Editor's Note: At the XIV International AIDS Conference in Barcelona in July, science was practically dead. Politics was in. It seemed the doctors felt that research is useless if you can't use it to save lives. The movement that began in full force with the last international conference two years ago in Durban, South Africa, towards saving the countries that are dying, continued to get stronger. In his plenary address to the Barcelona conference, South African activist Zackie Achmat, of the Treatment Action Campaign, brought us up to date on how much progress has been made since Durban. Achmat delivered his talk by video because of a bacterial lung infection that kept him from traveling. He is a person living with AIDS who refuses to take antivirals until they are widely available in his country. An edited version of his speech follows.
But it is not only the activists and the advocates acting as a force for change. In his opening talk, Dr. Stefano Vella, the out-going president of the International AIDS Society, which organizes the international conference, talked about the growing advocacy role of medical providers. "I never saw in other fields of medicine this growing 'scientific activism' and the inclusion of the [concept of] universal access to health care in the scientific agenda of the most relevant AIDS research institutions of the world. Indeed, scientists progressively understood that they should take the lead with the idea that the advancements of medicine cannot be reserved to small numbers of people ... If there is anything that should be globalized, it is the right to a healthy life."
And in his talk at the closing ceremony, incoming IAS president Dr. Joep Lange said, "A specific issue close to my heart is access to decent HIV care, including antiretroviral therapy, for the millions and millions of infected people in developing countries who need it. The world can simply not afford to let them die, from a humanitarian perspective, from a developmental perspective and from a security perspective. And it is possible to do something about it -- it is actually quite simple. It is going to require enormous effort, yet it is simple. Do not be fooled: People make simple things complex to condone their inertia, and the inertia of those who are living off this epidemic. Or maybe not inertia, but simple lack of imagination.
"We need to be creative. For instance, you do not need a lot of infrastructure [clinics, labs, etc.] to deliver HIV/AIDS care. You do not need complex regimens. You do not need doctors and nurses to deliver the care in every remote corner of Africa. If we can get cold Coca-Cola and beer [delivered by truck] to every remote corner of Africa, it should not be impossible to do the same with drugs.
"Bad government and lack of leadership has actually killed more people with HIV than anything else." As for the money, Lange said, "I am actually convinced that the 10 billion dollars that is often quoted is an underestimation of what is needed. But even if it were 25 billion dollars per year, it would still be peanuts. Do you know how much the England-Argentina World Cup football match cost the UK [United Kingdom] economy? Two billion dollars. It just takes five to 12 football matches and a concerted global effort to really do something about HIV/AIDS. What are we waiting for?"
The international conference has spoken. As one report noted, "Discussions here have shifted from the feasibility of antiretroviral therapy for individuals in resource-poor countries to how quickly this can be accomplished." Leaders are demanding the world's political will to combat the epidemic. -- Enid Vázquez
When we last met in Durban we had hope and we had arguments about HIV treatment. Today we have facts. In Khayelitsha, outside Cape Town, Médicins Sans Frontières (Doctors Without Borders) have illustrated that people with HIV/AIDS, a majority with a non-existent or serverely damaged immune systems, could recover life, health and dignity with antiretroviral therapy.
The majority of MSF's patients who started ARV [antivirals] at a primary health care level had fewer than 48 CD4 cells and viral loads greater than 170,000 copies. Over six months, the majority achieved undetectable viral loads, and more importantly were able to re-constitute their immune systems. This follows on the success of Paul Farmer, Partners in Health, and the people of Haiti. So today when we speak to you of ARV therapy access in poor countries, we speak not only with arguments, not only with hopes, not only with desperation, but actually with facts and the lives of the people themselves.
The Durban Effect
The global community decided to campaign for affordable medicines and ARV access for poor countries and communities in the wake of the Durban 2000 conference. That campaign has given many of us the hope and the will to survive. Our movement has achieved many successes and met many challenges over the last few years. I want to highlight some of these successes and challenges.
