the extra requirements it added. But that, he warns, would be "sort of like tinkering around the edges" and not addressing the real problem which is the original Aug. 30, 2003 decision by the WTO to allow copies of patented drugs.

It's clearly not working, he said, since no one has taken advantage of it. Not one country has notified the WTO that it plans to import cheaper drugs.

It's an indication the barriers to accessing the life-saving drugs are simply too high, said Elliott.

He said he proposed to Clement's advisers that legislation be enacted that would automatically grant a compulsory licence to a generic manufacturer.

With that in hand, the company could negotiate contracts with various countries and pay royalties to the patent holder based on whatever deals were reached.

Equip women in fight, Gates urges - Tools needed to prevent HIV infection. Wants leaders, drug makers to act fast

Bill Gates wants world leaders and pharmaceutical companies to give women the power to prevent the spread of HIV by developing drugs that block the transmission of the virus.

"This could mark a turning point in the epidemic and we have to make it an urgent priority," Gates said last night to thunderous applause during his keynote speech at the opening ceremony of the International AIDS conference at the Rogers Centre.

"We want to call on everyone here and around the world to help speed up what we hope will be the next big breakthrough in the fight against AIDS."

The Microsoft chairman explained that in many parts of the world, women are at the mercy of the men in their lives and do not have the right to refuse sex, let alone sex without a condom.

"No matter where she lives, who she is, or what she does, a woman should never need her partner's permission to save her own life," Gates said.

It was a sentiment echoed by Peter Piot, the executive director of UNAIDS, who said a "top priority is to immediately double funding for microbicide research and development."

A microbicide is a vaginal gel or cream applied prior to sex that will stop the transmission of HIV, while oral prevention drugs are antiretrovirals that, taken before infection, may prevent the transmission of HIV.

In a joint keynote speech, Gates and his wife, Melinda, also called on the audience of more than 30,000 scientists, advocates and health workers from around the world to increase global access to HIV prevention and treatment.

"While there is promising research to report, the world, in my view, has not done nearly enough to discover these new tools — and I include our foundation in that assessment," said Gates, referring to the Bill & Melinda Gates Foundation, which has donated $650 million (U.S.) to the fight against AIDS — including $500 million just last week.

Last night's ceremony included speeches by federal Health Minister Tony Clement, Mayor David Miller, Premier Dalton McGuinty, Governor General Michaële Jean and conference co-chair Dr. Helene Gayle, as well as musical performances by Chantal Kreviazuk, Alicia Keys, Barenaked Ladies and Our Lady Peace.

There was much discussion among them about the simmering controversy over Canada's failure to get inexpensive generic drugs to poverty-stricken countries in Africa, as well as the Prime Minister Stephen Harper's absence from the conference.

Harper's office has said he could not attend the summit because he is touring Nunavut in the Arctic.

Comments by Dr. Mark Wainberg, conference co-chair and director of the McGill University AIDS Centre, prompted raucous applause and standing ovations from delegates.

"Mr. Harper, you have made a mistake that puts you on the wrong side of history," said Wainberg.

"The role of prime minister includes the responsibility to show leadership on the world stage. Your absence sends a message that you do not regard HIV/AIDS as a critical priority. Clearly, all of us here tonight disagree with you."

Money alone 'not enough'

All the money in the world will not be able to defeat HIV/AIDS unless great strides are made in preventing new infections — and that can only be achieved by giving women and other high-risk groups the ability to protect themselves, Bill and Melinda Gates said on the opening day of the International AIDS Conference.

At a news conference Sunday prior to the opening ceremonies, Bill Gates said that despite growing access to antiretroviral drugs in countries hard-hit by HIV/AIDS, between four and five million people worldwide will become infected in the next year.

"I want to emphasize we're going to have to do a much better job of prevention to stop the spread of HIV," said Gates, whose foundation just donated $500 million US to the Global Fund on AIDS. ``We'll never be able to deal with the numbers of people that would have to go on treatment if we don't make a dramatic breakthrough in prevention."

The Microsoft founder said he would call on the world to accelerate research into microbicides and oral drugs that would prevent acquisition of HIV. "We hope and expect that this could be the next breakthrough."

Such measures are particularly important because they would benefit women who now have to rely on men to agree to abstinence or condom use.

"And that simply isn't getting the job done," Gates said. "A woman should never need her partner's permission to save her own life.

"So there's progress on these but the pace has been too slow."

His wife, Melinda, stressed the need to use and make more widely available the tools known to stop the spread of the virus.

"Today fewer than one in five people who are at high risk for HIV have access to things like condoms, clean needles, education and testing," she said. "That's something that simply needs to change

"One of the things that we fundamentally believe about HIV the more that we've been involved in this is you have to put the power in the hands of women. That is going to be the way to change this epidemic."

Bill Gates and others called on all governments to join the battle against HIV/AIDS around the world.

"Obviously the AIDS epidemic is going to require all actors, particularly governments, to dig deep and make this a high budgetary priority," he said.

"The amount of money that's required for universal treatment or the things around prevention far exceed the amount that any individual government, certainly any foundation, can possibly provide."

Health Minister Tony Clement agreed that it will take the collective efforts of people like the Gateses, international advocacy organizations and governments to wrestle the pandemic to the ground — and the AIDS conference offers a fresh starting point for that endeavour.

"I can't imagine another venue, another event around the world that brings together a more dynamic, a more diverse, a more committed group of people," Clement said. "We need all of these people — all of their energy, all of their collective wisdom and all of their passion perhaps most of all.

"I know that I'll never be able to fully comprehend the absolute devastation that flows from the human loss associated with this pandemic. But I want you to know how committed I am and how the government of Canada is committed to continuing this fight until it is won."

Conference co-chair Dr. Mark Wainberg, a leading AIDS researcher at McGill University in Montreal, said "there is no doubt in any of our minds that HIV is the planet's public enemy number 1. This conference plays such a vital role in combatting the spread of HIV."

One goal of the conference is to make sure drugs are available to those who need them around the world, regardless of ability to pay, he said.

We all agree. Access to HIV drugs is a right and not a privilege."

But Frika Chia Iskandar, an HIV-positive woman from Jakarta, told the news conference that access to treatment is not just about pills — if people don't live close to medical care, access to treatment also means being able to afford to get to where the drugs are being dispensed.

As well, "stigma and discrimination are still happening," she said, noting that a dentist refused to treat her last year. "It's still there. Nothing much has changed."

The conference has brought an estimated 24,000 delegates and 3,000 journalists from around the world to Toronto for the biggest gathering in the now-biennial meeting's 21-year history.

Prime Minister Stephen Harper has said he will not attend the six-day conference because of other commitments, a decision that has rankled and baffled organizers, researchers and AIDS activists — not just in Canada but elsewhere in th world. Instead, Canada is represented by Clement and Minister of International Co-operation Josee Verner.

Former U.S. president Bill Clinton, the crown prince and princess of Norway, UN AIDS for Africa envoy Stephen Lewis, and actors Sandra Oh and Olympia Dukakis are scheduled to attend.

Conference workshops and plenary sessions officially begin Monday, and will deal with a wide range of issues — from scientific research to caring for those with HIV/AIDS to preventing the spread of the virus, which has killed 25 million people in the last 25 years and infected about 40 million worldwide.

New HIV drug appears to be 'very potent'

TORONTO -- Patients taking a brand new type of HIV drug have shown a quick reduction in the number of viruses circulating in their bloodstream, according to early data from a clinical trial that is to be announced at the International AIDS Conference in Toronto later this week.

The drug belongs to a long-awaited new class of HIV medications known as integrase inhibitors. They work to block the enzyme the virus uses to integrate its genetic material into the DNA of a host's cell and make copies of itself.

As more and more patients develop drug resistance to standard therapies, integrase inhibitors are raising hopes of a new first-line treatment against the AIDS virus.

"For people with resistance to many different drugs, this [early study data] offers them hope," said Martin Markowitz, one of the trial's investigators and a clinical director at the Aaron Diamond AIDS Research Center in New York.

But Dr. Markowitz, who is also a professor at Rockefeller University, cautioned that "it is too early to predict where this will lead."

Merck & Co. is developing the drug, one of two in the new class. Its compound, known for now as MK-0518, is involved in an ongoing clinical trial with 198 HIV patients who had previously been untreated for their infection. The studies are being conducted at 28 different centres around the world, including two in Canada.

At the outset, the patients had to have at least 5,000 copies of the virus in every millilitre of blood. They also had relatively low counts of the immune system's CD4 cells, which HIV attacks. Cell counts averaged between 271 and 314 per microlitre.

(Treatment usually begins when a patient has more than 100,000 copies of the virus or below 350 CD4 cells). Most of the patients in the trial, 160, were given the new oral drug in combination with two other antiretroviral therapies. Thirty-eight were given an existing type of HIV medication as well as the two other antiretroviral agents.

Based on data at six months into the two-year trial, Merck reports that 85 to 95 per cent of patients taking the integrase inhibitor drug regimen have seen their viral loads plummet to less than 50 copies.

Patients' immune-cell counts, meanwhile, increased by 139 to 175. Ninety-two per cent of patients taking the older drug combination showed similar results, but the effect took longer to achieve.

"What is striking is the rapidity with which the patients reached these lower levels [of viral load]," Dr. Markowitz said. "This looks to be a very potent drug."

The drug's antiviral effect was seen in patients taking the oral drug at doses ranging from 100 milligrams to 600 milligrams twice a day.

A press release from Merck states that side effects in the trial have so far been "mild to moderate, with nausea, dizziness and headache reported most frequently."

Dr. Markowitz noted that 10 patients have discontinued taking the medication, two for lack of efficacy, seven for reasons not related to the trial and one because of an adverse effect related to liver function.

Mark Wainberg, director of the McGill University AIDS Center and co-host of the Toronto conference, said the results sound encouraging.

What's more, Dr. Wainberg stressed, the research field desperately needs good news: "It's pretty urgent. People are still dying of AIDS because they are resistant to everything we have to treat them."

Researchers have found integrase inhibitors difficult to develop in part because it requires altering the viral genome without harming the DNA of the host. Dr. Markowitz said it is satisfying to finally see the new drug class move into clinical trials.

"We have drugs that target two of three enzymes that HIV requires for its life cycle," he said. "This is like the third leg of the stool."

Tiny grants, big hope in AIDS fight

In the Mashuru area of Kenya, a single woman with HIV who had no source of income now runs a small general store, is self-sufficient and, most importantly, is eating properly, thanks to a $140 grant from World Vision.

In the same region, a group of 15 women have used a $1,400 grant from the humanitarian organization to expand a small business of rearing goats for sale at market, using the added profit to care for HIV orphans and vulnerable children in their village.

“What's really crucial is to empower women to have a say in their lives so they can become less vulnerable,” said Carole Leacock, a HIV/AIDS program specialist with World Vision Canada, who noted that women in rural villages tend to be more stable, while men often travel to get work.

Unlike big business grants, injections of small amounts of money in Third World countries can play a critical role in developing a thriving local economy.

That's especially true in areas where disease has devastated households, creating a situation that perpetuates poverty and undermines the community safety net with people unable to care for themselves.

Ms. Leacock gave an audience at the International AIDS Conference in Toronto yesterday the results of a microfinance project in Mashuru, located about 120 kilometres southeast of Nairobi, where droughts in recent years have made people living with HIV and AIDS destitute.

Forty-seven microfinance projects last year gave people living with HIV and AIDS basic business training that improved their disposable income, health, nutrition, dignity and self-respect, as well as better access to anti-retroviral drugs, and decreased the stigma of the disease, she said.

“No one is going to bed hungry they were able to repair their houses, pay rents, create assets and send their children to school. Today, they continue to be engaged in gainful employment as small trades by reinvesting their savings.”

Ms. Leacock also said people can now afford the $3 bus trip for a 50-kilometre monthly visit to the nearest health facility that dispenses free anti-retroviral drugs.

“Every time we make a difference in one parent's life, we prevent another child from become orphaned. And that's very important to us.”

Results of another World Vision microfinance project in Tegucigalpa, Honduras, will be released at the conference tomorrow.

Dina Eguigure, a national manager of HIV/AIDS programs in Honduras, said that results of a two-year project found that helping people with the disease set up their own businesses increased “social inclusion of a group normally excluded from the formal economy.”

Nearly $50,000 (U.S.) was earmarked to help 150 families living with HIV, with 37 per cent of the money used by women with no formal education. Most women set up small businesses attached to their homes, selling traditional foods, small goods and second-hand clothes purchased elsewhere, she said.

“By the end of the project, they paid up their credits with no outstanding debts, showing their business skills and the solid coaching provided by the project team.”

Largely designed to improve the quality of life for adolescent women between 15 and 19 years of age and mothers living with HIV and AIDS, the project also trained teachers and youth leaders about sexual and reproductive health, HIV prevention and proper use of anti-retroviral treatments. It also strengthened community grassroots organizations and helped develop stronger government links, she said.

Four-drug cocktail no better, study finds

TORONTO -- Adding a fourth drug to the current triple-drug cocktail is no better at treating newly diagnosed patients with HIV, according to a study released at the International AIDS Conference yesterday.

The study, published in the Aug. 16 issue of the Journal of the American Medical Association, found that adding a fourth HIV drug, in this case abacavir, did not reduce the amount of virus in patients' blood. Previous smaller studies had been contradictory on the matter; some suggested that adding a fourth drug could more quickly beat back the virus, while other studies did not.

This study, which followed 765 patients over three years, found that in roughly 80 per cent of the subjects, the human immunodeficiency virus remained suppressed whether they were on the three- or four-drug cocktail, according to the results released by Roy Gulick, director of the Cornell University HIV clinical trials unit and associate professor of medicine at Weill Medical College of Cornell in New York.

"It doesn't look like adding a fourth drug to the very successful three-drug regimen taken today provides any additional benefit," he said at a morning news conference.

In the study, 765 HIV-infected patients who had never received treatment were randomly assigned to one of two regimens: a four-drug cocktail that included zidovudine, lamivudine, abacavir and the non-nucleoside drug efavirenz; or a three-drug cocktail of zidovudine, lamivudine and efavirenz.

According to Dr. Gulick, the rationale for the study was predicated on past success: Since the triple-drug cocktail worked better on HIV patients than the two-drug cocktail, researchers wanted to learn whether four drugs would be better.

In the study, which ran from 2001 to 2005, roughly the same number of patients in each group (88 per cent in the four-drug group and 85 per cent in the three-drug group) achieved undetectable levels of virus in their blood. After three years, 25 per cent of the four-drug group and 26 per cent of the three-drug group achieved so-called virologic failure, which meant that the drugs were no longer effective at reducing the levels of virus in their blood, according to the study, which was supported by grants from the U.S. National Institutes of Health.

