AIDS has now been with us for a quarter of a century, and there are people still alive who were among the first people to be diagnosed with HIV after the retrovirus was discovered and named in 1983. Think back to the world of that time: Ronald Reagan was President of the United States, and still locked in what seemed to be a permanent state of hostility with the USSR, whose collapse at the end of the decade was almost entirely unexpected. The greatest economic challenge to the United States was thought then to be Japan, and very few people anticipated the rapid rise of China.

AIDS had almost certainly existed in parts of Africa long before it appeared and was named in the United States, but it remains an epidemic particularly marked by its US history. The stigma that developed around its association with male homosexuals and drug users would be widely disseminated, and remains even today. US initiatives, including the development of a People with Aids (PWA) movement, AIDS activism, major progress in biomedical research and funding for international responses through the President’s Emergency Plan for AIDS Relief (PEPFAR), the Gates Foundation, and so forth continues to frame much of the global response, although other countries have often been far more progressive than the United States in their policies. This is true of Brazil’s early development of widespread treatment access, and of several countries’ policies towards homosexual men, drug users, and prisoners. In its policies for injectors within prison, Iran is ironically more progressive than the United States, although deeply repressive of sexual behaviour outside marriage.

In the first decade or so the United States was not a major presence internationally in the fight against AIDS, although the founding director of the World Health Organization (WHO) Global Program on AIDS, Jonathan Mann, was an American. Mann established the connection between health and human rights as a dominant paradigm for the international approach to the epidemic, one of the most significant moves in recent public health. The decision of the United Nations in the early 1990s to establish UNAIDS, as a unique hybrid body that is intended to coordinate and lead the efforts of all UN agencies in their responses to HIV, was led by others, and its founding director, Peter Piot, was Belgian.

US attention increased during the Clinton Administration, which played a significant role in putting HIV and AIDS on the agenda of the Security Council, with its first ever debate on a health issue in January 2000. That debate was followed a year later by a special meeting of the UN General Assembly, where the United States under the new president adopted a cautious position on both prevention and treatment access. Indeed, the final statement released by a coalition of most civil society representatives in New York signalled out the Bush Administration for criticism: “The United States was particularly damaging to the prospects for a strong declaration. Throughout the negotiations they moved time and again to weaken language on HIV prevention, low-cost drugs, and trade agreements and to eliminate commitments on targets for funding and treatment. It’s death by diplomacy,” said Eric Sawyer, veteran activist and 25-year survivor of HIV/AIDS, as highlighted in Global Network 2006. Specifically, the United States joined with conservative Islamic nations in refusing to name sex workers, men who have sex with men, and drug users as particularly at risk.

The establishment of the Global Fund to Fight AIDS, Tuberculosis, and Malaria owed a great deal to advocacy by US academic experts in public health and development, especially Jeffrey Sachs, but it was the UN secretary-general, not the president of the United States, who took the political lead in its establishment, nor was the United States particularly generous in its initial pledges. However, over the next few years, President Bush greatly increased bilateral assistance for AIDS programs, and total US public and private expenditure on AIDS programs and research now amounts to over half of all global spending on the epidemic. The Gates Foundation is a bigger donor to the Global Fund than countries such as the Netherlands and Australia. Pressure from the original “stakeholders,” such as gay organizations and some African-Americans, for American involvement was reinforced by the religious right, who developed considerable interest in the issue. The United States has become central in defining new paradigms and responses to the epidemic as the Bush Administration made the issue theirs, and cloaked it with a particular moral agenda.

While PEPFAR was admirable in its efforts to increase access to antiretroviral drugs (ARVs), its emphasis on prevention stressed sexual issues: abstinence outside marriage as a desirable goal, and particular hostility to all forms of commercial sex, which were often equated with sex trafficking. Whatever one’s moral position on these issues, these were unrealistic goals that denied the social, cultural, and economic realities that made middle class Protestant morality irrelevant for millions of people. There has been a gradual shifts in PEPFAR’s emphases, which are now closer to those pushed by UNAIDS and most other donor countries.

As the global impact of AIDS became more evident in the 1990s, the expectation was that western countries, lead by the United States, should lead and fund much of the response. Few countries were prepared, as was Brazil, to refuse US assistance if it came with conditions attached. Today the United States, through both government and foundation funding, is the dominant source of international funds for HIV, although government support is likely to decline under the combined pressure of financial stringencies and new priorities.

