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Financial Times: HIV / Aids: Discordant visions.

Changing outlook: demonstrators in Cape Town last year raise fears about finance for action to combat the virus. But in contrast to past wariness, South Africa sent its vice-president and minister of health to tell this week’s Vienna conference of a redoubled prevention, testing and treatment effort. The country has one of the highest HIV burdens

It was the talk of Vienna and spread rapidly around the world: a study unveiled at the International Aids Conference in the Austrian capital this week suggested a microbicide gel could significantly cut women’s risk of contracting HIV.

This boost to demoralised researchers, who have been battling for three decades to halt the virus, follows a rising optimism among doctors and patients in the two years since the previous conference in Mexico City. An increased availability of treatment has helped tackle an epidemic that has infected more than 33m people around the world and still kills 2m annually.

But the brutal realities imposed by the financial crisis mean budget cuts threaten to squeeze domestic and international support for healthcare and halt recent progress. The alarm is only just being raised about the painful trade-offs that are likely to be required ahead.

“I am scared by what I see today,” Michel Sidibé, head of UNAids, the United Nations’ coordinating group on the disease, told the conference in his opening speech. “Prevention models are coming up short. Some governments are cracking down on vulnerable groups. Treatment is not sustainable. Costs are rising.”

Since the start of the millennium, intensifying international action has led both to a gradual decline in the rate of new HIV infections and to a surge to more than 5m patients in the developing world who have been given drugs to keep them alive. Now, further work on HIV risks being squeezed by both a deceleration in fresh funding and a shift by many donors towards other diseases and approaches.

Some refuse to believe that the pace of HIV funding has to slow. Advocates such as Paul Zeitz from the Global Aids Alliance demand that US President Barack Obama should be held to his election promises to provide more support. He calls for an international tax on banks’ financial transactions to fill the gap. Even official agencies are adopting an attitude that may well prove overoptimistic. The UN-backed Global Fund to Fight Aids, TB and Malaria, which channels donor support from richer to poorer countries, has unveiled ambitious new fundraising goals.

Ahead of a pledging meeting this autumn, it has set a preferred target of $20bn (£13.1bn, €15.5bn) based on anticipated demand, and a minimum of $13bn, for the next three-year round of its operations. But just $10bn was agreed in the previous round – some of which still has to be paid over by donors. “If we had the resources, we could virtually eliminate mother-to-child transmission of HIV, save millions of lives through treatment and tens of millions through prevention,” says Michel Kazatchkine, the executive director of the Global Fund. “I can’t believe we will get less than what we have now. The question is how much more.”

There is hope for maintained support from some countries. The UK has ring-fenced both health and foreign aid budgets even as it undertakes deep cuts in almost all other departments. But elsewhere, the trend is less positive. Germany and Italy are among those thought likely to reduce foreign giving as they cut back at home. Zeke Emanuel, in charge of health issues at the US Office of Management and Budget, defends the modest increases proposed by the White House for global health by saying: “With a flat budget, this was a much harder sell than ever.”

A survey released this week by the Kaiser Family Foundation, a US think tank, shows disbursement for Aids from international donors already slipping, from $7.7bn in 2008 to $7.6bn in 2009, after a sixfold increase over the previous six years. Adding in contributions from poorer countries themselves, as well as companies and other funders, that left a $7.7bn gap to reach UNAids’ estimate of the resources needed to tackle HIV during 2009 of nearly $24bn – a hole that seems set to grow.

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T  he tensions are triggering demands for greater efficiencies in the $16bn Aids “industry”, symbolised by the 25,000 people – from academics and policymakers to patients – who together spent tens of millions of dollars attending the Vienna conference.

Speaking at the Monday opening, Bill Clinton, former US president, set the mood: “We have to cut the cost of delivery. In too many countries, too much money pays for too many people to go to too many meetings and get on too many planes. We have to spend . . . on people the money was designed to help.” Others, like Daniel Halperin from Harvard University, point to the need for greater targeting of existing funds to projects shown to deliver better results. That means less on general campaigns of sex education and more for circumcision, which in parts of Africa can cut infection.

But greater efficiency has its limits. The absolute sums spent have grown much larger in recent years – partly because the more HIV patients are given drugs, the longer they survive. This growing “treatment mortgage” means ever more new money is required to sustain existing programmes, before even adding a single new patient. The tension has been compounded by recently released changes to international treatment guidelines, which say patients should be started on therapy at an earlier stage after infection, when their immune systems are still stronger.

There is a hope that the long-term effect will be to ease the burden on doctors and hospitals by reducing or deferring the more serious stages of the disease. But the short-term consequence is yet more patients requiring antiretroviral drugs, at an estimated additional cost of $2bn a year.

Another hypothesis gaining traction among the optimists, but subject to intense debate, is the idea of “treatment as prevention”. Underlying this is the controversial notion that if patients’ viral load falls to undetectable levels – as is the case for a significant proportion of those in the west who receive consistent treatment – their ability to pass on the infection all but disappears. So if more infected patients in developing countries received drug therapy, the protection it gave “discordant” partners (those of a different HIV status) could reduce overall infection rates in their communities, almost like a vaccine.

The naysayers point out that much transmission takes place in the weeks after people have first acquired HIV, long before they have sought a test, let alone been put on treatment. Never mind that western countries still have significant new infections, including a rise among older people.