The Aug. 16 JAMA issue was published to coincide with the AIDS conference; its contents are devoted entirely to HIV/AIDS. Another study in the issue found that rapid expansion of free anti-retroviral therapy programs in Zambia produced favourable outcomes.

At the news conference yesterday, JAMA editor-in-chief Catherine DeAngelis said the AIDS epidemic now matches the deaths from the bubonic plague.

About 25 million people have died of HIV/AIDS in 25 years and about 40 million people currently have it. Anti-retroviral medications have turned HIV/AIDS, once a death sentence, into what many consider a chronic disease.

Simple solutions to save newborns

There was lots of buzz, at the opening of the 16th International AIDS Conference yesterday, about the new: new drugs; new technologies; new deals on funding and drug access.

Far away from the buzz, clinicians from the developing world talked about keeping pregnant women from passing the AIDS virus on to their babies.

There is nothing new about this: We've known how to do it for nearly a decade. It's cheap, and it's one surefire way of cutting down on new infections. And? More than 90 per cent of pregnant women with HIV around the world do not have access to any of the simple interventions that would keep them from infecting their babies. Seventy children an hour are infected with the virus by their mothers, and 45 die every hour from AIDS.

These numbers suggest that in all the understandable hunger for the new in AIDS, we have lost sight of the fact that we haven't yet figured out how to solve one of the most basic problems. And because this is a problem of women -- poor, rural women in Africa, in particular -- it has slid quietly to the bottom of the international AIDS agenda.

Women infect their babies with HIV three ways: roughly a third of them in utero; a third in delivery; and a third through breastfeeding.

Fewer than 500 children will be infected in North America this year, because it's very easy to prevent all three. If a woman doesn't breastfeed, if she delivers by cesarean and if she and her baby are given an anti-retroviral drug before or during labour, the risk of transmission is less than 2 per cent.

Of course, not every rural health clinic in Rwanda can provide a cesarean section. And not every Rwandan woman can feed her baby with formula safely, because many lack clean water. But the drug intervention -- that's easy. A single dose of the drug nevirapine can cut transmission by at least 30 per cent. That costs, at most, a couple of dollars, and manufacturer Boehringer Ingelheim donates it free in many parts of the world. Using two or three ARV drugs together can lower transmission by much more. But less than 9 per cent of pregnant women worldwide get any of these interventions.

African and Indian doctors talked about how they lack the labs and the staff to test and counsel all the pregnant women; how the women they see may come for an HIV test but never return for drugs because they live too far away and can't afford to take another day off work to wait in line at a busy clinic.

Dr. Agnes Binagwaho, who heads the national AIDS agency of Rwanda, talked about her country's program, which is, by African standards, a remarkable success: They're reaching 22 per cent of HIV-positive pregnant women with single-dose nevirapine. But that program is now imperilled. "We had funding from the Global Fund," she said, money they used to build labs and train and pay staff. "But that funding ends now."

Arletty Pinel, of the UN Population Fund, says the fact that more women don't get this service reflects the overall low priority put on maternal and reproductive health. These programs are almost universally minimally funded and minimally staffed, she said, and so it's no surprise that more women with HIV don't get the basic interventions. "Getting a pregnant women who is HIV positive is remedial, it's damage control -- and we don't do damage control well."

The World Health Organization announced yesterday that it now recommends putting pregnant women with AIDS on full ARV therapy from 28 weeks of pregnancy. A fine idea, but if less than 9 per cent of women are receiving a one-off drug dose, how on earth are Rwandan clinics that just lost their funding going to do full therapy?

One of the big topics at the conference this week is pediatric AIDS. It's high time that pediatrics got more attention. But in all those sessions yesterday, no one mentioned that there would be no need for pediatric treatment, if we just mastered the one-stop intervention that keeps mothers from infecting their kids

Prevention tools for women urged

Toronto — Women's issues were front and centre Monday at the International AIDS Conference as Melinda Gates called for prevention tools for women so they don't become infected by HIV.

“The two that are on the horizon that I think really could change the face of this disease are a microbicide, which is an odourless clear gel that a woman would use vaginally to block the disease, or an oral prevention drug that a women could take every day without her partner knowing,” she told a panel discussion entitled Women at the Frontline in the AIDS Response.

But money isn't the only obstacle in bringing these products to market, and making them accessible to women in developing countries who can't protect themselves against infected partners who don't use condoms.

“It really comes down to trials,” said Ms. Gates, who together with her husband Microsoft chairman Bill Gates gave a keynote address to open the conference, and recently announced $500 million (U.S.) in funding to the Global Fund to Fight AIDS, Tuberculosis and Malaria.

“We have 16 microbicide candidates today that are in first-stage trials, we have five that are on their way to second-stage trials, but the truth is we need an even more powerful microbicide than what's in trial today,” Melinda Gates said.

“And a lot of trials, both in microbicides and an oral prevention drug — in some ways what's even more promising — have been stopped. And so we need to have more trial sites created. We need more communities involved. We need more people willing to come forward to participate in trials.”

Activists need to make sure trials are ethical and done according to best clinical practice methods, she said. But they also need to insist that trials be done.

Musa (Queen) Njoko, a jazz artist and HIV activist in her native South Africa, was also on the panel. She was one of the first women and the first recording artist to disclose her HIV-positive status in South Africa.

“We need no longer continue having our lives controlled by other people,” she said. “It's our time, it's our lives, let's fight for our survival, let us fight for the future of our children.”

Earlier Monday, more than a thousand people from around the world took part in a march and rally near the conference site to demand urgent action for women and girls in the HIV/AIDS pandemic.

“Violations of women's and girls' human rights have a direct impact on HIV infection,” Louise Binder, co-founder of the Blueprint for Action on Women and Girls and HIV-AIDS, said in a statement.

“Violence against women and girls, poverty, lack of education and housing, and lack of property rights, all fuel HIV/AIDS infection rates among women and girls. HIV positive women's human rights are also regularly violated.”

Worldwide, almost 50 per cent of all HIV positive adults are women over 15 years old.

In Canada, women represented 27 per cent of positive HIV tests in 2005.

Actor Gere cautions India about American mistakes

TORONTO — Actor Richard Gere brought his star power to the International Aids Conference yesterday, calling HIV-AIDS the “true terrorist on the planet today.”

At a news conference to announce a public-service campaign in India, Mr. Gere said he has been involved in the HIV-AIDS movement since the 1980s and hopes India does not make the same mistakes the United States did in dealing with the epidemic.

“It is deeply important to me that India not make the mistakes we made in America,” said a silver-haired Mr. Gere, looking relaxed in a blue shirt and tan suit jacket. “We had no leadership. We didn't take it seriously and hundreds of thousands of people died who didn't have to.”

A report released last week by India's Registrar-General and Census Commissioner estimated that about 11 million people in India could die of AIDS-related illnesses by 2026. Based on demographic trends, the report said an additional five million children who might not be born as a result of the early deaths of HIV-positive women could be “missing.”

Yesterday, Mr. Gere sounded hopeful about India, saying the incidence of HIV is currently running at about 1 per cent of the population. If India is able to keep it at that level, “there's a good possibility we are not going to see 10 million or 20 million more die,” he said.

At yesterday's news conference, the Heroes Project, of which Mr. Gere is a co-chair, and STAR India, the leading television network in India, announced a two-year extension of their HIV-AIDS stigma reduction and prevention campaign through the use of public-service television messages, many of which send the message: “No Condoms, No Sex.”

As he has grown older, the New-York-based movie star explained that he has had to make some hard decisions about how he is to make his remaining years the most meaningful he can.

“Probably the most important [issue] to me was HIV-AIDS,” he said. “It's the true terrorist on the planet today.”

US criticised for HIV aid effort

Stephen Lewis, UN Special Envoy on Aids, said President George Bush's $15bn Emergency Plan for HIV/Aids was too focused on promoting abstinence.

He said Washington was practising "incipient neo-colonialism" by telling African nations how to fight Aids.

He also accused the West of failing to deliver on funding commitments they had made to fight the disease.

Speaking at the 16th International Aids Conference in Toronto, Mr Lewis said: "No government in the Western world has the right to dictate policy to African governments around the way in which they respond to the pandemic."

Sub-Saharan Africa remains the epicentre of the Aids pandemic, with two-thirds of all people living with HIV coming from the region.

Two million people died of Aids in the region last year and there were 2.7m new infections.

The Bush administration backs an "ABC" plan to fight Aids: Abstinence until marriage; Being faithful to one sexual partner; and if those conditions are not practised, the use of Condoms.

In 2003, the US Government approved a $15bn package over five years to fight the spread of Aids.

Abstinence programmes

But the US Congress has stipulated that a proportion of the funds must be spent on encouraging abstinence-until-marriage programmes.

Mr Lewis said abstinence programmes had been shown not to work.

"That kind of insipient neo-colonialism is unacceptable.

"We're saying to Africa: 'This is how you will respond to the pandemic' and that's not appropriate because African governments are eminently capable of deciding what their priorities are and what the response should be."

"You do not provide money on the condition that they reflect your ideological priorities."

Top US officials have rejected the criticism, denying it promotes abstinence to the detriment of other HIV prevention strategies, or that it is designed to appease conservative Republicans.

Mark Dybul, US Global Aids coordinator, said only 7% of funding for 2005 had been spent on abstinence programmes.

He said: "There is no evidence in support of what they are saying.

"It is colonialistic to not support ABC. ABC was developed by Africans for Africans - we are supporting their strategies."

Speaking to the BBC, Mr Lewis said the West had failed to provide sufficient funds to finance effective long-term prevention and treatment programmes.

"The G8 countries could help to break the back of this pandemic if they viewed it as an emergency like no other emergency - as the worst scourge on the face of the planet since the Black Death of the 14th century.

"That sense of urgency is not yet evident."

$332-billion illicit drug trade fuelling HIV infections around world: expert

TORONTO  - The illicit drug trade is fuelling HIV-infection rates in many parts of the world - and too much reliance on punitive drug enforcement is compromising efforts to prevent spread of the disease, the International AIDS Conference was told Tuesday. Australian physician Alex Wodak said that one in every 10 new HIV infections around the world occurs among injection drug users, and they are responsible for about 30 per cent of new infections outside Africa.

"And the proportion of global HIV infections attributable to injection drug use are growing," said Wodak, director of the Alcohol and Drug Service at St. Vincent's Hospital in Sydney.

"Drug use around the world is also a growing problem that the war on drugs has completely failed to arrest," he said, noting that the UN Office on Drugs and Crime estimates that the drug trade has an annual turnover of more than $322 billion US a year, which accounts for eight per cent of total international trade.

A recent report to British Prime Minister Tony Blair and his cabinet estimated that between 26 and 58 per cent of that business is pure profit, he added.

"So this is what's fuelling the epidemic of HIV in injection drug users worldwide. And we're now seeing drug use spreading into Africa."

Wodak said harm-reduction experts have known how to prevent HIV infection in IV drug users for at least 15 years, by educating drug users, providing clean needle syringe programs and getting "dirty equipment out of circulation."

There are also a range of drug rehabilitation programs, notably methadone for heroin users, that have proven successful, he said.

The major barrier to stopping the spread of HIV in drug users is "excessive reliance on drug enforcement" around the world, particularly in high-incidence regions such as central and eastern Europe and central Asia - "where the epidemic among injecting drug users is of alarming proportions," he said.

Wodak said the United States has the highest incidence of AIDS in the industrialized world, roughly five times greater than second-place Spain, in part because of its failure to control HIV among injection drug users.

"Yet the opposition in the United States prevents these pragmatic approaches being spread throughout the world." While progress is being made in the fight against HIV/AIDS, the disease is still spreading faster among injection drug users than harm reduction programs needed to slow transmission, he said.

"And I find it particularly galling and tragic in that this is one part of the epidemic we really could do something about," Wodak said, "and yet it's the politics in so many countries that prevents us from doing what has to be done."

Continuing on the topic of harm reduction - a widely used buzz word at the conference - a leading scientist said Tuesday that researchers are looking beyond the famous ABCs of HIV-prevention.

The ABCs stand for abstinence, being faithful to one sexual partner, and using condoms.

Gita Ramjee, director of the South African Medical Research Council's HIV Prevention Research Unit, is involved in numerous trials of HIV-killing microbicide gels and other prevention tools in the battle against HIV-AIDS.

"I have described a new acronym that goes right up to I," Ramjee told a news conference.

"We have an additional C for circumcision, D for diaphragm for HIV prevention, E for exposure prophylaxis - both pre-and post - F for female-controlled microbicides, G for genital-tract infection, H for HSV-2 suppressive therapy and I for immunization through vaccine.

"We have to believe that we are getting to I," she said.

Recent studies have found that treatment of herpes simplex virus HSV-2 infection appears to reduce levels of HIV in the genital tract and blood plasma.

Dr. Helene Gayle, co-chair of the conference, said some of the approaches discussed by Ramjee may be effective against HIV within the next few years.

"However, there are major hurdles facing new prevention approaches . . . in conducting clinical prevention trials," Gayle said.

Among them are finding groups of people for testing who are not yet infected and deciding what to do if a person sero-converts (develops HIV-infection) during a trial, she said.

Supporters of Vancouver's safe injection site turn up the heat on Ottawa

TORONTO  - Supporters of Vancouver's safe IV drug injection site turned up the heat on the federal government Tuesday, telling a news conference at the International AIDS Conference that closing the site is not an option.

Advocates say the facility, called Insite, has decreased public injecting of drugs, saved lives and led to a decrease in petty crime in Vancouver's Downtown Eastside, the inner city neighbourhood known for its high concentration of injection drug users. But they fear the new Conservative government has moral objections to the site and may be poised to close it.

"If we're really taking a moral position . . . it would be immoral to ignore the (scientific) evidence to date," said Dr. Thomas Kerr, a researcher with the B.C. Centre for Excellence in HIV-AIDS, which has been evaluating the pilot program through a series of scientific studies. A number have been published in the world's leading medical journals, including the New England Journal of Medicine.

The director of the centre for HIV-AIDS was more blunt.

"Let's just be clear. This is not about evidence," said Dr. Julio Montaner, an internationally renowned AIDS researcher who is about to become president-elect of the International AIDS Society.

"So whatever the government is currently considering has to be something. And it's up to them to tell us what they're looking at. We haven't been able to figure it out."

Insite operates under a legal exemption that expires on Sept. 12. Supporters of the project find the federal government's silence on its future increasingly ominous.

