SWITZERLAND MAY SEEM a curious country to start my travels. What can this eminently respectable and sedate nation know of HIV and Aids and the human problems they cause? The answer is that they know rather more than you might think. For example, during the brief period between 1987 and 1992 Zurich, and more particularly the Platzspitz Park next to the Swiss National Museum, offered clean needles and syringes to all comers and a freedom from prosecution while in the park. The idea was to tackle the burgeoning drug problem in the city and with it the spread of HIV and Aids. You could call it an experiment ahead of its time. In fact, it was a badly organised scheme which acted as a magnet for both drug users and pushers alike. Drug users (many from outside Switzerland) flocked to take advantage of what became known as ‘needle park’ and in 1992 the scheme was finally closed down. But I did not visit Switzerland to look in detail at the history of Zurich’s needle park or the challenge it faces today – except to register in passing that every country in the world faces a drugs problem and solutions need more than good intentions. Rather my intention is to travel two hours, thirty-eight minutes by Switzerland’s impeccably punctual trains to Geneva, which stands near the border with France. For, if any city can lay claim to be the health capital of the world, it is Geneva.

Clustered on a campus a few miles from the city centre with distant views of a range of snow-capped mountains is the massive headquarters of the World Health Organization. Formed after the Second World War in 1948, but with roots in the pre-war League of Nations, it is the specialist health agency of the United Nations. Facing it in a tower of long corridors is UNAIDS, which was started in 1996 specifically to give a new impetus to the battle against HIV and Aids. Back across the tree-lined oblong of lawn which divides the campus is the newest health body on the block: UNITAID, formed in 2006 with the aim of ensuring affordable medicines and getting the best value for money out of the billions of dollars now spent on tackling HIV and a range of other health conditions. They are temporarily, but appropriately, housed in portable cabins. A short distance away down the road towards the lake is the headquarters of the International Red Cross, while away from the campus altogether is an anonymous office building that houses the Global Fund to Fight Aids, Tuberculosis and Malaria, which gathers in money from governments around the world and distributes about $4 billion a year in aid directed at HIV (where 60 per cent of their budget goes) as well as at malaria and tuberculosis. There is no better place than Geneva to get a view of the history and advance of HIV and Aids around the world and the value of the measures taken to check it.

From a fairly early stage we knew how HIV was passed. As one of our British health leaflets said in the autumn of 1986, ‘all proven cases have been caused by semen or blood’. Shared needles was the blood route; sexual intercourse (gay or straight) was the seminal route and the one that caused most casualties. There never was any logical reason to believe, as many claimed back then, that HIV was somehow exclusively a ‘gay disease’. Although in the 1980s the wards in San Francisco were full of dying gay men, the hospitals in parts of West Africa were packed with young women. Given the widespread homophobia in most African countries, any suggestion that gay sex was a large scale means of transmission was fiercely denied.

Peter Piot, who later was to become the first director general of UNAIDS, tells a story in his autobiography No Time to Lose of meeting a general from Zaire (now the Democratic Republic of the Congo) whose clothes were literally hanging off his body and who obviously had Aids. He was proud of his sexual prowess and boasted of the many, many notches on his belt. ‘Naturally I’m a real man,’ he said. ‘A real man needs women, many women.’ Tentatively Piot suggested that he might also from time to time have had sex with a man. ‘What!’ Bellowed the general. ‘Never. How can you even think that. How filthy. How deranged.’

Piot worked in West Africa as an epidemiologist in the 1970s and made his name with his contribution to identifying the Ebola virus, which was uncovered in 1976 following reports that several Belgian nuns working in a hospital in Zaire had died from a mystery infection. Many more died before it was tracked down to the hospital itself and the lethally poor hygiene there. In an uncanny forerunner of HIV, the researchers found that the sharing of infected syringes had spread the epidemic.

