Which countries receive too little media attention given their AIDS prevalence? We know how much press attention countries receive overall (at least as based on citations in the Kaiser Daily HIV / AIDS Report, published since 1999 and probably the most widely read AIDS news resource). We also know how many people have HIV in each country (as cited by UNAIDS). If we combine these two data types, we can determine "media citations per million cases", giving an idea of relative media attention a country receives. Here is a table of the 40 developing countries with the highest incidence of AIDS ranked from "most neglected by the media" to "least neglected by the media":

	People with HIV	Kaiser Citations	Citations per million cases
Madagascar	140,000	6	43
Sudan	400,000	20	50
Colombia	190,000	10	53
Nigeria	3,600,000	208	58
Chad	200,000	12	60
Dem. Republic of Congo	1,100,000	72	65
Central African Republic	260,000	20	77
Burkina Faso	300,000	24	80
Burundi	250,000	20	80
United Rep. of Tanzania	1,600,000	133	83
Ethiopia	1,500,000	126	84
India	5,100,000	449	88
Cameroon	560,000	57	102
Mozambique	1,300,000	144	111
Malawi	900,000	111	123
Zimbabwe	1,800,000	224	124
Cote d'Ivoire	570,000	79	139
Myanmar	330,000	47	142
Ukraine	360,000	57	158
Lesotho	320,000	63	197
Mali	140,000	28	200
Ghana	350,000	76	217
Russian Federation	860,000	189	220
Angola	240,000	56	233
Zambia	920,000	236	257
Kenya	1,200,000	309	258
South Africa	5,300,000	1461	276
Guinea	140,000	46	329
Haiti	280,000	100	357
Brazil	660,000	237	359
Rwanda	250,000	97	388
Viet Nam	220,000	103	468
Swaziland	220,000	105	477
Namibia	210,000	102	486
China	840,000	445	530
Cambodia	170,000	102	600
Thailand	570,000	468	821
Botswana	350,000	291	831
Uganda	530,000	489	923
Mexico	160,000	159	994

Nigeria and Democratic Republic of Congo are particularly notable members of this list, representing 10% of the world's cases of HIV between them but garnering only 1% of press citations.

Full spreadsheet with these data is available here.

After several years in gestation, a new World Bank report on AIDS treatment options in India was recently released. HIV/AIDS Treatment and Prevention in India specifically addresses ART, and which policies the Indian government should adopt regarding the procurement and provision of AIDS medicines.

While the press coverage of the report tended to focus on projections of infection ("five million new cases a year in India in 2033"), the main story of the report (and underlying model) is really something else: ART will succeed or fail depending on what happens to condom usage. If ART promotes condom usage (because of tying treatment and prevention programs), then ART will lessen new infections. If ART discourages condom usage (because of disinhibition effects), then ART will increase new infections.

While AIDS economists can pick at the model, and while the Bank is a lightening rod for most policy reports such as this, the key messages regarding the interplay between treatment and prevention shouldn't be overlooked. In addition, the report serves as a well-presented primer on ART policy in environments with low but growing prevalence of HIV -- which is to say, most countries of the world. Kudos to the authors: Mead Over, Peter Heywood, Julian Gold, Indrani Gupta, Subhash Hira, and Elliot Marseille.

In The Tipping Point, Malcolm Gladwell describes how ideas spread through society, following "epidemic-like" dynamics. At one point he includes a provocative passage about AIDS, and what would have happened had we not discovered the virus. I include it here as food for thought:

"Not long after The Tipping Point came out, I happened to talk to an epidemiologist, a man who had spent the better part of his professional life battling the AIDS epidemic. He was a thoughtful fellow, and frustrated in the way that someone would be who has had to deal, on a daily basis, with such a terrible disease. We were sitting in a cafe talking about my book, which he had read, and then he said something startling: "I wonder if we would have been better off if we had never discovered the AIDS virus at all?" I don't think he meant that literally, or that he regretted the countless lives that have been saved or prolonged by anti-HIV drugs and the AIDS test. What he meant was this: that the AIDS epidemic is fundamentally a social phenomenon. It spreads because of the beliefs and social structures and poverty and prejudices and personalities of a community, and sometimes getting caught up in the precise biological characteristics of a virus merely serves as a distraction; we might have halted the spread of AIDS far more effectively just by focusing on those beliefs and social structures and poverty and prejudices and personalities."

In Bangkok there was frequent discussion of monitoring and evaluation programs, particularly with respect to the "three ones" -- one plan, one coordination mechanism, one m&e framework. Despite the great importance of m&e, there isn't a lot of obvious activity in this area. The UNAIDS site has the most comprehensive M&E section of any organization -- but it hasn't been updated for two years. The best (only?) recent resource on M&E, the "Monitoring and Evaluation Toolkit" compiled by the Global Fund and others, has, according to AltaVista, only four organizations linking to the Global Fund's document download area: The Global Fund, WHO, USAID (co-authors of the document) and AIDS Matters. (As a point of contrast, the UNAIDS 2004 Report on the Global AIDS Epidemic has about 150 organizations linking to it.) The Global Fund is, at the least, ramping up m&e efforts (including advertising two job openings for M&E officers), and I know that donors continue to try to coordinate on M&E issues. The next twelve months are pivotal in persuading donors that initial investments in combating AIDS are sound -- which is very little time for enhancing efforts.