"I'm very concerned this will become a political decision. We need this to be a health-based decision," said NDP MP Libby Davis, who represents the area in Parliament.

"I'm very concerned about the chaos if it is closed down. It does bring a measure of stabilization to the community."

"The site is not contributing to increased crime or new cases of addiction; it is controlling the spread of HIV because addicts have access to clean needles and is in fact encouraging them to seek treatment," Liberal Senator Larry Campbell, former mayor of Vancouver, said in a release in which he and Liberal health critic Ruby Dhalla called on the federal government to keep Insite open.

It is estimated the safe injection site serves between 4,000 and 5,000 injection drug users drawn years ago to the Downtown Eastside, where a large number of rooming houses offer cheap accommodation.

The concentration of so many injection drug users in a few city blocks led to enormous social problems, with drug users shooting up in alleys and high rates of petty crime in a neighbourhood that borders the city's very popular Chinatown.

Studies conducted by Montaner's researchers point to decreases in car break-ins, fewer overdoses that lead to death, less syringe sharing and less shooting up on the street.

The researchers say the results have been so positive that people who initially objected to the pilot project - local merchants, the Vancouver police - are now firmly on side.

"So if the police department can see it, if the business community can see it, if the residents of the area can see it, if the city of Vancouver can see it, what is there that you cannot see, Mr. Prime Minister?" Montaner asked at the news conference.

While experts believe the facility could reduce the risk of the drug users becoming infected with AIDS by providing clean needles, the three-year pilot project hasn't been long enough to assess that scientifically.

But Montaner said on every other criteria measured, the site is reducing risk to the addicts who use it, pointing more of them towards rehabilitation programs and improving life in the city's core.

"The site has already proven itself of value in terms of treatment of overdoses, treatment of infections, referrals to detox, increasing public order, preventing bad outcomes in these individuals. What else do we need to justify continuation?" he asked.

"When you do a test in Canada, it's to find out if something works or it doesn't work. OK, the answer is it works. What do we do from here? And closing it is not an option."

A woman representing the drug users in the area said she knows what to expect if Insite's doors close next month.

"I start going to a lot more funerals again," Diane Tobin, a representative of the Vancouver Area Network of Drug Users, told the news conference.

New data presented yesterday compared nearly 2,000 men in Kenya, some circumcised and some not, and found the rate of new HIV infection to be roughly two-thirds higher among the uncircumcised men. Another study found that if 20 per cent of adult men in the South African township of Soweto were persuaded to have the surgery, it would prevent 53,000 new HIV infections over 20 years.

“Even modest programs can convey substantial health benefits and should be implemented immediately,” epidemiologist Kyeen Mesesan said.

Now all eyes are on trials underway in Kenya and Uganda, from which data will be available next year. Should they show results similar to those in Orange Farm, the United Nations may begin to recommend male circumcision as a crucial health intervention much like polio vaccination.

Circumcision lowers the risk of HIV infection because the skin that is removed contains more of the cells to which HIV easily attaches — it cuts off the sticky bits, essentially.

The problem is that adopting male circumcision as a public health measure to stop HIV infection brings with it a great, swampy mess of problems — and those got short shrift in the fervent discussions about the science yesterday.

Circumcision is, of course, much more than a medical procedure. For Muslims and Jews, it's a religious rite. For many of the cultures of east and southern Africa, it's a hugely important marker of boys' transition into manhood. But in cultures that don't circumcise males, that decision is often equally sacrosanct.

How is the World Health Organization, or national governments, going to persuade people to, first, start doing it, if culturally they are non-circumcising people? (Roughly half of African societies routinely circumcise at some point in a man's life.) Second, how do you persuade a society with an elaborate ritual for 17-year-old boys to instead start circumcising infants, on whom it's a much easier operation with far fewer possible complications? Another big concern is that, once circumcised, men will believe their level of risk is so low they won't use condoms (when of course the operation offers no such total immunity) or that youth, hearing about the practice, will get the mistaken impression that they do not need to take precautions, although a study from Kenya presented yesterday found that essentially there was no increase in risky sex among men who were circumcised.

“Is this going to take resources from other known HIV-prevention interventions — will it be taking resources that maybe could be employed in better condom promotion or education?” mused Tim Farley, who heads the sexually transmitted infection control team for the World Health Organization.

The Swazi waiting lists suggest that it's not necessarily difficult to persuade adult men to get the operation. But other acceptability studies in Africa have shown that less than half of men are willing.

Fashioning a fight against AIDS

Microbicides a new champion in AIDS fight

TORONTO — With the search for an AIDS vaccine proving elusive, scientists and activists are increasingly pinning their hopes for slowing the epidemic on microbicides, easy-to-apply gels that would act as an “invisible condom” to prevent infection.

“The prospect of a microbicide is thrilling,” said Stephen Lewis, United Nations special envoy for HIV-AIDS in Africa. “Regardless of its effectiveness, it will inevitably save millions of lives.”

In fact, a recent study conducted by the London School of Hygiene and Tropical Medicine estimated that a microbicide that reduced the risk of infection by 40 per cent — and that was used by 30 per cent of women at risk in low-income countries — would avert more than two million HIV infections a year and save $1-billion (U.S.) annually in health-care costs.

Gita Ramjee, director of the HIV-AIDS program at the South African Medical Council, said it is impossible to overstate how desperately women — who make up three-quarters of new infections in sub-Saharan Africa — need some form of protection.

They do not know if they will be infected tonight, tomorrow night or the next night. The threat is always there,” she said.

Worldwide, an estimated 38.6 million people are infected with HIV-AIDS, half of them women. The epidemic is spreading fastest among young women aged 16 to 24.

Condoms are an effective means of blocking transmission, but condom use is low. In much of the world, women do not have the power — physical, legal or social — to negotiate safer sex. They must succumb to sex when, where and how their partner chooses, even if that partner is HIV-positive.

Microbicides can be packaged in a gel, foam, vaginal ring, sponge, suppository or douche form. Scientists are hoping to develop products that, in addition to blocking the transmission of HIV-AIDS, will prevent other sexually transmitted diseases such as herpes, gonorrhea and chlamydia and, in some cases, also have contraceptive properties. Unlike other forms of protection such as condoms and cervical caps, they also hope to produce products that are long-lasting, able to thwart the virus for days, or even months.

“Women need multiple drugs with multiple delivery options,” said Zeda Rosenberg, chief executive officer of the International Partnership for Microbicides, a group based in Silver Spring, Md.

She said that variety in microbicides is essential because, like birth control, “women have different needs at different stages in their lives.”

Currently, there are dozens of microbicides in development, but five are at a fairly advanced stage, and being tested in humans. One of these, called C31G (brand name Ushercell), is Canadian, and being produced by Polydex Pharmaceuticals Ltd. Results of the first studies will be published late next year, and the product could be on the market by 2009.

Microbicides work in various ways. Some, such as Carraguard, a seaweed-based gel, create a physical barrier that keeps HIV from reaching cells where they will latch on and infect a person; others, like Ushercell, which is derived from cotton, disable the virus by stripping off its outer covering. Another class of microbicides boosts the vagina's natural defence mechanisms by raising pH levels and creating an acidic environment hostile to viruses.

The key is finding out whether the products, which work in the lab, will be effective for people living everyday lives.

There are concerns that the advent of microbicides will be seen as a substitute for safer sex practices such as condom use, and that the products will be shunned because of a belief they prevent pregnancy. (Scientists stress that both contraceptive and non-contraceptive microbicides will be developed.) Alex Coutinho, executive director of the AIDS Support Organization of Uganda (TASO), said the science of blocking is the easy part. The hard part is creating products that women will actually use and that are affordable and readily available.

“It's not just about microbicides, it's how you deliver microbicides that really matters,” he said. “Women need something they can fit and forget.”

The current standard practice, recommended by the World Health Organization, is what's called voluntary counselling and testing (VCT). People must present themselves to testing sites and undergo both pre- and post-test counselling about HIV.

It is a legacy of the early days of the AIDS epidemic in North America, when the disease was first recognized among gay men and intravenous drug users — who, as marginalized groups, needed the promise of confidentiality, or often anonymity, to be persuaded to be tested. This culture of delicately handled testing was exported to Africa and the rest of the developing world; it is viewed as a human-rights violation to test a person for HIV without express consent.

But in recent years some of the major figures in public health have been arguing that VCT is a mistake. AIDS, they say, is a disaster, and relying on volunteerism in the face of a stigmatized disease is madness. Look how Canada handled SARS. You weren't asked to volunteer for a test when you stepped off that flight from Hong Kong, now were you?

Yesterday, Botswana's formidable Health Minister, Sheila Tlou, explained that in 2004 her country had a problem. Botswana, where one in three pregnant women tests positive for HIV, has a strong health system and was the first country in Africa to offer free AIDS treatment. Despite that, very few people were volunteering for tests.

That made sense when there was no treatment; what's the point of being tested for a fatal illness if you'll just be sent home to die? But testing numbers barely crept up once the drugs were widely available.

So in early 2004, Botswana's government decided instead to introduce a “routine offer of testing.” Everyone who comes into contact with the health system is offered an HIV test, and the onus is on the patient to decline.

Ms. Tlou said the policy has been a success; it has nearly tripled the numbers of people who are tested, and receive treatment, and helped to lessen the stigma around AIDS by making it less of an “exceptional” case. Now you get an HIV test like an allergy test.

But the minister faced off yesterday against an array of human-rights activists who say the routine testing policy has substituted one problem for another. Women in Botswana have great difficulty, culturally, rejecting the suggestion of a person in authority, said Grace Sedio, an activist living with HIV. They'll be tested when they don't really want to, when they aren't ready for the news or may face violence at home if they disclose they have HIV. They certainly won't embrace “positive living” or a complicated treatment regimen if they aren't ready, she said. Others raised the fear that the goal of routine testing is primarily to produce numbers to show donors that progress is being made.

While it's not fashionable these days to champion routine testing, many African health-care workers will tell you quietly that making the test standard policy (with, of course, an opt-out) is the only way to get over the fear. Sick people assume their doctor or nurse will suggest an HIV test if they see the possibility of infection, one Zimbabwean doctor told me yesterday. “And you can't say that because a woman is poor and African, she is not capable of truly consenting to a test she is offered,” she added.

He never suffered the opportunistic infections others endured. He never picked up anything life threatening. Although his viral load soared and certain immune cells plummeted, blood test after blood test showed a healthy presence of other immune cells.

"It became more obvious to me, especially after [my partner] died, that I was being spared."

The 59-year-old Toronto man may well have his family history to thank. Mr. Rosenes carries a gift in his genes — a mutation that confers a natural resistance to HIV. In all likelihood, it was passed down to him from his ancestors in Europe, where the protective trait is most prevalent.

From the earliest days of the epidemic, doctors have puzzled over long-term HIV patients who show little progression from infection to full-blown AIDS. Some have never had to take even a single drug to keep the virus in check. Others, despite repeated exposure, have never contracted it.

The question now is whether their good fortune truly is inherited.

The mutation Mr. Rosenes carries is the best-known example of genetic resistance to the AIDS virus. It offers not immunity, but a form of protection that drug makers are keen to mimic. But there are most certainly other genetic traits that confer resistance or susceptibility to HIV, and the race to find them has begun in earnest. An effective treatment, perhaps even a vaccine, hangs in the balance.

In the United States, two separate research groups have recently identified traits linked to HIV susceptibility. Scientists at the British Columbia Centre for Excellence in HIV/AIDS are recruiting HIV patients considered to be "long-term non-progressors" who have never actually developed AIDS.

This spring, an international consortium of universities launched an ambitious project to scan the whole genomes of hundreds of HIV-positive Europeans and Africans for mutations that might be linked to the disease. Some scientists even suspect genes may partly explain why HIV has hammered certain regions more than others, sub-Saharan Africa in particular.

"My hypothesis is that there are biological differences in susceptibility, and knowing them will be crucial for the development of a vaccine," said Jacques Pépin, a professor of microbiology and infectious diseases at the University of Sherbrooke. "If we don't know why some people get infected and others don't, why some people get sick and others don't, we'll never understand how the virus works or how to stop it."

Mr. Rosenes has made good use of his time. He's been chair of the AIDS Committee of Toronto, a board member of the Canadian Treatment Action Council and the willing subject of research.

In the mid-nineties, he submitted his blood for an experiment at McGill University investigating ways to boost the immune system. Not long after, the lab called to tell him about the protective quirk they'd found in a gene called CCR5.

"I really found out about it in a fluky kind of way," Mr. Rosenes recalled.

CCR5 is a gene that produces tiny keyhole-like entry points on the surface of the immune system's T cells. They're known as chemokine receptors. HIV, like a savvy burglar, happens to have the right set of molecular keys to unlock them and break into the cell to cause infection. There are about 23 different mutated versions of the CCR5 gene. But the most common and best understood is one called CCR5-Delta32. People with this mutation have 32 bits of genetic code deleted in the CCR5 gene. The missing bits result in fewer entry points on the cell surface, upping the chances of shutting out HIV.

People who have one Delta32 copy — as Mr. Rosenes does — have partial resistance, with a two- to four-year delay in the progression of HIV. Those who inherit two copies of the Delta32 mutation — one from mom and the other from dad — have almost absolute protection.

"If they have one copy, we call them lucky. If they have two copies, we call them really very lucky," said Richard Harrigan, director of the research lab at the B.C. Centre for Excellence in HIV/AIDS.

Mr. Rosenes, vice-chair of the Local Host board of directors of the 2006 International AIDS Conference in Toronto this week, feels that his mutation "helped to bridge the gap" between the time he contracted the disease and when effective drugs became available in 1996.

"I understand it as a key factor in my long-term survival," he said.

Since its discovery in 1996, studies have piled up showing the protective mutation is more common in certain places in the world. In Europe and West Asia, the prevalence rate runs as high as 10 to 15 per cent, and the numbers rise the farther north you go. In Southern Europe, it's roughly 4 per cent or less. A 1998 study that tested 2,500 people from 16 European countries found the highest frequency in Denmark and the lowest in Corsica.

One per cent of Caucasians are estimated to have the two copies that confer near-immunity to HIV. In particular populations, such as Ashkenazi Jews of Eastern Europe, a group that includes the ancestors of Mr. Rosenes, estimates peg the rate as high as 15 per cent. But in native Indians, East Asians and people in sub-Saharan Africa, home to two-thirds of the world's AIDS cases, the mutation is rare to non-existent.

To Dr. Pépin, the pattern supports his view that certain populations face a higher biological risk of contracting HIV.