A few years after the first Ebola cases, the first cases of Aids were officially recognised. In 1981 there was an American report that five young gay white men in Los Angeles had contracted a mystery illness and later that year the medical correspondent of The Times in London reported that ‘an unexplained epidemic of infections and cancer among young male homosexuals is causing growing concern in medical circles’. Only one death had been reported in London but in the United States the figures had shot up during the year with 180 reported cases and seventy deaths. The report added that homosexuals who had developed the disease had been found ‘to give very low responses to standard tests of their immune systems – a condition known medically as being immuno-compromised. That has led American doctors to name the condition the ‘gay compromise syndrome’.

It was the beginning of the flood, but were these actually the first cases? Few believe that. There may be disagreement about just when the first cases occurred, but there is general agreement that it was long before the headlines of the 1980s. One apparently certain earlier case was unearthed by Michael Worobey, an American ecologist, while he was working in West Africa. He reasoned that unexplained deaths exhibiting symptoms which were later identified as Aids almost certainly would have led doctors in the 1950s and 1960s to have ordered biopsies. It was just possible that some of these biopsies might have survived – and so it proved. At the university of Kinshasa, wax encased biopsy samples had been stored carefully away. Finally, after months of painstaking research, he discovered remnants of HIV in a tissue taken from a 28-year-old woman who had died in 1960. Some researchers believe that there are earlier cases also waiting to be verified.

But where did it come from? To my mind the most convincing theory on the origin of HIV is put forward by Timberg and Halperin in their 2012 book Tinderbox. Roughly condensed, it is that the HIV had been slowly spreading unnoticed, perhaps for decades, before the first cases came to official notice. Genetically, HIV closely resembles strains of the virus SIV (simian immunodeficiency virus) found in chimpanzees, and therefore it was reasonable to think that there could be a link. In West Africa, chimpanzees are sold by the side of the road as bush meat and what could have happened is that a man became infected, through an open wound, either when picking up the bloody animal he had just hunted or in preparing the animal for sale. Either way, the man became infected with the virus and in turn he sexually infected others. The long, long route of global transmission began.

At first, Timberg and Halperin suggest, the virus was contained locally in a remote part of Cameroon but gradually, in the colonial years of Africa and afterwards, the virus spread more widely. Some of those who had been infected locally travelled down the Congo River to what was then Leopoldville and is now Kinshasa. The big city facilitated the spread and from there the virus went by road to neighbouring parts of Africa. But how did it travel to the United States? The simplest explanation is by ship and by infected seamen to the West Coast of the United States, perhaps to a port city like San Francisco. Another branch of basically the same theory gives Haiti an unwilling part in the story. After the Belgians withdrew abruptly and without preparation from the Congo in 1960, there was a need for professional groups, like teachers and engineers, that the colonial power had failed so lamentably to train locally. Some of these posts were eagerly filled by well-educated Haitians anxious to escape for a while the notorious rule of François (‘Papa Doc’) Duvalier. When they returned to Haiti (on holiday or more permanently) that country became a HIV staging post to the New World.

Outside the world of epidemiology all this sounds fairly extraordinary if not fanciful. Who has ever heard of the biggest epidemic to strike the world in modern times being caused by some harmless chimps in an under-populated part of Cameroon? Is it really possible that they could have been the root of an infection which wiped out men and women by the million throughout sub-Saharan Africa as well as gay men in the bath houses of San Francisco and the drug users in the slums of Moscow? Surely it defies belief? But then you have to remember the history of other viruses. In the 1960s the Marburg virus was identified after a number of pharmaceutical workers in Germany had been infected by a batch of monkeys imported from Uganda. Seven of the twenty-five who had been in direct contact with the monkeys died. One trace takes the Marburg infection back to cave-dwelling African fruit bats and suspicion also falls on them as the root cause of the Ebola virus. As for the wider communication to the general population, we should remember that the Great Plague of the seventeenth century was spread by fleas on the backs of rats. In modern times there is no better way of sending a virus around the globe than through sex and drugs.

