A colleague recently asked me "without bogging down in details, 'how do we cure AIDS?'" We're now 20 years into the disease and should have a cogent answer for this. Mine might be:

a) Be dedicated to prevention efforts, especially making sure to tie them aggressively to new treatment programs;
b) Target at-risk populations;
c) Move fast.

It seems like a simple list, although when I consider organizations responsible for the global AIDS response, they are greatly constrained around these three goals:

- Any organization with public funding finds prevention efforts difficult because of the political sensitivity of appearing to neglect treatment (this applies to public health in general, not just AIDS);
- At risk populations (sex workers, drug users, prisoners, gay men) are in many cultures political hot-potatoes making funding tricky (easier to support mother to child transmission or abstinence programs);
- No large bureaucracy can move fast -- multilaterals measure time in years, while AIDS measures time in days.

Some organizations can sidestep these constraints. The Gates Foundation can, for example, make a quick $100m grant to prevention efforts for Indian truck drivers, and a short while later add another $100m, something no other organization can really do. For the most part, though, the fit between the dynamics of the AIDS epidemic and the structure of organizations combatting AIDS is a poor one.