"Everybody in the field knows the prevalence in Africa is higher than the rest of the world," he said. HIV rates in parts of sub-Saharan Africa are higher by 400-fold compared with Scandinavia, he noted.

Most people accept that most of the gap can be explained by socio-economic differences that have nothing to do with DNA, said Dr. Pépin, who worked in Africa during the 1980s. These include the region's poor state of nutrition and lack of access to hygiene, health care and education. The urbanization of Africa has also brought men to the cities, leading to more transient sex, more commercial sex and a higher prevalence of other sexually transmitted diseases. All of these things increase the risk of spreading HIV.

"If you look at a map of the world, you see the regions with the highest prevalence are sub-Saharan Africa and the Caribbean, places where there are populations who came from Africa as slaves," Dr. Pépin said.

To investigate this, Dr. Pépin decided to look at a place of mixed populations and determine if there was any correlation between a person's geographical ancestry and HIV prevalence. He picked 34 countries in the Americas, including Haiti, largely populated by descendents from sub-Saharan Africa; the Dominican Republic, with its blend of Spanish, European and African descendants; Cuba, with a 10 per cent African and 30 per -cent mixed European population; and Argentina, which imported relatively few African slaves.

He then relied on HIV prevalence rates in the countries of origin to predict the prevalence rates among population groups in the countries of mixed populations — and they closely matched.

"What I observed is not due solely to behavioural factors," he said of the work, published last summer in the journal of Tropical Medicine and International Health.

The pattern, he pointed out, is also what you might expect to see when something like a CCR5 protective mutation is present at such low levels in one population and higher levels in another.

"But there is not a single factor that explains it all," he said.

The CCR5 gene mutation sprung up as most do: a one-time, random event in a single person. Initially, scientists thought it happened fairly recently, popping up just 1,000 years ago and then spreading rapidly across Europe, helped by the Viking raids of the 8th to 10th centuries, but more so because the mutation offered some form of a survival advantage.

"There must have been some kind of an epidemic in Europe, which extended to North Africa, that wiped out the people who [did not have the mutation]," Dr. Pépin said. "It's possible that populations in Africa suffered a little bit, but maybe [that epidemic] didn't reach portions of sub-Saharan Africa."

A number of candidates have been suggested: the bubonic plague, typhus, influenza. But to Montgomery Slatkin, a population geneticist at the University of California at Berkeley, none of these fit the bill.

These historical infections, he explained, did not result in enough deaths in a short enough time period to change the frequency of the CCR5 gene type to such an extent.

Dr. Slatkin and his team constructed a mathematical model of the mutation's spread and concluded smallpox was the likely candidate. The highly contagious virus killed up to 40 per cent of its victims in Europe during the Middle Ages and hit the continent's northern countries especially hard.

But scientists now suspect the mutation may be much older than originally thought. German researchers discovered it in the DNA of 2,900-year-old Bronze Age skeletons and in the remains of people who died of bubonic plague in the 14th century. Further genetic analysis also suggests it may be 5,000 to 10,000 years old.

Given these findings, Dr. Slatkin said a number of factors could have contributed to the spread of the protective mutation in Europe. But the smallpox epidemic, he said, "remains a plausible explanation" for its relatively high frequency in Europe.

In fact, Dr. Slatkin estimates that if AIDS continues its deadly spread in Africa, the resistant trait could soar from near zero in the southern part of the continent to as high as 10 per cent in 200 years.

When Sunil Ahuja entered the arcane world of immune-system receptors in the early 1990s, it was, he says, "a sleepy field." But after CCR5's role in HIV was uncovered a decade ago, "there was a stampede."

Yet Dr. Ahuja, now an HIV researcher at the University of Texas Health Science Center at San Antonio, points out that a raft of other traits, both in and around the CCR5 gene, deserve attention.

"People have tended to focus just on this," Dr. Ahuja said, "but what about all of its other partner [mutations]?" Dr. Ahuja, collaborating with Lieutenant-Colonel Matthew Dolan of the U.S. Air Force Wilford Hall Medical Center, turned his eye to the genes that produce chemokines.

Since HIV locks on to chemokine receptors as its "kiss of entry" into a cell, he decided to investigate the genetic production of chemokines — molecules the body makes naturally to lock on to that same entry point. A gene called CCL3L1 does exactly that.

When Dr. Ahuja and Col. Dolan analyzed blood samples of more than 4,300 HIV-negative and HIV-positive people of different ancestral backgrounds, they found an astonishing thing: The human genome has mysteriously stockpiled extra copies of this gene.

Some individuals carry as many as 10 to 15 copies of the CCL3L1 gene (generally, people have been thought to inherit two copies of a gene, one from each parent). People of African descent, Dr. Ahuja said, were found to have on average six copies; Hispanics, three and Europeans, two. The study, published in Science in March of 2005, found the fewer copies of this gene people have, the more susceptible they are to being infected after having unprotected sex with someone who is HIV positive.

This is because with extra genes, the body throws so many of its own molecules at the CCR5 entry point, it gums up the lock and makes it tougher for the AIDS virus to break through, Dr. Ahuja explained.

From this, you might assume Europeans are more prone to HIV infection since they have fewer copies of this blocking gene than African populations. But the researchers found that the risk was relative to a person's population — it increased if you had fewer copies than other people in your ethnic group.

African Americans were found to be more susceptible to HIV infection if they had fewer than four copies of the gene. Hispanics were at greater risk if they had fewer than three copies and Europeans if they had less than two copies.

"What we see here is a gene dosage effect," Dr. Ahuja said. "The more genes, the more protection."

Having below the group's average number of genes significantly increased the risk of getting HIV — and the chances of having rapid disease progression. That risk may be even higher if there is a low number of the CCL3L1 gene and the riskier, unmutated form of CCR5.

"The point is that this is going to be a very complex story," Dr. Ahuja said. "There are many questions yet to answer."

Researchers face three major hurdles in finding genes linked to HIV infection. First, doctors don't often come across patients like Mr. Rosenes, who appear to have a natural, if partial resistance to HIV. In B.C., Dr. Harrigan said the trial studying long-term non-progressors has yet to recruit any patients.

Without the big numbers of a large study, it can be tricky to tell when a trait is important or just a personal quirk.

Nor is there any simple way to factor in all of the environmental and behavioural forces that affect a person's risk of contracting HIV.

Even Dr. Pépin admits that his study predicting HIV prevalence in mixed populations is limited by its inability to completely take environmental or behavioural factors into account.

Third, it has been difficult to know exactly where in the genome to look for traits that might confer resistance or susceptibility.

But the newly formed Center for HIV/AIDS Vaccine Immunology (CHAVI), a consortium of universities and academic institutions around the world, has this year launched a massive study it hopes will overcome these issues.

"We have these beautiful machines [for DNA analysis], and the money that the Gates Foundation has given to us, and we have had no people [to study]," said Amalio Telenti, an HIV researcher at the University of Lausanne in Switzerland who is working on the project.

But CHAVI has in fact just recruited 600 Caucasians from Europe and Australia who have all contracted HIV within the past decade. Researchers have access to their personal histories and medical files, and plan to scan half a million genetic mutations in each subject.

Dr. Telenti said the team is using the mutations set out in the Haplotype Map. That map is the first catalogue of the different genetic mutations found in four of the world's major populations — European, Chinese, Japanese and Nigerian.

Once this is complete, the second round of the project will focus on Africans or people of African descent, Dr. Telenti said. He then hopes researchers in other countries will use their approach to scan the genomes of other populations.

But while they are studying groups by ancestral background, Dr. Telenti said he does not expect to find major HIV-response differences between populations.

Rather, he said, it will more likely be the subtle effects of a number of traits.

"No one is looking for a miracle gene, but to help find targets for antiretroviral [agents]," Dr. Telenti said. "We need to understand the basis of susceptibility, and to what extent genes can explain that."

For Mark Wainberg, director of the McGill University AIDS Centre in Montreal, the hunt for genes that affect a person's response to HIV is well worth it, since it may lead to more effective therapies.

"Finding the mutation in CCR5 has already led to efforts to make a drug to block this," he said. "The thinking is, if there are healthy people walking around out there with deleted copies of this gene, then it would be a safe target for a drug."

As well, genes are already known to influence the way people respond to drugs, an issue that is becoming more urgent in the face of growing resistance to current antiretroviral therapies.

But Dr. Wainberg, co-host of this week's International AIDS Conference, also worries that people who believe they carry some form of genetic protection against HIV will become complacent: "It doesn't matter if you have one copy or two copies [of a gene], you should still have safe sex," he said.

Research suggests he has good reason to worry. A 2001 study found a correlation between gay men who carry two copies of the protective CCR5 mutation and an increase in risky behaviour.

Dr. Ahuja saw himself how the public might overestimate the power of genes to protect them from infection. When he once told The New York Times that two copies of the CCR5 protective mutation was like a "genetic condom," his voicemail clogged up with people wanting to know where they could buy it.

"Our guess would be that these viruses have been jumping from chimps into humans on countless occasions in the past," said Paul Sharp of the University of Nottingham, a leading expert on HIV's evolution. "But most of them don't make it to be an epidemic. In fact, until recently, none of them had made it out of rural areas or infected enough people to be noticed."

HIV is believed to have been killing people in Africa for roughly 50 years before the world knew the virus existed. Yet scientists have since discovered the pandemic virus was one of three types of HIV that jumped to humans around the same time. But due to a fateful confluence of events and genetic accidents, only the one — HIV-1, group M — gave rise to the global scourge that continues to stump medical science.

The king of freeloaders

HIV belongs to a group of pathogens known as retroviruses. They were once considered rare, medical curiosities and only late in the 20th century were they discovered to actually infect humans.

They have no ability to replicate outside of a host cell and they carry their genetic material not in the double-stranded code of DNA, but the single strand of RNA that makes proteins.

HIV is a retrovirus with just nine genes tucked inside a round protein envelope. Magnified, it looks a little like the wheel of a ship, circular with spikes radiating from its surface. The virus makes its way through the world on rivers of bodily fluids, striking humans at their most intimate points of contact — sexual intercourse, childbirth, breastfeeding. Tainted blood and intravenous drug use have also been sources of transmission, and HIV has developed uncanny methods to spread itself. Outside of a human host, it's powerless.

"It's a bit wimpy that way," said Richard Harrigan, director of the research laboratories at the B.C. Centre for Excellence in HIV/AIDS. A few hours outside of a human body and the virus is no longer infectious, he said; nor can it be easily grown in a lab dish.

But inside a T cell, the story is dramatically different. T cells are lymphocytes, or white blood cells, that orchestrate the body's ability to fight infection. The HIV attacks them, specifically a type known as CD4, like a guided missile.

The virus breaks in with its own set of keys and slips into the host cell like an unwanted guest. Then it settles down to become the king of freeloaders, injecting its own genetic material into the DNA of its host and making an HIV factory of the very cell that was designed to kill it.

New viruses eventually burst out of the host cell to wreak fresh rounds of destruction. "Integrating itself directly into the DNA of the host means you can't get to it easily to cause its destruction without the risk of damaging the host's cell," Dr. Harrigan said. "It also makes lots and lots of copies of itself every single day."

How many copies?

"Oh," he said, "about 10 billion."

It started with chimps

Chimpanzees had long been the suspected source of the AIDS pandemic. HIV bears a close genetic resemblance to a chimp infection known as simian immune deficiency virus, or SIVcpz.

But it was only this spring that an international team of scientists, led by Beatrice Hahn at the University of Alabama, was finally able to confirm that this chimp virus exists in the wild and that it was indeed the progenitor of HIV-1.

Dr. Sharp, who, along with researchers in France and Cameroon, has worked with Dr. Hahn's group since 1991, said the study, published in Science, was a long time coming. Collecting blood from wild apes was considered too invasive and dangerous, so researchers spent years developing molecular tests to run on chimp droppings instead. The samples, amassed with the help of trekkers, were scooped up from 10 remote areas of forest in central West Africa and preserved in tubes.

Molecular tests on the samples were able to determine the species and sex of the animal to whom it belonged, whether it carried antibodies for an SIV, or genetic material of the virus itself. The results showed the virus most closely related to the HIV-1 pandemic strain was indeed the SIVcpz strain.

Researchers believe it jumped to a single human from a chimp in southeast Cameroon about 70 years ago.

Scientists can estimate the date because viruses are believed to mutate at a fairly constant rate. By comparing the oldest known HIV strain with its progenitor chimp virus, they can clock when the two diverged and one crossed the species barrier.

"The only missing part of the story is from one person [contracting it] around about 1930 or a little earlier, getting infected with the virus and then getting it down to Kinshasa," Dr. Sharp said.

Kinshasa is considered ground zero of the AIDS pandemic, since the HIV-1 subtypes there are older and more diverse than anywhere else in the world.

"We would imagine that this virus has been transmitted down rivers ending up in Kinshasa, known as Leopoldville in those days," Dr. Sharp said. "The virus needed to get to somewhere like that, it needed to get to a big city before it could really get started as an epidemic."

The earliest known case to come from the continent would not, however, be diagnosed for several decades. A blood sample taken in 1959 from a Bantu man participating in a medical study in Kinshasa was found in the 1980s to be HIV positive. By then, the virus had the world's attention.

Mass cellular slaughter

Ask where the AIDS virus ranks among its peer pathogens and scientists rarely hesitate: "In terms of its smarts, it's right up at the top," said Mark Wainberg, director of the McGill University AIDS Centre. "Not only does it know how to escape from everything we throw at it, but if you're the virus, your main objective . . . is to survive and spread yourself to as many people as possible. You don't do that if you're a virus that kills your host within a week. If you want to be efficient at spreading yourself, you want your host to stay alive for a number of years and remain infectious throughout that time."

In its early stages, HIV triggers a mass slaughter of its host's T cells, most notably in the gut. Tissues that line the intestines contain more lymphocytes than any other single site in the body.

"This is the largest organ in the body in terms of the immune system. If not the heart, the soul of the immune system," Dr. Wainberg said.Scientists have found it can take up to four months before the immune system kicks in to produce antibodies that can be detected in a blood test.

"The immune response you see with HIV is somewhat slower than what you see with lots of other infectious agents," Dr. Wainberg said. "Probably because the immune system is overwhelmed, partly because the virus is infecting the very cells that we need to respond quickly. It's a very insidious virus."

The earliest phase of infection is also the most contagious. With no immediate immune response, the patient's "viral load" — the medical term for the number of HIV particles in a given volume of blood — soars.

"Before a person knows they are infected, they are at their most infectious and because they don't know it, they are not practising safe sex," Dr. Wainberg said.