Whatever the explanation, there is no doubt about the sheer speed of the next stage. Between 1981 and 2000 the number of people living with HIV around the world increased from less than one million to over twenty-seven million. Sub-Saharan Africa was the very worst affected, with around a quarter of the population infected in some countries, but most other countries have also felt the impact. Deaths rose to alarming and tragic heights and antiretroviral drugs were still in short supply. At the same time the theories of the denialists that HIV was not the cause of Aids, or that it was an epidemic that affected only gay men, were shot full of holes. In Britain in the 1980s I was often accused of overreacting to the danger. Given that it was a virus which spread so rapidly, which could kill so many and had no cure, and what has happened around the world since then, I am amazed at my moderation.

Aids could have been checked early, but the world was tragically slow to recognise what was happening and even slower to do anything substantial about it. As one WHO official told me, ‘We allowed the tragedy to explode before our eyes.’ In the 1980s and 1990s the developing public health crisis was clear for anyone who wanted to see but many of the countries it most severely affected were largely out of sight of the rich West. In particular they were the African countries south of the Sahara desert that did not have the resources or the health systems to tackle such an epidemic. In truth they desperately needed international help – although perversely some African nations refused to recognise the monster that was at their door and even rejected help when it was offered. The result was that the most basic and cheapest prevention tool – the male condom – remained largely unavailable in the countries where the epidemic was expanding the fastest. The efficacy of circumcision as a substantial, but not total, protection had yet to be recognised. The plight of injecting drug users and sex workers was widely ignored – as it still is. The resources devoted to the fight were hopelessly inadequate.

Sir Richard Feachem, the founding director of the Global Fund, said that in the 1990s,

A similar perspective comes from Peter Piot. Looking back to 1995, when he started UNAIDS, he says:

UNAIDS started to improve the position slowly. The first priority was to get better estimates of the scale of the disaster. Up to then the collection system was fairly rudimentary. One country insisted in putting in its return in pencil and, more seriously, countries like Russia, South Africa and India accused the agency of exaggerating the epidemic. As it happened, in 2007 UNAIDS was forced to concede that in a number of countries, including India, they had indeed overstated the figures. I remember being in New Delhi at the time that the Indian figures were downgraded – to an almost audible sigh of official satisfaction. Today UNAIDS says that it now asks for and receives much more detailed information. Dr Peter Ghys, the director of epidemic monitoring, says that the figures rest on ‘much more data both in quantity and quality’.

What these figures show is that the first decade of the twenty-first century was a period of undoubted progress. Antiretroviral drugs had first appeared in 1986 as single agents with limited efficacy. By 1996 highly active antiretroviral therapy using multiple drugs in combination became available but at sky-high prices. Slowly, as prices came down, they became more available to people in the developing world. At the same time they became dramatically easier to take. Rather than a cocktail of perhaps twenty pills taken at the same time, by 2010 patients needed to take only one – although this pill still contained three different compounds. UNAIDS played a valuable role in this development but the real game-changers were the start of the Global Fund in 2002 and the President’s Fund in the United States (PEPFAR) the year following. From this point big resources began to flow.

Ironically the Global Fund to Fight Aids, Tuberculosis and Malaria was a product of the 2001 meeting of the G8 assembly of the top economic nations in Genoa, where 200,000 anti-globalisation protesters battled with brutal Italian riot police. Richard Feachem (in words which would have been approved by most of the Genoa demonstrators) said of the meeting ‘We were driven by the passion and anger of the advocates, activists and affected communities. Business as usual was clearly not going to do the job. Something new, different and far more impactful was required.’

The Global Fund was a new step in that it put responsibility on the nation asking for help to put forward the schemes they thought most important, rather than having it decided for them. ‘No longer would young and inexperienced staff members of agencies in Washington, London or Geneva dream up what was best for Malawi,’ Feachem says. ‘Ownership of programmes, of success and of failure, would lie with the country and not with the Global Fund.’ In its first five years the fund raised around $11 billion and supported projects in 140 countries.