In the constitutional court judgment on the issue of the mother to child HIV prevention, the court quotes the South African government's assessment of HIV and AIDS as an "incomprehensible calamity." Although the facts and arguments I will use are rooted in South African realities, in many instances the arguments elsewhere are similar, or they can be used to illustrate the differences.
The Impact of HIV/AIDS on Morbidity and Mortality
The Department of Health stated last September that 24% of all public hospital admissions were due to HIV/AIDS. This demand for hospitalization will increase steadily every year in the absence of significant alternative interventions. We would like to ask, what are these interventions?
To us this is not only a matter of the cost to the state, but the lives of mothers, the lives of women, the lives of children and the lives of men. Many of us in our productive years, many of us who have not yet have reached the prime of our lives. Central to all our work on HIV prevention and treatment are the issues of life, dignity and access to health care.
HIV prevention and treatment cannot be separated. Not to treat HIV effectively will destroy the already weakened health care systems in poor countries.
Combine Prevention and Treatment
From a purely public health care perspective, it is shortsighted not to treat HIV, to say that we must focus on prevention and exclude treatment. On the other hand, it is unconscionable, because what we are speaking of are not cold statistics, but our lives. Our lives matter, the five million people in South Africa with HIV matter and the millions of people throughout the world already infected with HIV, their lives matter. And so, it is not simply the question of the cold statistics that we are putting to you, but a question of valuing every person's life equally. Just because we are poor, just because we are black, just because we live in environments and continents that are far from you, does not mean that our lives should be valued any less.
It is critical that every treatment activist also becomes a prevention activist. Active prevention of mother and child transmission, assisting rape survivors, all these issues and above all, the use of condoms for everyone who is positive. Making clear to people with HIV that they should use condoms -- such a prevention message is critical to all our treatment efforts. Therefore the dichotomy between prevention and treatment is one that this conference should lay to rest immediately. We need to stop this counter productive debate.
Let us return to practical concerns. What are the practical obstacles to getting the vision of the World Health Organization that three million people should be on treatment by the year 2005?
Voluntary Licenses for Generic Production
The partial price reductions and insufficient donations by drug companies will not assist in the long term to deal with the epidemic in a sustainable and an effective manner. What is required is generic competition and therefore we appeal to all the drug companies with brand name medicines to issue non-restrictive voluntary licenses at between 3-4% royalty, to ensure that poor countries and communities have access to ARV therapy. This will eliminate the unnecessary conflict between the activist community, government and drug companies.
Health-Care Essential for Development
To be able to deliver drugs to people, to be able to save the lives of the millions with HIV and AIDS, we need effective public health care systems. We can only start by endorsing both Amartya Sen and the World Health Organization's Commissions on macro-economics report that regards health care as an essential public good. Not only for dignity and life, but as a component of a sustainable development strategy for most developing countries. We therefore endorse the request for additional funding for health care systems across the globe by the World Health Organization to ensure that public health care systems are effective and that they deal with HIV and AIDS, with TB, with malaria and with all the diseases of poor people.
Support the Global Fund
A necessary element to enable public health care systems to deliver ARV therapy in poor countries is the funding of the Global Fund on AIDS, TB and Malaria. It is unfortunate that the fund has not received the necessary amount of between seven and 10 or 11 billion dollars called for by the UN Secretary General, Kofi Annan. We believe that the United States, Europe, Japan and countries like South Africa and Brazil all have an important contribution to make to that fund, to ensure that all poor people get access to treatment with ARV. We appeal to you to step up the activism in your countries to ensure that the Global Fund has the money that it needs.
Political Will and Denialism
There is an additional element essential for all of us to get access to life saving treatment and that is political will. Many of you know the South African government's position on HIV and AIDS was not only scandalous, did not only reduce many of us to despair, did not only take away the hope of many thousands of people in our country, but it also threw health care workers and our health system into disarray. That position has now fortunately changed. However, we still believe that we all have to be vigilant, that we should encourage the South African government and all its officials to maintain a position that HIV does in fact cause AIDS. And more importantly, that HIV can be treated as well as prevented.