Once the immune system responds, the viral load drops, reducing the risk of transmission. The viral load can remain low and stable for several years. But that number will eventually rise again, resulting in big losses of T cells that can lead to acquired immune deficiency syndrome without effective treatment.

AIDS leaves the body with an immune system so crippled that opportunistic infections, such as pneumonia, tuberculosis and certain cancers pose a sudden and serious threat. Yet one intriguing hallmark of HIV in humans is how few T cells actually become infected. "At any given time, it's less than 1 per cent," Dr. Wainberg said. "Yet the number of losses of T cells can be profound."

Dr. Wainberg said the accepted theory is that HIV not only kills the cells it directly infects, but that infected cells secrete a substance toxic to other, uninfected T cells. This in turn triggers the body's own killing of these other cells.

Adapting to new hosts

The HIV-like virus chimps carry is a descendant of two other ape viruses — one that infected red-capped mangabeys and another that infected Cercopithecus monkeys.

"The ancestors of those two monkey viruses have recombined to form what is now the chimp virus [that gave rise to HIV]," Dr. Sharp said.

No one knows exactly when chimps contracted it, but it's estimated to be anywhere from 70,000 to 1.5 million years ago. Neither can anyone say how the virus first affected chimpanzees. It may well have wiped out all chimps without a natural resistance, Dr. Sharp said. "We know at the moment, these viruses don't cause any illness in chimps. They get infected, but they never get to the stage of deteriorating.

"The real problem with AIDS is that you are destroying your own T cells, and when you've destroyed your own T cells you are susceptible to infection. If somehow the immune system can avoid recognizing the virus and destroying them, you may be okay."

The chimp's immune system, for example, has somehow learned to simply ignore the infection, Dr. Sharp said.

Dr. Sharp has lately been studying the three separate HIV-1 groups that jumped from chimps to humans on separate occasions. His hope was to find something that distinguished them from the chimp virus that spawned them.

"The logic of our ongoing analysis was to say, well if we find a site in a gene which is the same in each of the HIV groups, but different in all the chimp viruses, then those are changes that have occurred in all of the three groups leading to HIV," he explained, "that would be too big of a coincidence for it to just be an accident. It must be something that has been selected for as the virus adapts to its new host."

The hunch bore fruit. Dr. Sharp has located a single chemical change in a protein important to the core matrix HIV-1. The change is there in all three groups of the human form of the virus, but not the chimp virus.

What's more, Dr. Sharp learned that a research project 10 years ago showed that when chimps are infected with HIV-1, the virus does not fare well. But over time, the virus adapts and the protein switches back to the original form it originally had in chimpanzees.

"This tells you it's important for the chimp virus to have it one way, and to move into humans to have it this other way."

Looking to the future

People often ask Dr. Sharp how it could be that a virus like HIV could go undetected for half a century, infecting one person in 1930 to 40 million by 2000. But he's done the math, and he feels numbers as well as geography explain it.

"If you did just the simplest epidemiological plot . . . you see only about 2,000 people infected in 1960. . . . Even by 1980, you are only getting up to a million people.

"It takes a long time for the numbers to build up. It really is not at all surprising that nobody knew about this virus in 1960; there just weren't that many people infected and they were all in Central Africa.

"So it's no surprise to me that the virus went undetected for so long."

What concerns him more is that about 30 species of monkeys in Africa carry simian immune deficiency viruses. "With continued exposure to these viruses, more of them could jump into humans," he said.

"There is an ongoing risk."

"That's how it is now, with the young people gone," she says. She has two sons left, but one, Lakson, has been too sick to work since February. The other is off trying to find a job at a sawmill. If he finds work, his wage will buy food, but it won't extend to a trip into town, where Lakson could get an HIV test.

Things in Kitwe are terrible. The situation isn't new, and to most of the world, it isn't even that interesting. The intriguing question is this: In Kitwe, and places like it, why aren't things worse?

In the late 1990s, as the world woke up to what AIDS was doing to Africa, international agencies began to make increasingly alarming predictions. The World Bank and United Nations pointed out that the disease was robbing sub-Saharan countries of the precious development gains they had made over the previous couple of decades -- that child mortality was rising, not dropping, that life expectancies were in free-fall.

They began to predict that the continent's frail economies would not only fail to grow, but that they would contract as the most productive workers died. That police services and militaries would buckle as their young, male ranks got ever thinner. That gangs of unsocialized orphans would turn to crime and violence. That people would starve as farmers grew too sick to work. That governments, robbed of their civil servants, teachers and nurses, would no longer function. That citizens weakened by illness or the demands of caring for others would withdraw from public life.

Experts began to predict the imminent collapse of the worst-hit countries.

Here's the World Bank in 2003, commenting on South Africa, the continent's most robust economy and the world's most-HIV-infected country: "If nothing is done to combat the epidemic . . . a complete economic collapse will occur within three generations."

And here's Stephen Lewis, the UN Special Envoy on HIV-AIDS in Africa, in 2002: "I wouldn't discount the possibility, 10 or 15 years down the road, of failed states."

The phrase "failed states" evokes images of a country in complete anarchy. But sometimes states fail more quietly, when they cease to be able to provide any level of services to their people, or to control their territory in anything but name. This sort of collapse began to seem particularly plausible in southern Africa, where three countries have HIV-infection rates approaching half the adult population and even those qualifying as "better off" have one in four adults infected.

To a great degree, many of the worst predictions have come true. By 2004, troop strength in Malawi's military had fallen below 50 per cent of what the government said was needed to maintain national security. In Botswana, life expectancy declined by about 30 years, to 35, between 1990 and 2004. Africa's share of world trade declined from 6 per cent in 1980 to less than 2 per cent in 2002. Africa is the only region of the developing world where food production fell over the past 20 years.

Botswana (37 per cent HIV prevalence), Swaziland (43 per cent) and Lesotho (39 per cent), all of them tiny countries with populations under 2 million people, seemed marked for dissolution. Even larger countries seemed to be at risk.

Zambia, for example. Although it has 11 million people, fertile land and mineral wealth, Zambia has always been one of the world's poorest countries. When its HIV infection rate crept past 20 per cent, many wondered how long the country could last.

The country's Minister of Agriculture said last year that production would have been two or three times higher if not for the number of farmers who had fallen ill or died. Zambia had full-scale food emergencies from 2002 to 2004, caused partly by lack of rain but hugely compounded by AIDS. The disease has also gutted other industries as well -- the Zambia Business Coalition says 82 per cent of known causes of employee deaths are HIV-related. The health system is at 50 per cent of necessary staff levels; Zambia has 600 of the 1,500 doctors called for in the national plan; only a third of nursing jobs are filled. In ministry buildings, there are whole hallways of empty offices, with staff sick, dead or at funerals.

And yet, Zambia's economy grew by 5.2 per cent last year. Copper mines are reopening as mineral prices push higher; the government is gearing up for a national election; there are rush-hour traffic jams in the cities and a crowd turns out for a public appearance by Miss Zambia 2006. Things are bad, but this is not a failed state.

Paul Spiegel, a Canadian in charge of AIDS policy for the UN High Commissioner for Refugees and a veteran of work in hard-hit African states, says the question increasingly puzzles researchers in all fields. "The hypotheses on everything from . . . orphans to states collapsing due to lack of people have not happened, and why is that? It's clear that coping strategies are more resilient than anticipated, but we haven't done enough research at community level to really know how it's working."

In Zambia, it is clear that the basic resilience of communities -- the capacity to absorb emotional, physical and financial burdens -- has proven far greater than anyone would have dared predict.

"It's amazing what this human race can do in the face of the most adverse conditions," says Brian Chituwo, a doctor who is minister of both health and education.

In most cases, communities have stepped in to pick up the burden of care and support that can't be met by the state. Take Stanley Chinoya from Kitwe, who spends his mornings at an orphan centre run by a local community group, Children In Distress. Here, he is finally learning his letters, and the volunteer teacher hopes he can catch up to children his age in a year or two. The group will then use international donor money to pay his school fees. Another local charity recently arranged for Stanley to receive anti-retroviral drugs.

Martin Rupiya, an expert on AIDS and security with the Institute for Security Studies in Pretoria, says the second thing to note about is that, in many cases, the state's presence was slim to nil to begin with.

"There are lots of parts of Africa where government simply doesn't exist," he says. "The Western idea of the state doesn't recognize the lifting done by traditional structures."

Catherine Sozi, a Ugandan doctor who heads the UNAIDS mission in Zambia, says Zambians organized to take care of the sick at home, to foster orphans, to pool their labour, because there was not and never had been any sort of official structure that might fill those roles. Indeed, she said, Zambia's national response to AIDS has been predicated on the idea that community groups will do the work.

"The government can provide policy and they're not bad at that, but they're not implementers, they can't do," she said.

Two other factors have helped to stave off the anticipated disaster. First, there are signs that HIV infection rates are levelling off or even dropping. Zimbabwe, Kenya and Ethiopia have all, in their latest surveys, found indications of slowing infection rates. And HIV, by its nature, allows time to adapt, with a lag of up to 10 years from the time people get infected to the time they begin to fall ill, and another few years before they die.

Most important, though, is treatment. Although Africa lags woefully in the provision of life-prolonging ARVs to people with HIV, it is also true that treatment has accelerated beyond what many people imagined possible just a few years ago.

Zambia, for example, has 51,000 people on public treatment -- only a quarter of those who need it, but up from 3,000 at the start of 2004. That number is enough to start to cushion the impact of the disease; it's the reason why there is only one person in each bed in Kitwe Central Hospital, and why there are men available to work in the area's reopened copper mines.

Military forces, meanwhile, have continued to function, even though their personnel -- young men in environments where alcohol and commercial sex are widely available -- are prime candidates for infection. Military discipline and structure means that all personnel can be inculcated with prevention messages, tested for HIV, treated and closely monitored. As a result, most African militaries now far outdo their governments in responding to the disease.

And despite the undeniable losses of productive young workers, African economies have not imploded as was anticipated -- partly because of the reality of who dies, says Alan Whiteside, head of the Health Economics and HIV-AIDS Research Division at the University of Kwa-Zulu Natal in South Africa.

"Some people are more important for driving a political system, an economy, etc.," Prof. Whiteside muses. "And the reality is that if you in some way have your drivers, your core, protected -- either because they are not infected or they can access ARV therapy -- then the epidemic won't have the same effect. I don't mean just the elite, you need the entrepreneurs . . . people who make things happen."

That's why Zambia is still showing modest growth, he says. It's why Uganda, the first African country hit by AIDS, averaged 6.5-per-cent annual growth through the past decade, becoming a development poster country even as deaths from the disease hit their highest levels. It's why South Africa, the most infected country in the world, posted its 87th consecutive month of growth in March.

The other doomsday prediction that did not come true in Africa was that of the orphans. Yes, the streets of Lusaka and Kitwe are filled with street children, a sight almost unknown of 12 years ago. But they haven't organized into criminal gangs and aren't considered an imminent threat to national security.

"I don't think that gangsterism will ever materialize," says Father Michael Kelly, an Irish Jesuit priest who has taught in Zambia since 1955 and is a leading expert on orphans. "There are young men and women in the [slums] trying to organize to do something -- it may be very shallow, but they are trying to hold the fabric together."

But Father Kelly and many others wonder how long it can last.

"Every community response has a limit," Dr. Chituwo says. "And the family network is cracking."

Dr. Sozi from UNAIDS agrees. "We're underestimating the impact, still. Go to clinics, go to the schools, if you're talking about development of a country -- that's where you're supposed to see it. Go to farms, the agricultural sector, the towns outside the capital -- the infrastructure is collapsing. It's too early to say disaster has been staved off."

Because of the way AIDS works -- waves of infection, then waves of illness, then waves of death -- it's possible only to say that total disaster has been delayed, Prof. Whiteside notes.

"We are still at the beginning of this . . . To really know what the epidemic means, we will have to wait 35 years," he says.

Anne Mumbi, the director of Children in Distress, watches Stanley Chinoya struggle with his letters and says something else gets lost in the doomsday scenarios.

"Zambia without AIDS would have been very different," she says. "We've lost quite a lot of those brilliant young people that I knew at university . . . in terms of human resources, well, your development depends on the human capacity you have." Zambians have proved resilient, yes -- but at what cost?

"The miracle of it is that somehow people survive," she said. "But you can't call it living."

Resilient states

In the late 1990s, as the world woke up to what AIDS was doing to Africa, experts began making alarmed predictions about the worst-hit countries. But although the damage has been great, these countries have not collapsed. Infection rates are dropping, treatment has improved and economies have churned on, while local communities have stepped in to take over many state roles.

Life expectancy

Average life expectancy at birth (years)

Population

Total population, in millions

Gross domestic product

Per capita (U.S. dollars)

*constant 2000 U.S. dollars

SOURCE: THE WORLD BANK

The massive effort required to stop this disease must be led by governments and international organizations such as WHO, UNAIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria. But, in many places, the governments are simply not able to do the job because of limited resources or -- as in the case of South Africa, Russia, Ukraine, most of the Caribbean and, until recently, India and China -- because of denial.

The only hope we have to start winning the war against AIDS is to have a clear and consistent message to overcome stigma and dismantle denial.

At the same time, we need to mobilize society for proven, effective interventions, including widespread HIV testing so people who test negative can remain negative, or be referred for treatment if they test positive; consensus on the use of condoms to prevent the sexual spread of HIV; development and distribution of anti-AIDS drugs that work well if appropriately prescribed and adhered to; and rolling-out treatment programs in the developing world is possible, feasible and often can be more effective than treatment in industrialized countries.

To help fill this gap, there is a huge potential role for the business sector. It was this simple theory that led to the creation of the Global Business Coalition on HIV/AIDS (GBC), a non-governmental organization that has grown from fewer than 20 companies five years ago to more than 220 today.

These companies, based around the world and employing more than 11 million people, have committed themselves to a broad range of activities.

These vary according to individual company core competencies but generally aim to educate and test workers and spread information about AIDS to their local communities or, in the case of great communications companies that are members -- such as Viacom, HBO, Reuters, BBC World Service, Yahoo, STAR, Sohu.com, Independent Newspapers, the French network TV5, and many others -- to a global audience. In some cases, GBC members offer treatment to infected workers and often to their families (this group includes Anglo American, De Beers, Eskom of South Africa, Coca-Cola, DaimlerChrysler, Heineken and Lafarge). A few of our members, led by American Express and Gap, have gone a step further and joined Product RED, a campaign committing a percentage of sales from certain products, such as the American Express RED Card, to the fight against AIDS. The GBC is especially proud of its eight Canadian members, which include Alcan, Barrick Gold, Indigo Books and Music, M*A*C Cosmetics, Power Corporation of Canada, Royal Bank of Canada, Sun Life Financial and TD Bank Financial Group. These companies make corporate Canada a leader in the effort to involve business in this fight.