So where does the world stand today? Not surprisingly, in Geneva health officials argue that they have made massive progress – and they have. The rapid expansion of antiretroviral therapy (ART) is rightly claimed as one of the most remarkable achievements in public health history. The drugs now reach over ten million people around the world, which is a twentyfold increase since 2003. In Africa in 2000 very few received treatment (0.1 per cent); today treatment is provided for over 40 per cent who are judged to need it.1 Deaths are almost a quarter lower than their 2005 peak and life expectancy has risen significantly in a whole range of countries. New infections have reduced by a fifth since the turn of the century and there are many fewer babies born with HIV.

In a few short years the President’s Fund from the United States and the Global Fund from Geneva have grown to become by far the biggest donors of aid for HIV in the world. Although they are frequently not given credit for it, the American contribution dwarfs all else. It not only gives directly through PEPFAR and USAID, it provides almost a third of the Global Fund’s resources; America is precluded from giving more on the basis, so it is said, that if they did the rest of the world might sit back and leave them to it. As it is, Britain and France are the Fund’s next biggest contributors (Britain having doubled its contribution in 2013) but rich countries like Germany and Japan inexplicably lag far behind. A range of other international organisations such as the World Bank also make contributions together with a never-to-be-forgotten small army of civil society organisations such as those of Bill and Melinda Gates, George Soros, Elton John and Bill Clinton, together with Médecins Sans Frontières, the International HIV Alliance, the International Aids Vaccine Initiative and many, many more. Global HIV investment from all sources in 2012 was almost $19 billion – a tenfold increase since 2001. An even more hopeful trend is the way that national governments that have in the past been recipients of outside aid are increasingly taking responsibility for their own populations. South Africa now claims to finance 80 per cent of its treatment spending.

To sum up this progress, I will quote one senior WHO doctor who suddenly revealed his credo. ‘We have an extraordinary opportunity,’ he said.

He is right. The opportunity is there. The progress that has been made is dramatic. The lives that have been saved represent a magnificent achievement. Equally, we should be in no doubt about the debit side of the balance sheet. Deaths may be down from their peak of 2.5 million a year but the toll is still an appalling 1.6 million a year. New HIV infections continue to outpace new treatment. The South Africans may be increasingly providing for themselves, but many other countries have not followed suit. Many nations rely almost entirely on outside support when financing schemes for drug users, sex workers or men having sex with men. Ministers don’t like getting involved in such potentially embarrassing and unpopular areas.

Yet it is precisely in these ‘key populations’ where we need to make progress. A UNAIDS survey in 2012 showed that, in forty-nine countries that produced data, the prevalence of HIV among injecting drug users was at least twenty times greater than in the general population, and in eleven of them prevalence was at least fifty-fold higher. Yet prejudice against drug users and the mistaken belief that harm-reduction policies increase crime means that clean needles and methadone can become a government ‘no go’ area. Even when countries have such programmes, the supply of clean needles can be sparse. In the measured words of UNAIDS, ‘The world is far from being on track to achieve the global target.’ Or – to put it more bluntly – despite all the advances, we are failing.

Some would argue that there is some underlying sympathy with drug users. Most middle-class families in the West (and not just the West) have had some experience of it through children, relations or friends. Not many have escaped. Men having sex with men, on the other hand, often raises an almost primeval response. In many parts of the globe homosexual men are ostracised, discriminated against, and assaulted. They become easy prey for blackmail and extortion. When he wrote about equal marriage in 2013 Dr Carey, the former Archbishop of Canterbury, talked of Christians in Britain becoming ‘a persecuted minority’. If the noble prelate wants to see a real persecuted minority he should look to the gay community.