Less open to question is that the longer that more patients are on treatment, the more there are who will develop resistance to “first line” drugs and require alternative fallback therapies, most of which remain on patent and at higher prices. Brazil, which has long championed widespread HIV programmes, is already facing such pressures and is intensifying demands for a fresh attack on intellectual property rights that allow pharmaceutical companies to charge high prices for their innovative medicines.

Dominique Limet, head of ViiV Healthcare, a joint venture of GlaxoSmithKline and Pfizer that develops and sells HIV medicines, says patents are needed not just to reward the investments companies make in new research but also to control the manufacturing quality of a new generation of drugs. He argues that companies such as his are helping ensure that new treatments are made widely available, through licensing their patents to producers and discounting drug prices.

“Everyone is excited about intellectual property,” he says. “But it’s about funding, infrastructure and the ability to deliver the product including the use of community groups.”

Lydia Mungherera, a Ugandan doctor and activist who herself has HIV, like many living on the frontline of the epidemic is frustrated with such abstract discussions. “We are already being told to turn away people who have tested positive for HIV. That will lead to men taking the drugs prescribed for their wives,” she says. “It’s a disaster. When we start seeing people dying, we won’t be saying the same thing.”

In a report this month, Médecins Sans Frontières, the medical charity, warns of “alarming backtracking” on funding, saying that turning away patients discourages people from even being tested and, provoking a resurgence in new infections.

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Uganda also shows, however, that countries with serious epidemics need to do more to ensure they use money effectively. The Global Fund suspended some grants after clinics inexplicably ran out of medicines and officials would not account for how money was spent.

Donors such as the Global Fund may in future need to be much more ruthless in deciding which countries to support. That means scaling back on funds to richer recipients such as China, which Mr Kazatchkine argues should pay more itself for HIV work abroad as well as at home.

Mr Sidibé singles out Russia as among countries that need to ease laws that impede efforts to tackle HIV. It still criminalises methadone, for example, an oral drug that elsewhere is offered as a substitute for opioids to persuade users to abandon the use of shared syringes.

More broadly, UNAids has just unveiled Treatment 2.0, a set of proposals designed to improve efficiency through measures including “task shifting”, so that community health workers and nurses take on much treatment work until now conducted much more expensively by doctors.

Pepfar, the bilateral programme established by George W. Bush, former US president, has itself modified policies that had been driven more by ideology than evidence, such as a previous refusal to fund groups involved in needle exchange programmes for injecting drug users, or which explicitly refused to condemn prostitution.

Eric Goosby, who oversees Pepfar, is focused on achieving what he estimates could be savings of 20-30 per cent through administrative changes, shifting work away from US-based consultants to people living in recipient countries. He also calls for more focused prevention efforts, without which treatment will struggle to catch up with the number of new infections.

In the years ahead, that should include more focus on circumcision as well as potential new approaches including the microbicide gel. Meanwhile, all those working on HIV are hoping they can rely on greater value for money to overcome funding shortfalls. As Mr Sidibé puts it: “Our success will not be measured by increased coverage but by the number of lives we are able to save.”

A topic that has long been practically taboo among those working on Aids is coming back into fashion: the search for a cure. The subject was the centre of a “really interesting buzz” at this week’s global conference on the virus in Vienna, says Kevin Frost of Amfar, an American policy group funding research in the field.

Frustrating efforts in the 1980s and 1990s left industrial and academic researchers believing that the search was a distraction from more practical short-term work to tackle the spread and treatment of HIV. But studies presented in Vienna suggest a spirit of enthusiasm among a new generation.

Hopes were raised last year by a report of a Berlin HIV patient who appeared to have been cured. But Anthony Fauci of the US National Institutes of Health warns that the case was “very much an outlier”. It involved a stem cell transplant from a donor with a rare genetic mutation to a patient with leukaemia who had received radiation therapy. “True eradication” – by which all of the virus is removed from the body – is “very, very difficult. We do not yet have the drugs that are able to accomplish it.”

By contrast the “functional cure” described in the journal, Science, by Didier Trono of Lausanne’s Ecole Polytechnique, this month holds out more promise. Such a cure helps maintain the virus at extremely low levels in the body without the need for antiretroviral drugs.

Professor Trono points out that, while the “viral load” can be very substantially reduced by cocktails of antiretroviral drugs used in recent years, it rapidly builds up again once treatment is stopped. Yet the drawbacks of long-term use include side-effects and increased resistance.

On Thursday in Vienna, Bionor Immuno, a Norwegian company, showed that its “therapeutic vaccine” has enabled some patients to remain off antiretroviral therapy for months while retaining very low viral loads.

Like products at still earlier stages of development, it boosts the body’s own immune system, allowing it to fight the virus and reducing the need for additional drugs. The vaccine works best if taken early, before the body’s natural defences are irreparably damaged. Several other biotech companies, and larger pharmaceutical groups such as Merck and Gilead, continue to research in the area.

However, the new generation of vaccines poses a commercial challenge. If a functional cure requiring only very occasional use were developed – in contrast to combinations of drugs taken for many years – there would be enormous demand. But high rates of HIV among the poor would create huge pressure to sell at low prices. Which would leave drug companies with the problem of how to make a profit.