Smaller businesses cannot usually do much on their own, and here more government effort is essential. And public calls, like those of Stephen Lewis, the UN Secretary-General's special envoy for HIV/AIDS in Africa, that private-sector corporations must devote a fixed 0.7% of pre-tax profits to the AIDS effort are simple-minded and work against the very noble goals they seek. But we should not argue over such empty rhetoric; there is work to be done. At the end of the day, when our careers -- in whatever field we have chosen -- are over and our children and grandchildren ask us what each of us did to fight the worst health crisis in history, what will our answers be? Will we have any answers at all?

Richard Holbrooke, a former U.S. ambassador to the United Nations, is president of the Global Business Coalition on HIV/AIDS.

Politicians should understand that religious values will not prevent millions of people who profess to adhere to those values from having unprotected, non-monogamous sex. The promotion of condom use should not replaced by alternatives that hinge on breathtaking transformations in human nature. Condom use can prevent the spread of HIV, period.

Politicians should understand that the establishment of safe needle-exchange programs for intravenous drug abusers will not promote illicit drug abuse but will help to prevent the spread of HIV. Promotion of these programs should not be a matter of political debate, since their implementation will neither promote promiscuous sex nor illicit drug use for children of parents who impart their own family values to their offspring.

A less politically charged prevention tool has emerged with evidence that male circumcision in poor countries may help to reduce the spread of HIV. (Circumcision is thought to interfere with transmission because the foreskin contains cells that are important portals of entry for HIV into the body.) World health officials are now assessing how best to train surgical specialists to perform circumcisions in areas where the procedure is not widely available. Politicians should understand the importance of financing this training.

We also need to promote prevention research. One key initiative is the development of microbicide products that women can self-administer intra-vaginally before sexual relations to protect themselves against HIV. Many women, particularly in developing countries, understand that their sexual partners put them at risk of HIV infection and that condoms represent an effective barrier but are not empowered enough to insist that a condom be used. The study of antiviral vaginal gels and foams is now far advanced, but additional resources are urgently needed to fund the testing of these agents.

And we need further study on pre-exposure prophylaxis of HIV disease. This concept is based on the notion that the same antiretroviral drugs used to treat people after infection might also interfere with the initial HIV infection, if taken daily by individuals at high risk. Sadly, clinical studies that were to have tested this hypothesis in developing countries have now been stopped, in part because of pressure by those who thought they were being performed to benefit the drug companies that provided their drugs for testing. The likely consequence of success in clinical trials would be that such drugs would be manufactured at low cost by generic manufacturers.

These issues all fall at the intersection of clinical science, public health policy, and the ethical considerations that must guide research and clinical trial implementation. Given the status of HIV as our common enemy in the most important war that humankind is now fighting, let's hope the political will to translate scientific achievement into successful prevention efforts will prevail.

Dr. Mark Wainberg is director of the McGill University AIDS Centre and co-chair of the XVI International Conference on AIDS.

Million receiving ARVs in Africa

More than one million HIV-positive people are receiving anti-retroviral therapy in sub-Saharan Africa, a UN agency says.

The World Health Organization says there has been ten-fold increase in treatment since December 2003.

The UN's goal is to provide universal access to HIV prevention programmes, treatment, care and support by 2010.

WHO HIV/Aids Director Dr Kevin De Cock told Aids conference delegates in Canada much still needed to be done.

Although sub-Saharan Africa has the greatest number of people on treatment, and the second-highest rate of treatment coverage among those who need it, the region still accounts for 70% of the global unmet treatment need, Dr De Cock said.

"We have reached just one-quarter of the people in need in low and middle-income countries, and the number of those who need treatment will continue to grow," he said.

"Our efforts to overcome the obstacles to treatment access must grow even faster."

Some 24% of people needing ARV treatment worldwide were receiving it by June 2006, he added.

Lemons and garlic are displayed next to condoms and anti-retroviral drugs on the South African stand at Toronto's international Aids conference.

Apples, nectarines and other tastier fruit were apparently included earlier, but were soon eaten, an official said.

South Africa's health minister has long promoted a diet including garlic and lemon as a way of treating Aids.

In 2004 the government began providing Aids drugs but activists still question its commitment to fighting HIV.

The exhibition represents "South Africa's response to Aids - the most comprehensive in the world," an official at the stand told the BBC's Lee Carter.

"The theme is talking about issues around nutrition, and also prophylaxis and treatment," he added.

But the approach attracted controversy, particularly since the bottles of anti-retroviral drugs were only added to the stand some time after the fruit and vegetables went on display.

'Despicable'

One doctor from the paediatric Aids unit at Baragwanath Hospital in Soweto challenged the organisers of the exhibit to provide scientific evidence that any of the foodstuffs on display were clinically effective.

"It's despicable that you bow to the minister's wishes and put the exhibit together in such a way," Dr Harry Moultrie said, quoted by Beeld newspaper.

At the same time, a Southern African Development Community (SADC) report says the main reason for the spread of HIV/Aids is people who have multiple sexual partners and are not consistently using condoms.

The study says casual sex and intercourse with sex workers are no longer the main causes of new HIV infections.

It says traditional high-risk groups, such as prostitutes, mineworkers and truck drivers, are, in fact, better protecting themselves against infection.

AIDS immunity under the microscope - 17/08/06

One in every 300 people living with HIV never becomes sick or needs to take even a single drug to fight their infections, according to a surprising statistic released at the International AIDS Conference on Wednesday.

Researchers have long known that some people have a natural resistance to the AIDS virus. But only now, 25 years into the epidemic, are they discovering the scope of a phenomenon they're calling “elite controllers.”

These are people with HIV who have the mysterious ability to stop the virus from replicating, even without medications. An international research consortium is now anxiously recruiting elite controllers for a new genetics study.

“If we could discover how these individuals can co-exist with this virus without damage to their immune system and could find a way to replicate that ability in others, we would have a recipe for halting the HIV epidemic,” said Bruce Walker, a professor at Harvard Medical School and one of the study's key organizers.

Researchers believe solving the biological mystery could form the basis of a vaccine.

“There is a reasonable chance we will come up with something very important with this,” said Dr. Walker. “We need patients.... We need to get the word out.”

Researchers have to enroll at least 1,000 elite controllers in order to make sure they have enough numbers to make meaningful genetic discoveries. About 200 patients are expected to be recruited from Canada, where 25 patients have already signed on.

Rafick-Pierre Sékaly, a McGill University immunologist and study investigator, said the Canadian subjects have been HIV positive for seven to 15 years but are healthy and have never required treatment.

In most people infected with HIV, the human immune system cannot stop the virus from replicating without medication. In the absence of treatment, HIV makes so many copies of itself it eventually overwhelms the host's immune cells and the person grows sicker.

But an elite controller has fewer than 50 copies of HIV per millilitre of blood, Dr. Sékaly said. This is a level considered undetectable by current tests. Researchers also hope to recruit 1,000 so-called ‘viremic controllers.' These are healthy people whose blood samples show 2,000 viral copies or less.

The researchers had stipulated at the outset that subjects had to be infected for at least a year to qualify for study enrolment. But doctors have found the 200 patients enrolled so far have lived sickness- and treatment-free with HIV for an average of 15 years.

“You're sitting across from these patients,” said Dr. Walker, “and you just feel like, oh, the answer is there right in front of you, we've just got to fish it out of them.”

He also guessed it was unlikely that these people would ever see their infections progress, and that they would, in the end, likely die of something other than AIDS.

Loreen Willenberg, a 52-year-old landscape designer from Diamond Springs, California, learned in 1992 that she was HIV positive. Since then she has battled the emotional impact associated with the stigma of having HIV in a small town, and opted only to “come out” with her HIV status earlier this year.

But the disease, she said, took no physical toll: “I'm in perfect health,” Ms. Willenberg told a press conference Wednesday. “I've maybe had one cold in 14 years.”

In response to a journalist's question about her diet, Ms. Willenberg said she eats many fruits and vegetables, but that she is not a vegetarian. She added that she is not a fast food eater and never has pop or candy in the house.

But Dr. Walker noted other elite controllers in the study eat fast food “non-stop.”

The test subjects also do not have in common any of the genetic traits known to be associated with HIV resistance, said Dr. Walker, who is also director of the Partners AIDS Research Center at Massachusetts General Hospital.

Neither have these elite controllers “contracted some wimpy form of this virus,” Dr. Walker said. Some of these protected patients know who infected them and those people have gone on to get ill. But researchers still plan to sequence the DNA of the viruses infecting them.

It is unknown at this point if any elite controllers have ever passed on HIV. But having a low viral load is believed to significantly reduce the chance of transmission.

Doctors have long remarked on the puzzle of the patients, also known as “long-term non progressors.” But it wasn't until the mid-1990s when viral-load testing became available that researchers were able to clearly identify people who could keep HIV in check.

Dr. Walker said that a majority of these elite controllers have not disclosed that they are HIV positive.

“They also feel a sense of guilt because they are survivors,” Dr. Sékaly said. “They have seen their friends die and they have never even been sick.”

Ms. Willenberg once wrote an article on her strange condition, entitled, “Partially HIV Positive.” “She didn't feel like she belonged to the infected or the uninfected,” said Dr. Walker.

Dr. Walker estimates that 2,000 people in North America are elite controllers. But he suspects the one-in-300 number applies to HIV infected people all over the world. Research in South Africa, he said, indicated a similar finding.

Just recently, Dr. Walker said, he gave a course to 500 doctors who treat AIDS patients and asked how many had elite controllers in their practice. “Half the hands in the room went up,” he said. “Then I asked, “what have you done with [them or this information] and they throw their hands up in the air ... no one knows.”

Among the theories researchers are considering is that elite controllers may have natural anti-viral factors in their cells. It could be that the immune system of the elite controllers offers up a weaker immune response to HIV, preventing the body from over-killing its own T-cells. But all of these things are likely to be effected by genetic traits.

The study team plans to take blood and DNA from study participants and promises strict confidentiality.

Their genomes will be scanned for mutations already identified in the Haplotype Map. That map spun off the human genome project and pinpointed the most common gene mutations in four different ethnic populations. The McGill team will then analyze the function of the important traits they find.

“One of the key problems with the development of a vaccine,” said Dr. Sekaly, “is that we don't know what response to mimic."

Delivering vital medical care — on the house

TORONTO — Some came requesting rapid HIV tests. Others sought methadone for their opiate addiction. And a fair number, looking tired and weary, came with more mundane complaints of sore throats and headaches.

More than 300 people attending the International AIDS Conference during the past few days have sought medical care at the health clinic, a cheerful place tucked in a basement corner of the Metro Toronto Convention Centre.

At the side of the clinic, which usually functions as a bar, are all the usual things one might expect in a makeshift supply cabinet and a little more: antibiotics, anti-inflammatory drugs, medicines to treat sexually transmitted diseases, pregnancy tests and Plan B, an emergency contraceptive.

“The idea of providing health services is to make it convenient and cheap,” said Brian Cornelson, the conference's medical director. “What we want people to do is minimize the time that they would need to be away from the conference to get health care and not to be avoiding health care at the early stage of an illness because they are afraid of the cost and uncertainty.”

At the free clinic, doctors and nurses see those with addictions, patients suffering from headaches or fatigue, and they see the unusual — such as a man who had a malfunctioning screw on his leg brace.

Wamarou Traore, a 49-year-old virologist from Burkina Faso, a West African country, was fiddling with his custom leg brace, a device made necessary after he was struck by polio as a child.

“It's all this walking around,” Dr. Traore said in an interview, in explaining how the screw was about to break.

Dr. Cornelson, an amiable man with a towering stature, examined his patient's brace and recognized it had to be fixed straight away. And he managed to work a little bit of magic: He telephoned St. Michael's Hospital, where one of his contacts arranged for Dr. Traore to get the brace fixed free of charge at an orthopedic appliance provider on the east side of Toronto.

No sooner did that end when Mark Bardsley, a 46-year-old from Philadelphia, came in complaining of dizziness, a tingling from head to toe and difficulty concentrating. The night before, he said, he suffered from a headache but nothing as severe as the migraines he had in the past.

Mr. Bardsley, who is also a registered nurse, gave his history: he has high blood pressure, is HIV-positive and has suffered some recent prostate problems. More than a decade ago, he suffered a transient ischemic attack, known commonly as a mini-stroke, following a visit with a chiropractor.

After doing a neurological exam and checking and rechecking his blood pressure, Dr. Cornelson, who works at St. Michael's Hospital as an HIV primary care physician, was concerned that Mr. Bardsley may be having another mini-stroke.

But after a careful examination, he was satisfied Mr. Bardsley's condition was likely related to his elevated blood pressure and the aftereffects of a migraine. He instructed Mr. Bardsley to increase his blood pressure medication and, if his condition worsened, he should call 911 and go to hospital.

The assurance that HIV test results in Canada are kept confidential was part of the draw for five patients seeking to know their status. Rapid test results of the five — three from Africa, one from Iran and one from Canada — were all negative, Dr. Cornelson said.

As well, seven patients have received methadone for their opiate additions, either by prearranging care before coming to Canada for the conference, or in a few cases, requiring it after it was spilled or lost. While the services of health care staff are free, the methadone, which is given orally with an orange drink, is not. The patient must pay.

“Some have come once and some have come on more than one occasion,” said Thea Weisdorf, a family physician at St. Michael's who is on call to treat those who require methadone. “Some missed seeing their regular provider or may have gone a few days without methadone.”

Whatever brings patients to this health clinic, many of them will be greeted by a smiling Grace Bezaliel, who works at the front desk of the clinic as a clerical administrator. She took a week's vacation from St. Michael's so she could work for free in the clinic during the conference.

“I came here as a refugee from Zimbabwe in May of 2002 and I want to give something back,” Ms. Bezaliel explained. “I have lost friends to AIDS.”

Playing up the ‘play safe' message

TORONTO — Every day, an estimated 1,500 children under the age of 15 become infected with HIV/AIDS. A larger number still lose one or both of their parents to the disease, further swelling the ranks of the 15 million AIDS orphans.

Getting to those children — the next generation — with a strong prevention message is seen as one of the key elements in reining in the epidemic.

But how, especially when far too many children, and girls in particular, do not have access to education?