To a greater or lesser extent discrimination is the experience of millions of gay men, lesbians and transgender people around the world. They are not loved and too many governments follow the public. Ministers know that such minorities are not a popular cause in their countries and they can safely look the other way. At best their attitude is that if international bodies want to provide testing and treatment, then that is up to them and it saves governments the embarrassment of even trying to persuade their own public to support such policies. And that is precisely what happens. The figures from Geneva show that in low- and middle-income countries no less than 92 per cent of the finance to tackle this obvious issue of public health is provided from international sources. The receiving countries could hardly show their distaste for the groups most vulnerable to HIV more clearly.

In almost eighty countries homosexuality is a crime which leaves gay people open to prosecution and imprisonment – even the threat of execution. It will be a brave man who comes forward for testing in one of those countries and risks exposure to the law. The public health result is bad for him and bad for others – most often wives and partners – as the virus is spread further. Some apologists claim that often the law is not enforced rigorously – as if this prevents corrupt police and officials from extracting money, or does away with the stigma that surrounds gay sex, or indeed does anything for public health.

And then there is sex work. Even its name raises controversy. In London one minister insisted that all references in a sexual health paper which had referred to ‘sex workers’ should be changed to ‘prostitutes’. In Geneva they prefer ‘sex work’ and if you want cooperation from sex workers then it is a more sensible description – and you do need cooperation if for no other reason than the fact that, in the precise words of UNAIDS, ‘female sex workers are 13.5 times more likely to be living with HIV than are other women’. That of course is an average across the world; it misses out the sky high rates in countries like Swaziland (70 per cent), Guinea Bissau (40 per cent) and Uganda (36 per cent).

The law round the world is equivocal. Sex work is illegal but tolerated. Almost everywhere there are legal restrictions but almost everywhere the police turn a blind eye or, just as likely, take protection payment from the sex workers. Corruption bedevils the whole area but no one much cares. On national agendas sex workers come low, if not last, in the table of priorities. In Kiev, for example, the leader of the sex workers’ association had never met a government minister and was embarrassingly overjoyed to be photographed with an ex-minister like me.

There are other issues also that need to be tackled but may well offend the more sensitive. An obvious example is sex in prisons. The first bridge to get over is that it happens at all – which it self-evidently does. So what are the consequences for policy? One is the provision of condoms which is now accepted in most sensible countries although, for some reason, testing for HIV (even on a voluntary basis) is often still regarded as a step too far. This is in spite of the evidence from Washington DC that the vast majority of prisoners raise no objection.

As for antiretroviral treatment the impact has been obviously hugely beneficial but we should never forget the excluded. For the last decade the guidance from the WHO was that antiretroviral treatment should be started when the CD4 lymphocyte count in the blood went below 350 cells per micro litre of blood. The CD4 count of the average reasonably healthy HIV-free person is between 600 and 1,000. The major danger of serious life-threatening complications from HIV comes when the CD4 count falls below 200. The WHO has now reviewed this limit and the 2013 guideline is that those with HIV should start treatment not at 350 but when the CD4 count falls below 500. That changes the goal posts substantially and means that, in spite of all the progress, only a third of the twenty-eight million people with HIV living in low- and middle-income countries are now receiving antiretroviral treatment when they need it.

Children are particularly disadvantaged. Extraordinarily, they receive proportionately less antiretroviral treatment than adults and that position is unlikely to change soon. Of approaching seventeen million children who have lost one or both parents to Aids, almost fifteen million are African. A further unwelcome trend is that in several countries there is now an increase in risky behaviour – men and women taking more partners, a decline in the use of condoms, even the sharing of needles under the influence of so-called recreational drugs. The assumption, particularly of users in the prosperous West, is that antiretroviral drugs are available and so even if they do contract HIV they can still look forward to a long and unrestricted life. The risk of HIV does not hold the same terror as before. Perhaps the prevention message is all too often failing or – even more likely – has never been seriously attempted.

