Recently there have been extraordinary developments in laying the groundwork for making AIDS prevention and treatment more widely available throughout the world. Now it is up to everyone involved to help make sure that these possibilities become real.

The July 14 announcement that a simple treatment with nevirapine could greatly reduce mother-infant transmission-- even if the woman first receives medical care only during labor--was widely reported (see AIDS Treatment News #323).

Also, the U.S. is significantly increasing funding and commitment to international AIDS programs, for the first time in many years--and for the first time, is planning to include access to treatment, especially for opportunistic infections and tuberculosis.

In addition, the campaign to raise awareness of the problem of patented drugs being priced out of reach of developing countries continues to be extraordinarily successful (see "Congressional Hearing on U.S. Role in Global Epidemic," below).

Here we ask Paul Boneberg of the Global AIDS Action Network (GAAN) to give us his perspective on current U.S. political changes. Paul started one of the earliest AIDS organizations, Mobilization Against AIDS, in 1984 in San Francisco; MAA fought successfully for greatly increased funding for AIDS research and prevention.

In 1994 he left MAA to start GAAN, which moved to Washington in 1995, mainly to work with the Global Health Council, and the National Organizations Responding to AIDS (NORA), on international issues. GAAN has focused especially on the appropriations process, trying to increase U.S. funding for international AIDS programs and to make sure the funds are well spent.

GAAN is especially interested in helping existing U.S. AIDS organizations become involved in global issues, in whatever way is most appropriate for each organization.

[Note: This writer was a founding board member of GAAN.]

The following interview took place on July 29, 1999.

Interview with Paul Boneberg

John S. James: What are the most important recent changes in the U.S. response to global AIDS issues?

New Funding and Commitment

Paul Boneberg: There have been several. One is the issue of funding, which is basic because it is so real; if you win on a funding battle, it can drive everything else. U.S. funding for international AIDS programs has not increased significantly since 1993, when President Clinton took office- -although HIV infections cumulatively have increased 300% in that same period.

This year we had the first major breakthrough, where both the House and the Senate appropriating committees for foreign operations increased funding for U.S. global AIDS programs by $25 million to $30 million, depending on how you look--a 15% to 20% increase.

That is an extraordinary breakthrough, the most significant increase in U.S. recent history, and it will be a model for other nations to increase their assistance as well. It is now virtually certain that this U.S. increase will occur. Also, because of the efforts of Sandra Thurman (Director of the Office of National AIDS Policy, in the White House), the White House has proposed a global AIDS initiative, now at $100 million (this figure includes the $25 to $30 million, above, that is already being appropriated). U.S. international AIDS funding could nearly double next year-- from about $125 million to about $225 million. USAID (U.S. Agency for International Development) programs alone would go from $127 million to about $180 million, and the U.S. Department of Health and Human Services (HHS) would launch programs they are not now doing, about $30 million.

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This will be for next year; it is not a done deal, and will rely on reprogramming money from Justice, within Defense, and funds that have been obligated but not spent in USAID.

There is a very serious commitment in the people I talk to in USAID, the White House, and elsewhere, that there will be a profound increase in funding, above the $25 to $30 million.

Some have suspected that the increases in funding are not real, but done for the November 2000 election. While the election is clearly helpful, the fact is that people have worked on this for many years--and that Congress is controlled by the Republicans, and the increases in the House and the Senate certainly are not being driven primarily by the election.

And the commitment coming out of the White House is a recognition that it failed to increase funding sooner, and needed to do so.

Also, we pushed very hard to make sure that this funding will not come from other health programs, either in foreign assistance or in HHS.

There is no way to be sure, until the funds are actually there and nothing has been cut, but certainly we obtained every commitment we could that funds will not be taken from other development programs in USAID, or from other health programs within HHS.

People need to see this as real, and as something we need to make as effective as possible--not something that is just fraudulent and therefore does not deserve our attention.

James: Where can our readers learn more about this initiative?

Boneberg: It is described in a 29-page document, Report on the Presidential Mission of Children Orphaned by AIDS in Sub-Saharan Africa: Findings and a Plan of Action. This report was published by the Office of National AIDS Policy and is available at:www.whitehouse.gov/ONAP/

Medical Care in U.S. Foreign Assistance

Another huge change is a new commitment to care. For the first time, the United States is saying we are going to spend tens of millions of dollars to get access to drugs for opportunistic infections and other kinds of care, to most of the people in the world with HIV. This is extraordinary; we have never done it before.

Until two years ago, the U.S. strategy formally said that basically everything would be prevention, meaning almost entirely condoms. In the last couple years, official policy has allowed support of medical care also, as part of a prevention-care continuum.

But recently, GAAN has learned that there are no care programs, except for research into how to do such programs. If you ask officials at USAID about it, they basically say that they are doing care; but when you push them, what they mean is they are testing people for HIV- -but not giving them access to medicines, not providing them nutrients--and when they have such plans, these are for a research setting, not a care delivery setting.

The new money, and the new commitment to care, are two huge changes. And they will drive changes within USAID, within HHS, within the White House, Treasury, Commerce, and other departments, as these agencies move forward to work on a broad initiative that will now have lots of money behind it.

We are seeing major movement on building infrastrucure, and expanding infrastructure to also include getting drugs into bodies, meaning drugs for opportunistic infections and tuberculosis, and for prevention of HIV infection during childbirth.

So far no donor nation has done much on care; the French have mentioned it, but we do not see much money moving forward.

For the United States to say that we are going to commit tens of millions of dollars to make drugs available to people with HIV, and to help pregnant women have access to treatment to stop mother-to-infant transmission, is a revolutionary change.

U.S. AIDS activists need to help make sure (1) that this happens, and (2) that the money is well spent.