“Sport, physical activity and play are low-cost, effective tools to reach young people with key prevention methods about HIV/AIDS,” said Bruce Kidd, dean of physical education at the University of Toronto. He has done extensive work in Zambia

Thursday, the 16th International AIDS conference will feature the first session on sport as a tool for HIV/AIDS education.

Right to Play, a Toronto-based humanitarian group founded by Norwegian speed-skating star Johann Olav Koss, uses sport and play as development tools for children in 23 of the world's poorest, war-ravaged countries. It reaches an estimated 500,000 children a week.

The “Live Safe, Play Safe” program focuses specifically on HIV/AIDS education. It's a soft-sell approach, where the focus is on having fun, but education messages are blended into the games children play.

For example, “condom tag” involves designating one child as HIV/AIDS who tries to tag others; the catch is that children carrying a condom balloon are safe. The games are preceded by a discussion led by a coach-educator.

Safari Kayisire, a Right to Play athlete-ambassador in Rwanda, said the key part of the program is for children who have suffered through war, displacement and the AIDS epidemic to have fun. But he added that, while shy at first, children look to him as a mentor allowing him to have frank and open discussions about HIV/AIDS.

“There's a lot of misconceptions about AIDS, and it's tough for parents to talk to their children about the problem,” Mr. Kayisire said.

Dr. Kidd said children the world over love to play and fascination with sport and games can be harnessed to teach them about HIV/AIDS. He said playing sports builds self esteem and helps develop important social skills that are essential as a child matures into a sexual being.

He cited research that showed teenagers involved in sports initiate first intercourse at a later age, have lower rates of sexually transmitted infections, lower rates of teen unwanted pregnancy and are less likely to be victims of sexual abuse.

Critics, however, say it's a stretch to think this research, conducted in wealthy countries, necessarily applies to children dealing with the harsh realities of HIV/AIDS in developing countries. They also complain that the impact of play-based programs has not been rigorously tested, and say money would be better spent on more tried-and-true measures.

Joey Cheek, a U.S. speed skater and Olympic medalist, made headlines around the world when he donated the $40,000 bonus he received for winning gold in Turin to Right to Play. He said he had no doubt about the effectiveness of the program because he has seen the faces of children involved in the programs.

“This really drives home the prevention message, and it does so in an intuitive and fun way,” he said.

Canadian speed skater Clara Hughes celebrated her gold-medal victory in a similar fashion, donating $10,000 of her own money to Right to Play. That, in turn, generated hundreds of thousands of dollars in donations from the public.

Mr. Cheek has now travelled to the AIDS Conference to promote the group's latest initiative. “I've spent my whole life in the selfish pursuit of Olympic glory and I wanted to do something more meaningful,” he said

Thursday, Mr. Cheek and Mr. Kayisire will conduct a “Live Safe Play Safe” session in downtown Toronto.

Chinese prostitutes raise AIDS risk

Mainland Chinese prostitutes, who flock to Hong Kong in large numbers to make a living, are failing to protect themselves, and the number of HIV/AIDS infections is expected to rise, social workers say.

Groups that counsel sex workers say prostitutes are frequently questioned by police, searched, detained and expelled if condoms are found on them. This is prompting many prostitutes from mainland China to ditch the prophylactics for fear that they will be caught.

Although condoms are legal and Hong Kong laws do not empower police to detain anyone found with a condom, police are intimidating and expelling prostitutes from China, the groups say. Prostitution is legal in Hong Kong, but foreigners violate the conditions of their stay if they are caught working.

Social workers say such police must stop this practice or it will fuel a rise in sexually transmitted diseases such as AIDS.

"Police must stop using condoms as an excuse to arrest women because this makes women vulnerable to disease," said Elaine Lam of Ziteng, the most established help group in Hong Kong that is devoted to commercial sex workers.

Loretta Wong of AIDS Concern, another Hong Kong group, added: "The government is contradicting itself. Although the Health Department is promoting condom use, the police (are) using it to prosecute sex workers."

Their call strikes a chord with key messages delivered at the 16th International AIDS Conference this week in Toronto. Experts agree that preventing transmission of the disease among prostitutes is crucial to controlling the AIDS pandemic.

"There are still far too many instances where punitive laws, stigma, gender inequities and lack of access to needed prevention and care services conspire to fuel the HIV pandemic," said conference Co-Chair Dr. Mark Wainberg, director of the McGill University AIDS Center

At the conference opening on Sunday, Microsoft founder Bill Gates, whose foundation has given hundreds of millions of dollars to fight AIDS, criticized governments and politicians who refuse to talk to and help prostitutes.

"We need tools that will allow women to protect themselves. This is true whether the woman is a faithful married mother of small children, or a sex worker trying to scrape out a living in a slum. No matter where she lives, who she is, or what she does a woman should never need her partner's permission to save her own life," Gates said.

POVERTY

Some 650,000 people in mainland China are living with HIV/AIDS, according to the latest UNAIDS report, but only 32,500 are classified as female sex workers -- a figure that social workers say is a gross underestimation.

In Hong Kong, there are an estimated 300,000 prostitutes at any given time, half of whom are from mainland China, Ziteng said. This figure stood at 200,000 in 1991.

Since Hong Kong was returned to Chinese control in 1997, it has become increasingly easy for mainland Chinese to visit the city, and many flock here for higher wages, although they come illegally.

According to Lam, prostitutes in China earn as little as five yuan (US$0.60) in construction sites and along truckers' routes, to 300 yuan ($38) in posh karaoke bars for the very few lucky ones.

Many choose to come to Hong Kong, where they earn between HK$40 (US$5) and HK$150 (US$19) from each customer. They need to fork out, or borrow, at least 5,000 yuan (US$626) to secure two-way visas to Hong Kong, which are good for only seven days.

"Because they have such a short time to try to make money, many of the girls are desperate and have no bargaining power. When customers offer to pay more for unprotected sex, the girls will agree," said Chung Sze-wan of Ziteng.

Many women are also ignorant. "We know of girls who have never seen condoms in their lives," Chung said, adding that women who manage to recoup the money they paid to come to Hong Kong and make a profit are those who do not insist on safe sex.

"Many of them have children and husbands and they want to protect themselves, but they still take the risk. They literally ... risk their lives," she said.

Ziteng provides free health screenings for sex workers and in a 2005 survey, seven out of 58 women tested positive for the human papillomavirus, which is sexually transmitted. There are more than 100 strains of this virus and high-risk types can lead to cancer. Six of the seven women were mainland Chinese.

The health risk is not confined to China and Hong Kong as many of these Chinese women are traveling further afield.

"We see them going everywhere after transiting in Hong Kong. Malaysia, Singapore, Italy, Japan, Australia, Taiwan," said Lam.

"People see them as a carrier of the (HIV) virus but they are really victims because they are forced not to use condoms."

'Elite' HIV patients mystify, intrigue doctors

TORONTO  - As many as one in 300 HIV patients never get sick and never suffer damage to their immune systems and AIDS experts said on Wednesday they want to know why.

Most have gone unnoticed by the top researchers, because they are well, do not need treatment and do not want attention, said Dr. Bruce Walker of Harvard Medical School.

But Walker and colleagues want to study these so-called "elite" patients in the hope that their cases can help in the search for a vaccine or treatments.

"What in the heck is going on in people that successfully control this virus?" Walker asked a news conference held at the 16th International Conference on AIDS.

"If we can figure out how people are doing that, we can try to replicate it."

So far Walker and colleagues have not been able to find out why certain people can live for 15 years and longer with the virus and never get ill. The AIDS virus usually kills patients within two years if they are not treated.

Some even appear to have weak immune responses, he noted. "Is it just that these people got infected with a wimpy virus? The answer to that is no," Walker said.

"Some of the people know who infected them," he added, and in those cases, the person who infected the "elite" patients always went on to become ill.

A few years into the AIDS epidemic, researchers identified people who were called "long-term non-progressors." These were patients infected with HIV who did not become ill.

Many have become ill as the years have gone by, and required treatment.

Walker said a few of the long-term non-progressors were now classified as "elite" patients. But the difference is that the "elite" status is clearly defined by how much virus they have circulating in their blood.

Loreen Willenberg, of Diamond Springs, California, is a newly designated "elite." Now 52 and healthy, she said she became infected in 1992.

BAD DREAM

"I dreamed that I was HIV positive," Willenberg told the news conference.

"I was really going through a very bad flu." She sought testing, and after getting an inconclusive result was later declared HIV positive.

HIV patients are not immediately put onto drugs that can keep them healthy, but wait until the virus reaches a certain level in the blood or until the virus kills a certain number of immune system cells called CD4 T-cells.

Willenberg, a landscape designer, never got to that point

"I am in perfect health. I think I have had maybe only one cold in the past 14 years," she said.

Walker has tracked down 200 elite patients and has now joined up with other prominent AIDS researchers to find at least 1,000 "elites" in North America and as many as possible globally.

Based on research done so far, Walker estimates there are 2,000 of them in the United States.

His team wants to take blood and DNA samples to see what might be different about them. Confidentiality is promised.

The recently published map of the human genome will make this possible.

They will compare key genetic sequences of the "elite" patients to genetic readouts from healthy people and from other HIV patients. Maybe a few genetic variations can explain what is happening, Walker hopes.

World Bank urges Thai model for AIDS prevention

TORONTO  - Developing countries with few resources to fight AIDS could take their lead from Thailand's prevention programs of recent years, which have allowed it to provide nearly free drug treatments to patients, the World Bank said in a report on Wednesday.

A former hot spot for the virus, Thailand has more than halved the number of new HIV infections over the past decade, and has won praise for its National Access to Antiretroviral Programme for People Living with HIV/AIDS (NAPHA). The program, started last October, provides antiretroviral drug treatment for nearly 80,000 Thais, more than 90 percent of those who need it.

But the seeds were planted about a decade earlier when Thailand made AIDS prevention a top priority. It introduced initiatives such as the 100-percent Condom Program, which promoted usage among sex workers.

This and other programs, combined with a wide network of district level hospitals and rural health clinics, have enabled it to control infection levels and allowed it to implement the NAPHA program, the bank said.

Without the prevention campaigns, Thailand would have had 7.7 million HIV cases and 850,000 AIDS cases in 2005, about 14 times more than today, the bank estimated in a report during the 16th International AIDS conference in Toronto.

"What we figured is that for every dollar they spent on prevention, they saved about $43 in treatment costs. That makes a benefit-cost ratio of 43-to-1, which is unheard of," Mead Over, a World Bank economist and co-author of the report, told Reuters.

The bank estimates Thailand has avoided the need to spend an extra $18.6 billion on treatment over the decade through 2012.

It says countries such as China and India, where the epidemic is at an earlier stage, could take lessons from the Thai programs

"Thailand's past success with prevention is the most important reason the country can afford universal access to (AIDS treatments) today. Furthermore it is an essential condition of its continued ability to afford treatment in the future," said Over. 

UP TO 6 MILLION COULD BENEFIT

Under the NAPHA program, a patient can walk into a hospital or rural clinic and pay 30 baht (80 U.S. cents) for treatment.

In the report, the bank says that 5 million or 6 million people worldwide could immediately benefit from similar treatment, but only 700,000 are receiving the therapy.

However, the bank warns that Thailand's costs will rise as an increasing number of surviving patients -- the bank estimates 572,500 Thais were living with HIV/AIDS in 2004 -- turn to so-called second-line drugs, which are seven to 28 times more expensive than those given as the first course of treatment.

Many of these drugs are patented and sold by large pharmaceutical firms. This means Thailand will have to decide whether to pay their prices, negotiate more favorable terms or exercise its rights under World Trade Organization rules to issue compulsory licenses, which allow other makers to produce a patented drug without permission from a foreign patent owner.

The bank says by exercising compulsory licensing, Thailand could save about $3.2 billion in health costs through 2015.

But by doing so, the government would run afoul of U.S. policy, which is a serious concern, Over said, noting that $3.2 billion represents just a fraction of the value of Thai exports to the United States in the past year.

MSF demands action for half a million AIDS infants

TORONTO - Urgent action is needed to treat more than half a million children in need of AIDS drugs and to slash the price of these life-saving treatments, a top medical relief agency warned Tuesday.

Doctors Without Borders (Medecins Sans Frontieres, MSF), said at the world AIDS conference here that only five percent of 660,000 children around the world who desperately need antiretrovirals -- the so-called "cocktail" of AIDS drugs -- had access to them.

The Nobel Peace Prize-winning agency also lashed giant pharmaceutical firms for failing to invest in pediatric AIDS drugs. Most child victims of AIDS live in developing countries, and caring for them does little to swell corporate profits, it charged.

Many infant AIDS victims live in crushing poverty and contracted the disease as infants from HIV positive mothers who themselves have no treatment or prenatal care, MSF said.

Tragically, without medical care, half the children born with HIV die before the age of two.

"We know that treating children works, but with better tools, we could be treating so many more," said Moses Masaquoi, a doctor with MSF in Malawi.

"We see the number of children born with HIV constantly growing in Africa, because expecting mothers don't have access to ante-natal care and children born to HIV positive mothers are largely lost to follow-up.

"It is an enormous frustration that we meet in our daily work."

More than 2.3 million children are living with HIV, the majority in sub-Saharan Africa, where the disease has cut a swathe through poverty-stricken populations.

Of these, 660,000 have an immune system that has been badly compromised by HIV, exposing them to the risk of killer infectious diseases such as tuberculosis and pneumonia.

MSF warned that international agencies already battling AIDS have been late to spot the devastating toll among infected children, and said if the situation is not tackled soon, remedies will come too late.

Alongside the warnings, MSF released two studies which showed good results among HIV infected children treated with antiretroviral drugs.

The potential benefits from such therapies however are limited, as pediatric medicines are overpriced -- costing up to six times more than equivalent drugs for adults, the agency said.

MSF said treating children was fraught with challenges. Diagnosis is tough because antibody-detection tests used for adults are inappropriate for newborns, and test results take too long to process.

The lack of pediatric doses means caregivers must split antiretrovirals used for adults -- an imprecise method of treatment.

For children who weigh less than 10 kilogrammes (22 pounds), even that strategy will not work. The only treatment option is a syrup that the agency said is difficult to measure, tastes bitter and often needs refrigeration.

"Sometimes it is not possible to treat children in the villages because you can't refrigerate a certain type of syrup, and the other one that does not have to be refrigerated provokes anaemia," said Myrto Schaefer of MSF in Australia.

"And then you have a baby of less than three kilogrammes who already has anaemia, and you can't give it to him!"

Adding to the frustration is the fact that the drugs that do exist for children are vastly overpriced.