The well-publicized Security Council and General Assembly sessions were followed by increasing attention from the G8, the group of the world’s leading economies (including Russia since 1997) who at the Gleneagles summit in 2005 pledged universal access to anti-HIV drugs in Africa by 2010. The G8 meeting saw the coming together of a number of factors which allowed this achievement, in particular the mobilization of extensive civil society networks through the Make Poverty History campaign, and the personal commitment of the host country, the United Kingdom, led by Tony Blair and strongly supported by Presidents George Bush and Jacques Chirac. This year may well have marked the high point of the developed world’s concern for African development in general, and HIV in particular: this particular confluence of interest may never be repeated.

The work at Gleneagles was facilitated by the adoption by the United Nations in 2000 of the Millennium Development Goals (MDGs), which have come to form the basic “global operating framework for development.” The sixth MDG specifies:

“Target 6A: Have halted by 2015 and begun to reverse the spread of HIV/AIDS, and Target 6B: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it.”

Additional MDGs, particularly those relating to the empowerment of women, reduction of child mortality, and improving maternal health, are all closely related. The MDGs will come to an end in 2015, and there are already extensive discussions about what goals might be set by international agencies and donors in a post-MDG world. There is no reason to assume that a future set of international priorities will include HIV/AIDS. However, the AIDS community might well reflect on how the lessons we have learned about the connections between human rights and health could be enshrined in a post-MDG declaration.

Six years after Gleneagles, the world is a very different place. Two aspects in particular are relevant to this discussion: declining concern with AIDS globally, and significant shifts in the balance of economic and cultural power.

It is no longer possible to suggest that HIV is a global pandemic that will see the horrific figures from southern and eastern Africa reached in other parts of the world. Even in Papua New Guinea, probably the worst affected country in the Asia-Pacific region, infection prevalence is less than a tenth of that in many African countries. Yet less than a decade ago in 2002, the conservative scholar Nicholas Eberstadt warned in Foreign Affairs of a major pandemic in Eurasia that “will alter the economic potential of the region’s major states and the global balance of power.” This did not occur, and the tragedy of AIDS today is that it is unequally affecting the most vulnerable and marginalized, both in terms of geography and behavior, and it is increasingly difficult to persuade most people that it is a global priority on the same level as climate change, food and water shortages, and the growing collapse of viable states across many parts of the world.

In the same way, simplistic arguments that HIV would be spread through a breakdown of security and alarmist stories about the very high rate of HIV among soldiers and peace keepers have been largely discredited by careful research, as summarized in reviews produced by the AIDS Security & Conflict Initiative. However, this does not mean that dislocations of conflict do not increase vulnerability to infection while making it more difficult to establish effective programs or even provide basic information and resources. The long-term impact of growing needle use and commercial sex in parts of the world ravaged by conflict—think of the huge population shifts across Iraq, Afghanistan, and Pakistan over the past decade—are likely to lead to increasing HIV infections among the population, and once a certain number of people is infected, the epidemic has the potential to escalate rapidly.

It is not simply a matter, as some AIDS advocates have suggested, of using the skills of climate change advocates to better sell the demands of HIV. The political reality is that we cried wolf too often, and the more dire warnings have failed to materialize. In most parts of the world AIDS is not a major crisis, and the perception that it has received too much attention and funding is growing. It is absolutely true, as the eminent group who prepared the AIDS 2031 Report of the book, AIDS: Taking a Long-Term View, have argued: “Closing the looming funding gap for AIDS would require only about one percent of annual global spending on armaments.” In the absence of new generalized epidemics affecting large parts of the adult population, as is true across southern Africa, such appeals will fall on deaf ears. When there were plausible arguments that HIV threatened political and military stability in significant countries, it shot to the top of international attention. It is hardly surprising that as these fears have failed to materialize, so interest in the epidemic has lagged.

It is a further tragedy that as the biomedical means to control HIV increase, the resources available are likely to further decrease, which suggests the absolute imperative of concentrating resources on cost effective prevention programs. Unlike many of my biomedical colleagues, I remain unconvinced that these should depend upon testing and treating. One of the most experienced HIV clinicians and researchers, Jonathan Weber of Imperial College and St. Mary’s Hospital, believes that the widespread use of Pre-Exposure Prophylaxis might actually increase the spread of HIV if users feel protected enough to dispense with condoms, as quoted in the New Scientist of July this year. The danger, he suggests, is that emphasis on new biomedical technologies will lead us to forget the proven impact of condoms and clean needles, and the imperative of explaining the risk factors for HIV transmission.

Not only are traditional donor countries cutting back on their contributions to international development assistance, they are doing so within a world in which political and economic power is shifting rapidly. The G8 continues to meet, but it has been essentially replaced by the G20 as the steering group of major economies.