It is difficult to avoid the conclusion that, in spite of all the brave words about the bright future, the world still remains in crisis, and a quick tour of the statistics and policies on prevention, information and treatment around the world at present bears this out. Africa is still at the epicentre of the epidemic. As UNAIDS says, ‘There is always one piece of the pie chart that is biggest, one vertical column that is tallest, one trend line that is steepest: Africa.’ Out of the thirty-six million people who are living with HIV no fewer than twenty-five million live in Africa, predominantly south of the Sahara. In South Africa six million live with HIV, in Nigeria the figure is almost 3.4 million and in Kenya over 1.5 million. Overall in the countries of sub-Saharan Africa almost one in twenty adults live with HIV. In some African countries prevalence among sex workers is nearly 40 per cent and new infections among men having sex with men run at almost 20 per cent. The promotion of basic prevention measures like the condom range from patchy to non-existent. Even President Museveni’s much praised ABC campaign in Uganda – ‘Abstain, be Faithful, use a Condom’– is a pale shadow of what it used to be.

In Asia, India has over two million people living with HIV (although this is out of a population of over a billion) while in Indonesia the figure is over 600,000 and in Thailand 440,000. But we should not ignore some of the encouraging signs. Cambodia, for example, claims to have achieved universal access to antiretroviral treatment, while Thailand’s figures are a substantial improvement on ten years ago. Thailand’s work in providing condoms for sex workers rightly comes in for praise – as does the exuberance of some of the campaigning – but there is another side to the Thai coin. Like another ten countries in the region it threatens the death penalty for drug offences. UNAIDS summarises the gains across the Asian region as ‘insufficient and fragile’.

Elsewhere, stony-faced policies on drug users mean that in Eastern and Central Europe the rate of HIV infection continues to grow. UNAIDS estimates that half the new infections are because of drug users sharing needles. If any further proof was needed of the failure of the old Soviet policies in handling intravenous drug use you only need to look at the comparison between East and West. In Eastern European countries like Belarus, Georgia and Moldova the position continues to deteriorate, while in Western Europe (where clean-needle policies are now commonplace) infection has stabilised at a very low level. Western Europe generally has lower HIV prevalence but there is still a heavy price to be paid in those countries. Britain for example has 100,000 people living with HIV, which in drugs and care alone costs the health service about £1 billion a year and rising.

In the largely Muslim countries of the Middle East and North Africa there have been significant, and potentially ominous, increases. Although the numbers are comparatively small, it gives the lie to the assertion that men having sex with men ‘never happens here’. In Latin America it is estimated that about 1.4 million people live with HIV, with the biggest numbers in the drug affected countries of Mexico (170,000) and Colombia (150,000). The region with the highest infection rate after Africa is the Caribbean, with 1 per cent prevalence and Haiti accounting for over half the cases.

And then there is China. The official figures show around 800,000 people living with HIV, although some would put the number at over a million. In 2009 China reported that Aids had become the leading cause of death from infectious diseases for the first time, and later reports have shown that heterosexual sex is the dominant form of transmission. The result has been that over the last ten years China has made much more serious efforts to contain the virus than in the years before, which were characterised by denial and inaction. Clean needles and methadone have been introduced and 2007 saw the first major television campaign to promote condom use – twenty years late but notably successful. Even so, attitudes generally have taken longer to change. There was an attempt in 2013 to ban those with HIV from public baths and there continue to be stories of medical treatment being refused. Sex work exists in a kind of no man’s land. One health worker described it to me. On his way to work in the morning he would pass a number of brothels. The women would wave to passers-by from the windows but when there was a major ceremonial visit the brothels were closed – only to open again as soon as the visiting dignitary had left.