"Because the vast majority of infected children live in poor countries, most pharmaceutical companies are hardly investing in developing pediatric formulations," MSF said in a press statement.

Fernando Pascual, an MSF pharmacist, said the price of some infant formulations is reaching record levels.

Former US president Bill Clinton, at the conference in his role as a campaigner on issues including the AIDS epidemic, said he recognised the terrible plight of HIV-infected children, and was committed to help alleviating it.

"I have been despairing of this. I understood why the governments didn't spend money on pediatric medicines, in the beginning it was more expensive and wide swathes of young adults were dying," he told reporters.

Clinton said several global governments had now recognised the problem, and were devoting new funding to the plight of children.

"Pediatric treatment has lagged behind other treatment woefully for the last few years, given the change in funding priorities, it might actually jump ahead in the next two years."

MSF released data on Tuesday showing that given the right treatment, at the right time, the youngest victims of the AIDS epidemic, which has killed 25 million people, can be saved.

Figures showed that among 3,754 children under 13 years old in 14 nations, 80 percent were alive and continuing therapy after 24 months, with few adverse side effects, and patients' immune systems were improving.

Bangladesh worker angry at US AIDS help restrictions

TORONTO  - A U.S. "loyalty oath" that aims to curb prostitution and prevent sex trafficking has stymied one group's efforts to educate sex workers in Bangladesh and left thousands of women without support, a local activist said on Thursday.

Her eyes filling with tears, Hazera Bagum said her group, Durjoy Nari Shangha, had closed drop-in centers for sex workers in the Bangladesh capital in order to win U.S. funding.

"This feeling is like a broken heart, it's like a broken family," she said through a translator at a news conference during the 16th International Conference on AIDS in Toronto.

"All of them are street workers. The only house they have is when they go to a client for a few hours. Closing a drop-in center is like losing their homes, like losing their meeting point, losing their school, losing everything."

The sex workers collective -- its name translates roughly as "organization of women who are hard to repress" -- had 20 drop-in centers before December, offering sex and literacy education as well as moral support, toilets and a place to wash and rest for up to 5,000 women.

It closed them after signing what aid groups call the "prostitution loyalty oath" that requires groups receiving USAID funding to have a policy opposing prostitution and sex trafficking. The group now has just four centers, geared to children and childrens' rights.

Bagum said that before the centers closed, the group sold 73,000 condoms a month. That has fallen to 30,000, even though health experts agree that condoms are the best way of stopping the spread of AIDS.

A spokeswoman for U.S. President George W. Bush's emergency plan for AIDS relief said the U.S. plan targeted at-risk populations with "specific outreach services, comprehensive prevention messages and condom information and provision" and its ambassadors had visited many projects for high-risk groups.

"Our office has not received information that drop-in centers have closed, or that there has been any interruption in services that target sex workers as a result of our anti-prostitution policy," she said.

"Critics who continue to spread misinformation about (the plan's) policies are causing fear and confusion."

Some organizations say they have chosen not to accept USAID funding rather than compromise their positions, even though the locally available funding may be far smaller than the amount available through the United States.

"We are very proud of our decision," said Gabriela Leite, who works with eight local sex worker organizations in Brazil.

"It's our conviction that the sovereignty of our country should be respected."

 Bangladeshi community group working to educate sex workers in the country shared an international award for its contribution toward prevention of HIV/AIDS.

The newly launched Red Ribbon Award, announced at the 16th International AIDS Conference in Toronto, was shared by four other groups from Ukraine, Thailand, Zambia and Zimbabwe, the United Nations development agency UNDP said in a statement on Friday.

Each of the winners will receive $20,000 in prize money on World AIDS Day, on December 1, this year.

Blacks bear brunt of AIDS in developed nations

TORONTO  - HIV infections are rising in black men and women living in developed nations that have otherwise made strides against the disease, said participants at the 16th International AIDS Conference in Toronto.

"AIDS in America is a black disease no matter how you look at it, by gender or sexual orientation or age or socioeconomic class or region in the country in which you live," said Phil Wilson, executive director of the Black AIDS Institute, at a press conference on Monday.

"Black people bear the brunt of this epidemic."

People of African and Caribbean descent -- particularly heterosexual women and men who have sex with men -- have higher HIV infection rates than the overall population in developed countries like Canada and the United States, said conference participants.

Blacks make up 13 percent of the United States population, but represent an estimated 42 percent of people living with HIV/AIDS. Ontarians of African and Caribbean descent make up less than five percent of the population but account for 14 percent of those with HIV/AIDS and 19.5 percent of new infections in 2004 in Ontario, a rise of 82 percent in five years. Their HIV infection rate is almost 13 times the overall rate.

AIDS is the leading cause of death for African American women aged 25 to 34, and in 2003, 60 percent of all American females living with HIV/AIDS were black. African American women make up 68 percent of new HIV cases in the U.S.

"If we, as black women, in America do not decide today and every day that AIDS is our face and fight, in 2020 there'll be no black women in America," said Grazell Howard, first vice president of the National Coalition of 100 Black Women.

A study released by the Centers for Disease Control in June 2005 showed that black men who have sex with men in the United States had HIV infection rates higher than in sub-Saharan Africa, at 46 percent

Another CDC study presented at the conference showed that while American high school students were overall engaging in less sexual behavior that put them at risk for HIV infection since the early 1990s, decreases in sexual intercourse and increases in condom use in African American teenagers leveled off over the past few years, after progress throughout the early 1990s.

The study's findings showed that there may be a need to intensify prevention efforts in black and Hispanic adolescent populations in the United States, said Dr. Laura Kann of the CDC.

It's not only in the developing world that people die due to lack of access to treatment, said the Canadian Treatment Action Council. In the conference's host country, a variety of barriers stand in the way of treatment for HIV-positive immigrants, said Esther Tharao of the council.

Stigma -- both in the general population and their own cultural communities -- makes it hard for vulnerable populations to get care. Immigrants and refugees without residency status in Canada don't qualify for the country's public health care, and they face further difficulties due to differences in culture and language.

"We need a Canadian strategy to support communities from countries where HIV is endemic, and we need funding to make it work," said Tharao in a statement.

Several conference activities focused on mobilizing populations of African and Caribbean descent in the fight against HIV.

"For too long, our community has sat idly by as this epidemic has ravaged our families and claimed the lives of our brothers and sisters," said Cheryl Cooper, executive director of the National Council of Negro Women.

"We need to make some noise. Everyday, everywhere we need to start by saying, I am fighting against HIV. If we take to the streets and the churches and we use all these platforms, we can beat this," said Maxine Waters, a Representative from California.

AIDS researcher slams South Africa's inaction, world's silence

TORONTO  - A leading AIDS activist and researcher slammed the government of South Africa on Thursday for failing to take strong measures to stem the spread of HIV in that country - and lambasted political leaders elsewhere for not calling South Africa on its failures.

Mark Heywood, whose remarks drew a rousing response from an audience at the International AIDS Conference, also warned that a similar pattern of political avoidance could lead to an explosion of HIV cases in China, where UNAIDS has warned 10 million new infections could occur by 2010.

"When this number of people are dying in the face of anti-leadership and denial, then the world has to speak up," insisted Heywood, senior researcher and head of the AIDS Law Project at the University of the Witwatersrand, South Africa.

"There's a terrible silence by political leaders outside of South Africa. Bill Clinton can't get it out of his mouth to criticize Thabo Mbeki. Kofi Annan can't criticize Thabo Mbeki and the South African government. If there's this silence, then the crisis for us will go on and on and on. "

Mbeki, the South African president, long denied that HIV is the cause of AIDS and blocked the import of the antiretroviral drugs that have turned AIDS from a killer to a chronic illness for many infected people living in countries where the drugs are available. He and Stephen Lewis - UN Secretary General Kofi Annan's special envoy for AIDS in Africa - have butted heads so often that Lewis has been barred from undertaking his work in that country.

An estimated 5.5 million people in South Africa - a country of 47.5 million - are infected with HIV and roughly 800 people a day die from AIDS there.

Heywood said that while scientists have succeeded in developing tools to fight the transmission of HIV and blunt the virus's assault on the immune systems of those infected, a lack of political leadership is preventing the benefit of those advances from being fully realized. For instance, only 17 per cent of the people with AIDS who need antiretroviral treatment are receiving the drugs, he said.

"Governments have power. And governments have a responsibility to put those advances into place," said Heywood, who also noted that while the world knows how to prevent mother-to-child transmission of HIV, too many infants are still being born with the virus.

He incited delegates to the conference to demand political leadership. And he insisted that by the end of this year the United Nations should set firm targets for reduction of mother-to-child transmission and for delivery of antiretroviral drugs to those in developing countries who need them.

"Behind us are 40 million people (living with HIV-AIDS) who can't come and stay in posh hotels and walk the streets of Toronto," Heywood said.

"We have a responsibility to them."

Heywood also called for the resignation of Dr. Manto Tshabalala-Msimang, South Africa's controversial minister of health.

Tshabalala-Msimang promotes nutrition and natural remedies as key weapons in the fight against HIV-AIDS, promoting lemons, garlic and beet root as treatments. She has drawn criticism - and protesters - at the Toronto conference for using South Africa's booth in the exhibition hall to promote her ideas.

Heywood suggested tens of thousands of South African lives could have been saved had the country made a concerted effort to fight transmission of HIV.

Heywood warned that China experiences many of the same social problems that fuelled the transmission of HIV in South Africa and he questioned whether the global community would raise its voice to ensure that the 10 million new cases UNAIDS projects for the country won't come to pass.

Current official estimates set the number of HIV infections in China at 650,000. But UNAIDS believes that number could explode over the next four years.

"That can be stopped but it can only be stopped if the Chinese government mounts the necessary political will and works with civil society in order to stop that epidemic," Heywood said.

A Chinese delegate to the conference challenged Heywood's assertions from the floor, inviting him to come to China to see the situation for himself. The delegate suggested Heywood's comments about sex workers being jailed and other at-risk groups being further jeopardized by government policies weren't well informed.

Heywood countered, though, that the Chinese government is still jailing AIDS activists and perpetuating other human rights violations that undermine the fight against HIV.

Political leaders accused of AIDS genocide

“If you have evidence your inaction is responsible for millions of deaths, you promise to correct that situation, then you fail to deliver, what do you call that?” Julio Montaner said in an interview.

“It's not ignorance. It's not mere negligence. It's more than a crime against humanity.

“It can only be characterized as genocide.”

Dr. Montaner, director of the B.C. Centre for Excellence in HIV/AIDS in Vancouver and one of the world's leading AIDS researchers, said that life-extending drug cocktails must be made available to everyone in the world who is infected and would benefit, regardless of the cost.

“These drugs are so powerful that we have a moral imperative to make them available,” he said.

There are an estimated 38.6 million worldwide living with HIV/AIDS, according to the United Nations agency UNAIDS. According to data presented at the 16th International AIDS Conference, 1.6 million people are getting antiretroviral drugs in developing countries and as many again in the developed world.

Worldwide, only 21 countries (including Canada) are providing the treatment to at least half of patients who could benefit.

“These are unacceptable levels,” said Cristina Pimenta, the former head of the prevention unit of the Brazilian National AIDS Program. “We are moving backwards every day.”

What she means is that the number of new infections — 4.1 million last year — is far outpacing the number being newly treated.

Similarly, the cost of treatment and prevention is significantly higher than the spending commitment of governments.

Last year, an estimated $8.7-billion was spent on HIV/AIDS, about half of what is required to provide basic treatment, prevention and care.

Providing drug cocktails to everyone would cost an estimated $7-billion annually, and as much again for related testing and health care.

Mark Heywood, national secretary of the Treatment Action Council in Johannesburg, South Africa, said that the failure to provide treatment to people with HIV/AIDS should be a violation of fundamental human rights.

“We have the means, so what stops us from acting?” he said. “And what should be done about those in power who refuse to act? These are the most pertinent questions facing the next stage of the AIDS epidemic.”

Mr. Heywood said vague promises to act are not enough, that the United Nations must, by year's end, set firm targets for delivery of antiretroviral drugs and reduction of mother-to-child transmission of the disease.

He also called on delegates to hold politicians' feet to the fire to ensure they deliver.

Previously, the United Nations vowed to get AIDS drugs to three million by the end of 2005. They fell short of that target, in large part because countries like Canada failed to come through.

Two years ago, Canada adopted legislation becoming the first Group of Eight country to allow generic pharmaceutical companies to export life-extending medicines to developing countries that don't have the capacity to manufacture drugs themselves, but not a single pill has been delivered.
 

Rapid tests mean more learn HIV status

Rapid HIV tests lead to more people getting tested and receiving their results, according to a study by the US Department of Veterans Affairs presented at the 16th International AIDS Conference.

Both traditional testing and newer rapid tests were likely to result in higher screening rates for HIV, according to the study. But patients who received rapid testing were much more likely to learn their results.

HIV testing is cost-effective, but testing rates for at-risk populations in the U.S. are low. "Even people who are in care and are seeing their doctor on a regular basis, and are identified as being at risk for HIV infection, are not being tested at nearly the rate that they should be," said Dr. Henry Anaya, who presented the study.

Testing is important because people tend to reduce their risk behaviors when they know their HIV status, Anaya said.

Patients waiting for an appointment at VA primary/urgent care clinics in Los Angeles were randomly split into three testing groups. The patients were all between 18 and 65 years of age and were unaware of their HIV status. None had been tested in the past year.

The first group of patients was prompted to ask their doctor for an HIV test during their appointment; the second group was referred to a nurse for traditional HIV testing; and the third group was also referred to a nurse but these patients received the rapid HIV test.

Traditional HIV testing involves two appointments -- one for testing, and another some days later, to receive the results and counseling. Rapid tests involve an oral swab or a finger stick and results can be available in as little as 20 minutes.

Forty-one percent of the patients told to ask their physician for a test actually did, and 41 percent of those tested received their results. Double the patients who were referred to a nurse for testing actually did take the HIV test. Eighty-four percent of those referred for traditional testing received it, as did 93 percent of those in the rapid test group.

But many more patients in the rapid test group actually received their results -- 90 percent compared to 52 percent for those who had to return to get their results and counseling.

"The magnitude and direction of these results surprised even us," Anaya said.

The results show that referring patients for testing is effective in both cases, but rapid testing resulted in nearly double the patients ultimately learning their HIV status.

The testing project is currently being used in an outreach effort directed at homeless veterans with the Los Angeles County, and the hope is for it to be expanded nationally across the Department of Veterans Affairs, Anaya said.

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