The IAEN today published a follow-up interview with Paul Farmer in which he responds to reader questions from around the world. Highlights include his estimates of total costs in Haiti of "good AIDS care" ($500 per patient / year); time to a useful vaccine (15 years); and important "neglected ideas" (complete integration of prevention and care; community-based and supervised care called "DOT-HAART"; and the importance of linking AIDS projects to women's health and TB projects).  He also highlights the new treatment guide published by Partners in Health which is certainly one of the most important AIDS books this year.

There is increasing attention being paid to AIDS monitoring and evaluation programs -- with a good recent step being the publication of the "Monitoring and Evaluation Toolkit" from leading donors. Most attention is paid to a unified m&e framework, consistent metrics, and initial studies to guage long-term success.

Planning efforts, however, appear to overlook one thing: the most important funding decisions concerning AIDS will be made in the next 24 months. Whether funding will continue to increase or level off is a near-term issue. The comprehensive data from m&e programs for the most part won't be ready, particularly concerning "outcomes" (outputs is easier: grants made, funds dispersed etc.).

How can we portray positive outcomes to government donors before good data are back (which might take years)? One important piece is through stories, sending journalists and photographers to capture, even if anecdotally, the impact of AIDS programs. The Global Fund does a pretty good job at this (their "Global Fund at 30 Months" report, for example), but certainly more can be done, including in a coordinated way among donors.

A dominant theme in this year's AIDS conference will be the importance of tying prevention and treatment efforts. The latest report of the Global HIV Prevention Working Group entitled "HIV Prevention in the Era of Expanded Treatment Access" cogently illustrates the necessity of this linkage. Not only are both prevention and treatment efforts greatly enhanced by the synergies between the two, there are convincing reasons why inattention to the linkage -- or excessive focus on treatment -- could actually make things worse:

• the number of people treated are unlikely to catch up with new infections anytime soon;


• there are likely to emerge drug-tolerant strains of HIV;


• the introduction of therapies (or perceived therapies) can enhance risky behavior;


• treated people live longer, and therefore can in theory infect others.

I don't intend to be Cassandra-like in deriding the promise of treatment efforts -- I just hope enthusiasm for 3x5 won't eclipse the need for greatly expanded prevention, tied as closely as possible to growing treatment programs.

I arrived this morning to Bangkok and was pleased to see in my conference welcome materials -- along with the typical maps and schedules -- four brightly wrapped condoms. Congratulations to the Thai organizers for making this statement on the importance of condoms in fighting AIDS. I regret that in my country, inclusion of condoms would be pitifully controversial.

I was pleased to see the call for the Global HIV Vaccine Enterprise, which the White House press release describes as a "virtual consortium to accelerate HIV vaccine development by enhancing coordination, information sharing, and collaboration globally." I'm not clear, however, why not simply support IAVI, which seems to have a similar mandate: "to accelerate the research and development of promising vaccine concepts for the developing world from preliminary laboratory studies to clinical trials in humans". The initiative is apparently based on the recent Science article, which included Seth Berkley of IAVI as a co-author. The initiative has a seed $15 million which should be sufficient for planning, infrastructure -- and sorting through relationships with IAVI and many others.

The Copenhagen Consensus has released its prioritization of top global problems. HIV / AIDS topped the list. If you are not familiar with this astounding initiative, check the detailed Wikipedia entry (or competing Disinfopedia entry if you like). Wired Magazine also ran a nice interview with Bjørn Lomborg who directs the initiative. (I love the title of the article: "You Can Cure AIDS. Or End Hunger. Choose.")

The next challenge is to decide how to prioritize the notional $27 billion the Copenhagen Consensus allocates to AIDS. I'm hopeful they will continue their efforts -- or somebody will. If anyone wants to carry this torch, I've registered "AIDSconsensus.com" and am happy to give it to any smart initiative.

I'm very impressed by the Global HIV Prevention Working Group, a joint initiative of the Gates Foundation and Kaiser Family Foundation. The working group comprises 50 leading AIDS authorities from around the world that meet periodically, backed up by a very capable staff. The Working Group has released two reports (with one more soon to be published), each of which providing cogent directives in combating AIDS. The reports are probably the most clearly presented and credible documents of the kind anywhere. Every AIDS policymaker on the planet should have copies. Here are the two reports to date:

- May 2003 Report - Access to HIV Prevention: Closing the Gap: A Global HIV Prevention Working Group Report

- July 2002 Report - Global Mobilization for HIV Prevention: A Blueprint for Action: A Global HIV Prevention Working Group Report

My frustration with the initiative is they do fine work, publish their reports, hold a press conference -- and then seemingly disappear. So do their reports. Google lists only about 200 citations of the two reports combined. (As a point of reference, the World Bank's "Confronting AIDS" report and UNAIDS 2002 Epidemic Report have about 1700 citations each). If you're not getting the word out, why bother with the effort? I'm not able to find a dedicated Web site, editorial calendar, members list, contact list -- not to mention interactive features that could draw in many more global policymakers. There is a wonderful opportunity here that Gates and Kaiser could be jumping at.

Part of my interest in posting this information is to see how this post fares on the Web compared to the limited information provided by the Global HIV Prevention Working Group. If my measly blog entry ends up with higher search engine results, you'll know there's work to be done. Check back in six months!

Today we launched at the IAEN a new "Global Dialogue" with Helene Gayle, Director of the HIV, TB and Reproductive Health program at the Bill & Melinda Gates Foundation. In it she discusses the interplay between treatment and prevention, as well as areas that are in her opinion underfunded (including research).

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.