At this point I should perhaps make something clear. My purpose is not to attempt a comprehensive and detailed description of the position in every country of the world. UNAIDS does this admirably in its annual reports. My aim in visiting some of the major cities around the globe is to draw out some of the common issues that affect us all, to propose the policies we need if we are to make progress and to describe the main obstacles that stand in the way of bringing the epidemic under control. Of course I have not been everywhere and I make no apology for that. To attempt such a task would not only be gigantic but would put you out of date at one end of the world by the time you have reached the other. Even as it was, the political position in Ukraine changed out of all recognition from my first visit to the next, and is changing still.

In Geneva there is no doubt about how they see the way forward: give us the money and we will finish the job. In the words of one international worker there, ‘If the resources are available we can do wonders.’ The trouble is that it is a big ‘if’. There can hardly have been a worse time to ask for more resources than the last seven or eight years. International aid is not a popular cause at any time, let alone at a time of recession. Almost inevitably the cry goes up ‘what about us?’ Often it comes from people whose standard of living is infinitely higher than that of the grindingly poor, who are the usual beneficiaries of help overseas. Nevertheless, many politicians and newspapers see it as an all too obvious target for cuts. Their campaigns are aided by charges of official corruption and funds misapplied. And it can hardly be denied that even a cursory reading of the local press as you travel the world shows just how widespread that corruption appears to be, and that it certainly stretches into taking money intended for the sick and the dying.

We have seen one round of fund-raising abandoned by the Global Fund for lack of international support, while at the same time international resources for low- and middle-income countries have stopped increasing in real terms. This is of immense importance. As the Kaiser Family Foundation, which has been reviewing international assistance for HIV since 2002, comment in their 2013 report, ‘In the last decade donor governments drove a dramatic increase in funding scale-up, which helped to turn the tide of the epidemic. Yet donor funding has plateaued since the global economic turndown in 2008 and does not show signs of increasing.’ In other words, help has been frozen. Perhaps now, with the partial international recovery, conditions for giving will improve. Perhaps.

The trouble is that, historically, donor countries have seen giving money for HIV and Aids as different from helping other health conditions in one important respect. For most conditions, a single course of treatment will normally be sufficient. Even if it takes six or twelve months, the cured patient will make way for a new patient inside the budget. With HIV the position is radically different. HIV is a lifetime condition requiring a lifetime of treatment and, with present knowledge, a lifetime’s supply of drugs. As one Geneva official honestly conceded, ‘On present knowledge you need to keep people on treatment for the next forty years.’ Or, as I used to repeat time and time again back in the 1980s, ‘There is no vaccine; there is no cure.’

From the financial point of view this has clear consequences. Once you have placed people with HIV on treatment you cannot take them off and the likelihood is that they will need more care, not less, as their lives progress. The drugs bill could well increase. UNAIDS say, ‘As drug resistance increases over time more patients will require second and third generation medicines. Most of these more recent medicines will remain under patent for years to come resulting in potentially drastic increases in treatment costs.’

So what happens if you continue to freeze spending at its present historically high figure? It may sound eminently reasonable to hard-pressed finance ministers, but what it means in reality is that the epidemic will be given new legs. If you leave people untreated then the virus will have the opportunity to continue to spread. This is what happens in epidemics. This is how we got into this mess in the first place. It will mean more deaths, more suffering, more orphans and all the other human consequences that go with a failure of policy. Rather than meeting the UNAIDS target of reducing the utterly unacceptable total of 2.3 million new infections a year to 500,000, the danger is that the process could even go into reverse. The world would have given up much of the ground so painfully won over the last decade.

What we should do is to see how we can increase the treatment for those living with HIV while at the same time preventing the further spread of the virus. We need to know at what point the use of antiretroviral drugs benefits the public generally. One proposal is to go beyond even the WHO’s new guidance and in effect say that antiretroviral drugs should be given as early as possible as a prevention intervention. The point is this: if you leave the person with HIV untreated then he or she is infectious to others and the virus spreads. If the person with HIV starts effective antiretroviral therapy at the time of diagnosis and this is successfully sustained for the long term, then there is a real prospect that onward transmission could fall dramatically. That is the case made by those who advocate antiretroviral treatment as a means of prevention. They say that if antiretroviral treatment can be given as quickly as possible after a patient is found to be HIV positive that in itself will reduce the spread. Their claim is that prevention can cut onward transmission dramatically – by over 90 per cent. The point is given added emphasis in that HIV is dramatically at its most infectious immediately after acquisition.