Unfortunately, our government has not yet committed formally to a national treatment plan, in a country where nearly 300,000 people will die this year of AIDS-related illnesses. However, it is not only our government that is lagging behind.
Private Sector Responsibility
Regrettably, the richest corporation in our country, the Anglo-American Corporation, cancelled its pilot ARV programs to treat gold miners and miners who have suffered, who live in single sex hostels on their mines far from their families and who have HIV. We appeal to them to reinstate those programs and to treat those workers. Those workers have sacrificed their bodies and their families, allowing the company to make the enormous amounts of profit it does on the world market for gold and other minerals. We appeal to the entire private sector to make it possible for people to be treated, including companies such as Coca Cola, Ford Motors and Daimler Benz who have done a superb job. We appeal to all of them to work together to ensure that people across the globe have access to treatment, their workers in particular.
We have seen many successes. A tremendous example to all of us has been the Brazilian program. We commend the Brazilian government for an effective program. As all of you will know, TAC supported MSF in importing generic ARV into South Africa for the program in Khayelitsha. We will continue to support that action because we are opposed to patent abuse by the drug companies and we want to set an example that can work. However, we appeal to the Brazilian government to lead a political campaign to enable them to export its drugs to other countries in Latin America and Central America. There are many poor people in Ecuador, Nicaragua and other countries of that region who need these medicines urgently. This will sustain the Brazilian program in the long run because of economies of scale and cost effectiveness. But most importantly, it will give hope to the region itself.
On our doorstep in Botswana, the government has committed itself to a comprehensive treatment program for its people. However, its president, Festus Mogae, mentioned that he is not sure how sustainable that program will be. We appeal to the Gates Foundation, to the Merck Corporation and to the government of the United States to ensure that Botswana is able to use generic ARV to lower the prices and to be able to make its program sustainable, so that more than one third of its population who are already infected will be able to have treatment in a sustainable and an effective manner.
A critical element to be able to deliver treatment to people will be treatment literacy programs. Everyday in our communities we are able to educate people in workshops about nevirapine [Viramune], about AZT [Retrovir] and about side effects. We are able to sing songs about these drugs, we are able to educate people about fluconazole and cotrimoxazole. These are medical terms and pharmacological names that none of us knew when we were first diagnosed, or even much later. But fighting for our lives has made it essential and necessary for us to learn these things. Everyone can learn them. In our communities we have done workshops with people who have never opened a pharmacological textbook, but most of our people can speak eloquently and articulately about the medicines that they need to take, their side effects and how to look after themselves.
We believe that by working together -- nurses, doctors, scientists, patients and government -- all of us -- we can achieve the necessary required treatment literacy that will make our adherence possible.
Over the last few years, it has been the power of ordinary people that has held drug companies accountable, made governments accountable and made the global community accountable.
The TAC thanks the Health GAP Coalition [Global Access Project, Philadelphia], MSF, Gay Men's Health Crisis [New York City], all of our African comrades, our Brazilian comrades, Pela Vidda and people across Asia and Europe -- you have made our work much easier. We hope our work at home will be of some assistance to you. In the words of the labor movement, "an injury to one is an injury to all."
Born in 1962, Zackie Achmat joined the anti-apartheid movement in South Africa during the 1976 uprisings. He was detained and imprisoned on more than five occasions as a youth activist. He also organized for labor, health and community organizations. He was a founding member of the National Coalition for Gay and Lesbian Equality, which campaigned for the equality clause in the country's Constitution. He is still an active member of the African National Congress. Achmat was also director of the AIDS Law Project between 1994-97. He has researched, written, and directed numerous television documentaries.
In December 1998, he launched the Treatment Action Campaign (TAC). At the risk of arrest, Achmat volunteered for TAC's Defiance Campaign against Pfizer's patent to bring life-saving treatment for opportunistic infections into South Africa. TAC also opposed the HIV denialist positions in government and campaigned for access to antivirals for pregnant women with HIV. Achmat is also completing a master in philosophy of law at the University of Capetown.