Given that the G20 includes several countries with significant epidemics, most notably South Africa, and others with strong commitment to universal access, in particular Brazil, one might expect it to take a position of leadership on global efforts—both South Africa and Brazil are core countries in emerging new partnerships linking a number of middle income countries with increasing global political and economic influence. So far there is no sign that this is happening; the G20 may push for greater access to therapeutic drugs and greater support for generics, but it is unlikely to see HIV as a major concern. The G8 was able to mobilize donor countries in ways that the G20 is unlikely to do.

In part this is because the shifts in global power are creating new nationalisms and undermining western norms of individualistic human rights. Countries like China, Korea, and the Gulf states (which are becoming more important as donors to developing states) are more committed to protecting state sovereignty and far less likely to demand basic human rights than are more traditional western donor countries. While we see increasing pressure from western countries around issues such as sexual rights and protection of confidentiality, these are likely to be undermined by money from countries for whom these are not priorities, either domestically or internationally.

Thus, if there is to be continuing scale up of access to treatments, and in particular if treatment is to become a serious means of prevention, there will need to be far more emphasis on countries meeting the demand from their own resources. It is absurd that a country as rich as Russia receives funding from PEPFAR, which allows it to avoid obligations to its own citizens. This may be justified as a way of pressuring the government towards better policies, but at a time of declining resources there will need to be some careful triage amongst traditional donors.

Global “AIDS Community”

Over the past quarter century the threat of AIDS has created an extraordinary community of activists, experts, and officials. What began as a grassroots movement, largely growing out of the gay communities of rich western countries, has now become a truly global set of organizations and people, with new forms of activism pioneered in movements such as the Treatment Action Campaign in South Africa. Organizing around HIV was the impetus for building movements among some of the world’s most stigmatized populations—homosexual men, sex workers, drug users—and has allowed for debates on human rights to expand considerably to include a serious consideration of their issues. There are significant international organizations, such as UNAIDS and the Global Fund, which would not exist without the movement that drew attention to AIDS, and international and regional conferences continue to bring thousands of people together to reaffirm their mutual commitment to working together. For all the tensions that exist, there are few issues in which scientists, activists and governments have been able to create as many viable and enduring partnerships.

Cynics, of whom I am sometimes one, refer to “ the AIDS industry,” which suggests the way in which AIDS communities and activist groups have increasingly become professionalized and are led by people with the skills required to manage complex funding and bureaucratic negotiations rather than those people most immediately affected by the epidemic. There is need for more analysis of the way in which the various institutions created to meet the challenges of AIDS have evolved and are functioning. While at one level there is an increasing amount of monitoring and evaluation linked to donor funding, at the same time there is remarkably little critical literature which asks larger questions about the underlying questions on the frameworks within which these evaluations take place. Whilst there is a great deal of rhetoric around terms like “civil society participation” and “political commitment,” it is rare to see any critical debate about what these terms really mean and how they are best achieved in a rapidly shifting terrain. In practice too often these terms become shorthand for maintaining the same circle of experts, who spend large amounts of time flying around the world to attend consolations at which the same shibboleths are reasserted without sufficient reflection on the changing nature of both the epidemic and the larger political environment.

Institutions sometimes age faster than humans, and even though those created to fight AIDS are no more than two decades old, they are showing signs of sclerosis, whereby the need to perpetuate what already exists takes over from an analysis of new possibilities. I can immediately think of three crucial areas that are worth discussion but rarely surface:

Has UNAIDS outlived its purpose? Its website proclaims that UNAIDS “is an innovative partnership that leads and inspires the world in achieving universal access to HIV prevention, treatment, care and support.” Whether there remains a need for a separate agency to do this is a question that needs analysis, not just evaluations conducted by UNAIDS itself.

Is the influence of the Gates Foundation, now a major funder of global health programs, inimical to community empowerment, given its heavy emphasis on technical and biomedical solutions? More generally, how does the emphasis on “prevention science” limit possible applications to fund prevention programs that rely upon social and cultural research and transformations?

And finally, are the current round of AIDS Conferences worth the time, effort, and resources invested in them? This year it would be possible to spend almost one’s entire time jetting round the world to attend one AIDS Conference after another, and a genuine audit of their costs and efficacy is badly needed. The biennial Conference, scheduled to be held in Washington next year—the first Conference to be held in the United States since 1990—will attract over 25,000 people to what is essentially the trade fair of the AIDS world.

I do not have firm views on the answers to any of these questions. However, they are central questions about global governance that deserve to be analyzed and debated. The International AIDS Society proclaims a commitment to supporting research in “social and political sciences,” but so far there have been only small steps, and there is a continuing confusion between “social” and “behavioral” research. Unless we manage to frame HIV within a broader framework of development and social justice, it will inevitably be relegated to just another problem of African poverty, and lose the urgency and commitment that have been so dramatic over the past quarter century. Millions of people will die as a consequence of such neglect.