Human Rights

We also need to understand how HIV care relates to human rights. Medical care for people will usually include testing for HIV. And if you test people, you are putting them at risk, as we know from the murder that occurred last December in South Africa.

We need to focus strongly in the next several months on how to make sure that U.S. funding for care reaches people in developing nations in such a way that they can use it safely.

We cannot just go into a country and parachute doctors and drugs, and say here are medicines. One of the principal reasons that many women in developing countries do not seek prevention is because of the enormous stigma that is attached to them, their child, and their entire family, if they do.

In many countries it is difficult to get pregnant women to seek counseling and testing. And a huge percentage of women who are tested do not come back for the results.

The stigma issue is real, and we are hearing from people in developing countries that in many situations it is not safe to be tested. So a human rights component, and reducing the stigma, is key.

U.S. activists understand that to make care succeed, to provide drugs and medical care for people, we have to make it safe for them to access care.

So far human rights has not been on the official agenda. For example, there was the horrible murder of Gugu Diamini in South Africa in December 1998, after she revealed publicly on World AIDS Day, December 1, that she had HIV.

Our conversations with the Department of State indicate that the U.S. ambassador in South Africa said nothing, that the Department of State said nothing, that the White House said nothing, and in fact the highest levels of the Department of State did not even know that the murder had occurred--despite the fact that 20 U.S.

AIDS groups wrote, specifically calling attention. So there is a huge problem around human rights and safety of people with HIV seeking care, a problem that those of us who are concerned about getting drugs into bodies need to address.

Intellectual Property

James: How do you see the new attention to the effect of drug patents on access to treatment in developing countries?

Boneberg: It's completely complementary. The less expensively medicines can be obtained, the better. Building infrastructure, training physicians, and making it safe for people with HIV to seek care, is only part of the equation; it does no good if there are no medicines there for people, just as it does no good to have medicines if people will be threatened if they seek care.

The two go hand in hand, and build on each other. Those who follow trade issues and are now looking at medical care bring one set of issues and one constituency--and those who work with care from a medical and classical development viewpoint bring another, complementary perspective.

It is an extraordinary success that the Health GAP Coalition [www.healthgap.org] and others have been able to raise parallel imports and compulsory licensing, the whole intellectual property debate; this is extraordinarily helpful to the efforts to try to get care to people in developing countries.

James: How do you see the July 22 hearing in the House on the U.S. role in combating the global HIV/AIDS epidemic?

Boneberg: It brought to the highest possible forum, the United States Congress, the issue of access to drugs and intellectual property in AIDS.

I wasn't at the hearing, but the presentations I saw in writing were exceptional. My impression is that the bipartisan members of the Committee who stayed for the six-hour hearing thought so as well.

I am also told that there was bipartisan praise for Sandra Thurman and her initiative. Again, we see reinforcing agendas, reinforcing support on issues driving toward the same goal, which is getting drugs into bodies in developing countries.

I defer to James Love of the Consumer Project on Technology, and to Eric Sawyer, with the Health GAP Coalition, as to what the next step is. We are seeing continuing efforts to clarify the position of the U.S. Trade Representative.

I think that office has not gone far enough; that given the wrong position of the United States government on this issue, somebody needs to say clearly that the position was wrong, and that we are going to change it.

I think that James Love's analysis, which is that we are seeing good movement but it is not enough, is where GAAN would come down as well.

There are two issues. There are the intellectual property issues, what is the policy and what should it be; and then there is the electoral issue of what should the Vice President of the United States say.

I think the Administration, the Vice President, has not gone far enough to clarify that the policy has been wrong, and that U.S. intellectual property is not an obstacle, above and beyond the requirements of the World Trade Organization, to getting drugs into bodies in developing countries.

And right now, the United States is perceived to be an obstacle, by many people here and in other parts of the world. It needs to be absolutely clear that this is not our country's agenda.

There are intellectual-property purists, trade purists, in the U.S. Trade Representative's office and elsewhere, who cannot grasp that there is an extraordinary situation that vetoes their purity.

It's similar to the Administration on many levels being unable to recognize that this epidemic is an emergency, like a war. The key to changing is for someone in authority to say that we recognize this as an emergency. Once they say that, their position until now becomes indefensible.

If we were at war, and were allied with South Africa, and someone there were making bullets, would the U.S. Trade Representative say to South Africa, "You're stealing our patents for bullets?"

In a war situation that would be absurd; of course we wouldn't sue South Africa over patents on bullets, during a war. But we are willing to pressure them in the war against AIDS around patents on medicines.

The fundamental fallacy of the Administration's arguments on trade is very similar to its fallacy on why it has not provided funding, why it does not react on human rights, and so on--the Administration has not seen the AIDS epidemic as a crisis equivalent to war. If they saw that, all the other arguments would fall away.

The recent hearing was a major success; one cannot get a better forum than the U.S. Congress. The larger points are that the discussion occurred at all, and that it was not driven just by trade purists, it was driven mainly by people who care about Africa, and those who care about AIDS, as well as those who care about trade.

James: What can people do now to help on international AIDS issues?

Boneberg: Given that large amounts of funding are starting to flow, and given the strong concern among many activists, GAAN urges U.S. AIDS groups to involve themselves in global AIDS issues and projects.

The way to do so is to take an area or constituency in which your group is expert, and to try to work on that, either by connecting with people in developing countries, by looking at the policy issues in what the United States is doing, by attending conferences--there are many ways to engage, and now is the time to do so.

U.S. government funding alone is likely to almost double in one year, and probably increase dramatically after that. And we are also seeing major funding from pharmaceutical companies and others. In addition, new connections are developing between Southern groups and Northern groups.

The time is now for U.S. AIDS groups to engage themselves in reshaping the U.S. global AIDS response.

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