On 15^th September, a man dressed as a bear was being tugged around Red Square in Moscow on a leash by three blonde ‘naughty nurses’. Promoting a fetish club? No, it was a deadly serious demonstration by AIDS activists.

The bear was Russia, humiliated by its inability to deal with HIV. “People with HIV face a choice, to die quietly at home or try to attract the attention of the government,” said activist Alexey Yaskovich. He was protesting against the corruption and indifference that has meant only half the people in this increasingly prosperous country who need antiretroviral (ARV) drugs get them.

Next door, in Romania, the situation is at least as bad. Alina Dumitriu of local organisation Sens Positiv told HTU that the money for ARVs from the Romanian government ran out in September this year, with no more till January.    

“Hospitals are prescribing incomplete combinations: patients have to try and buy the rest.”

This is not just a European problem. In Zimbabwe, protests have broken out as corrupt, or just poverty-stricken, nurses steal ARVs from hospitals and re-sell them; in Uganda, where still only a third of people who need ARVs get them, people with HIV have started a “no drugs, no vote” campaign ahead of the 2011 general election. We face a global AIDS financing crisis and there is no consensus on how to solve it.

The World Health Organization (WHO) has issued its fourth treatment access report¹ showing that, while the number of people on ARVs went up by 30% last year, still only 52% of people in need of HIV treatment get it. More than 50% is an achievement. But 2010 was supposed to be the year we achieved 100% treatment access, according to the promise made by G8 leaders in 2005.

The WHO is worried that even present levels cannot be sustained: “Without sustained and strengthened financial and programmatic commitments, there is a significant chance that these achievements may be undone.”

The Global Fund for AIDS, TB and Malaria calculates it needs $20 billion over the next three years. But European countries, mindful of their financial crisis, are reluctant to sustain current funding levels. France, the most generous donor in Europe to the fund, has just given $1 billion but international health charity Médecins sans Frontières says that Germany and Italy may decide to give no money at all. Totting up even the vaguest pledges indicated so far comes up to 20% of the $20 billion target.

In the US, activists are furious with president Obama. While campaigning he indicated he would increase support for the other mainstay of HIV treatment – the US-only PEPFAR initiative – by $1 billion a year. Last year he increased its funding by 10% of that amount – not enough to match medical inflation.

It is not just about money. As the Russian situation shows, you can have plenty but still be unable or unwilling to treat your people.

The 2000s, says the WHO, saw an emergency response to AIDS. Rich countries parachuted in cash to fund disease-specific programmes. They acknowledge that this led to many lives being saved, but also to corruption and inefficiency. They say that we need to restructure HIV funding so we don’t just pump money into HIV but into the creaking healthcare systems that prevent the money being spent efficiently.

This would also ensure improvement in the other UN Millennium Development Goals (MDGs), such as maternal and child health, progress towards which was reviewed at a summit in September. In a pre-summit debate on “Smart Global Health Policy”,² Julian Schweitzer, former Human Development Director at the World Bank, decried the situation of “freestanding clinics that can only treat a particular disease, as well as cars sitting in Ministry of Health garages that can only be used for specific projects.” Ex-US AIDS Ambassador Mark Dybul’s solution in this debate was radical: turn the Global Fund for AIDS, TB and Malaria into a Global Fund for Health. Schweitzer, however, warned that this might become a corrupt monopoly in itself.

The search for solutions has split AIDS activists. Traditional treatment activists fear that structural reformers will de-prioritise HIV. In one example, Mark Harrington of the US Treatment Action Group accused Mead Over of the Center for Global Development of ‘genocide’ for advising Obama that the answer is not to pour money into HIV alone. Over responds that he is just championing prevention and structural reform, pointing out that donors have even refused the relatively paltry sum of $100 million to ensure the continuation of microbicide trials.

There are many other suggested solutions. One is a patent pool, whereby companies holding patents on drugs that would normally command high prices donate the patents to a communally owned pool; this ensures generic versions of new drugs can be manufactured legally. AIDS activists are now branding the EU, rather than the USA, as the worst patent enforcers as they try to strong-arm Indian drug manufacturers, who provide 80% of the world’s HIV drugs, into signing up to trade agreements preventing their export..

Then there’s the idea of the Robin Hood Tax,³ a tiny levy on every single one of the millions of international financial transactions that happen every day that would go to relieving global poverty and disease.

About the only thing people agree on is that the money must be made to work better. The global response to disease was revolutionised in the 2000s because people realised that HIV could not be met by ‘business as usual’. Today the way we fund HIV treatment and prevention has become the new business as usual, and we have find a new way to structure sustainability and permanence into the global fight to defeat AIDS.