But surely the cost of introducing such an ambitious policy would be prohibitive? The reply to that is that, in the end, everyone who has HIV will need antiretroviral drugs. What you are doing is bringing the cost forward, but with the bonus that if the policy is successful then new cases will reduce and the numbers of new infections will fall. Finance ministers will not like the cost being pushed forward, but the prospective gain for national exchequers and for public health in reducing the pool of those with HIV is obvious. There is also another bonus. As some of the antiretrovirals come off patent there will be the opportunity for cheaper generics. The newer medicines will remain on patent but some of the older (but proven) drugs will not. There is a once in a generation opportunity to achieve substantially lower drug prices.

But if we are to pursue such a radically new policy there are two conditions. First, those without HIV need to continue (or start) to take sensible precautions. All the old messages about using a condom, sticking to one partner and not sharing needles apply today. There is a shared responsibility in preventing HIV and governments must try anew to get this message across. Second, we need as a matter of urgency to reduce the vast number of people with HIV who are undiagnosed. Even in rich countries like the United States and Britain the number of undiagnosed is over a fifth of the total and in many other countries the proportion is much, much higher. As it stands, no policy, old or new, will reach them. The undiagnosed are not only a danger to themselves but a massive public health danger to everybody else. The need throughout the world is for more effective testing policies which also spell out the advantages of treatment.

The real decision for governments is whether we are prepared to switch to a policy of treatment and prevention, or bump along with the present policy of treating casualties while allowing fresh men and women to be infected. The question is where you put the interests of public health generally. Will we ever win the battle against HIV if we do not give prevention an infinitely higher priority? As it happens, a policy of ensuring that antiretrovirals are available for everyone who has HIV, irrespective of their CD4 count, holds out promise for both the patients and the public generally.

If I was to attempt an interim judgement, I would say that the world has come a long way but it now stands on the edge. We know the problems and we have shown that we can master most of them. The question is: have we the will to see it through? Have we the will to tackle the stigma and prejudice which gets in the way of so much progress? Have we the will to increase the financial support? Those questions need urgent reply. Over the next pages I will report on the response from eight further cities of the world: from Entebbe and Cape Town in sub-Saharan Africa at the epicentre of the epidemic; from the old Cold War capitals of Washington and Moscow together with Kiev, once a Russian satellite; from New Delhi, with its massive population and Sydney with its surprisingly pragmatic policies; and then back to Europe and London, where I first began. We might remember that in the world generally population trends are not in our favour. We can expect an increase in the world population of one and a half billion over the next twenty years. There will be more sexually active young people year by year. The dismal lack of sex education around the world will mean that many will be unprepared and ignorant.

To my mind the job is at best only half done. We still have countries that are in effect in denial, vulnerable groups that are surrounded at every turn by stigma and prejudice, governments that have lost some of the determination to succeed and have relapsed into complacency and a resistance to doing self-evident good. Too often the debate has changed. Rather than ‘What can we do to help?’ the question has become ‘Is this aid really necessary?’ In the West, Aids has too often slipped off the public and political agenda and ‘is it still a problem?’ is a startlingly common question. In writing this book I have been struck by just how many people in the West think that it is yesterday’s issue. We need to wake up to what is happening around the world. Unless we do we face continued human disaster. New efforts, new resources and new policies are urgently needed if we are not to go backwards. Today we are at a tipping point.

1. This is on the pre-2013 WHO definition of when treatment should begin, which I will discuss later in this chapter.