One of the dominant themes at the recent International AIDS Conference in Vienna was how to maintain the momentum towards universal HIV treatment access in the context of a global economic slowdown.

It is estimated that the Global Fund to Fight HIV, TB and Malaria, which funds treatment for 2.5 million of the 5.2 million people on HIV treatment in the world, will need up to US$2 billion over the next two years just to maintain the present number it supports. That figure doesn’t include funding for the extra million people that will need drugs if new World Health Organization guidelines to treat at CD4 counts below 350 are to be followed, let alone expanding treatment further. It is estimated that still only a third of the people with HIV in the world who need treatment are getting it.

The Fund has committed itself to pay for programmes worth $4-6 billion more than it has money to pay for, and given that its second-largest contributor, the European Union, actually reduced its contribution by $600 million last year, there was a lot of nervous questioning in Vienna about whether we would see reversals in treatment access.

HIV activists have also criticised the current US President, Barack Obama, for ‘flatlining’ funding for the President’s Executive Plan for AIDS Relief (PEPFAR) programme, which funds HIV drugs for two million people. Proposals to expand the mandate of the fund to cover maternal and child health could result in reductions in the funds available for HIV treatment.

There have certainly been reports of drug stockouts and people being forced off treatment from Uganda, from Russia and even in the USA, where 1700 people are currently on waiting lists for state-funded HIV treatment.

Ex-US president Bill Clinton, addressing the conference, had two messages, one optimistic and one sobering.

The optimistic one is that we seem to be turning the corner of the epidemic in terms of new infections. Global HIV prevalence has fallen by 17% in the last decade, partly due to better prevention, and there have been much more dramatic declines in incidence in young people in some countries – a 60% drop in young women in South Africa, for instance.

This appears to have been driven by behaviour change, but there is also evidence from some sources that HIV treatment is starting to have an impact on HIV incidence too, as the ‘take the test’ habit grows. Clinton said that the proportion of people in low- and middle-income countries who know their HIV status more than doubled from 15% in 2005-6 to 39% in 2007-8.

The sobering side of Clinton’s message, however, was that we could not rely on the mechanisms that have led to the remarkable expansion of HIV treatment into the developing world to keep the momentum going into the next decade.

He warned that newer funding mechanisms would have to complement the Global Fund/PEPFAR state-philanthropy model. Developing countries, many of whom had the resources to do it, needed to start funding more HIV treatment for their own populations – a criticism heard at other presentations during the conference.

Whereas South Africa, for instance, has committed itself to expand its own support for HIV treatment end prevention, the populous and oil-rich country of Nigeria still relies on international donors for 80% of its HIV treatment budget and currently treats only 40% of its population in need.

Dr Michael Kayode Ogungbemi of Nigeria’s National Agency for the Control of AIDS said: “The country has enough resources to give all the people who require antiretroviral therapy access to treatment. But the priorities of government are sometimes not informed by evidence or rational decisions.”

Clinton also said a massive increase was needed in private support for HIV. With the exception of a few billionaires like Bill Gates, Clinton said, the way forward was “to raise a massive amount of money in small amounts, by user-friendly means.” He gave as examples the air-ticket levy started by France which now fuels the UNITAID HIV treatment fund, the main supporter of his own Clinton HIV/AIDS Initiative, and schemes like SMS fundraising where people can donate to campaigns like the Haiti earthquake and Pakistan flood appeals by sending a one-word text.

Finally, he praised task-shifting: the training of nurses, community volunteers, and people with HIV to administer HIV testing, drug distribution and education/counselling to communities instead of doctors. South Africa had saved $300 million with its own task-shifting scheme, he said, and other countries needed to follow suit.

Clinton finished with a five-point plan to enable the continued expansion of HIV treatment: resist calls to deprioritise HIV; campaign for further drug price reductions, especially of tenofovir and second-line regimens; achieve large reductions in other treatment-associated costs; build better private donation structures; and “educate people why this is good”.

For more coverage of the conference, visit www.aidsmap.com/vienna2010.

The full news report on Clinton’s speech, including a link to a webcast of the session is available at www.aidsmap.com/page/1448242.