1 December 2022 – Mukesh Kapila

First published 1 Dec 2022 on Al Jazeera

Members of the AIDS Healthcare Foundation at a protest accusing a private pharma firm of profiteering, in Saint Louis, Missouri, the United States, on November 3, 2022 [Tim Vizier/AP Images for AIDS healthcare Foundation]

Arriving at Uganda’s Entebbe airport, I was struck by the miles of carpentry shops on the road to Kampala, building wooden coffins. It was the mid-1980s and I was studying the epicentre of a new condition devastating Africa: AIDS.

After infection with the human immunodeficiency virus (HIV), people can — after an initial, short, flu-like illness — remain well for several years. But with no treatment, the consequences are eventually always fatal. Around 85 million have been infected, and 40 million have lost their lives so far.

I witnessed that tragedy as a health adviser to the British government’s aid programme. But over the years, I also saw how the world fought back successfully against AIDS. Now, I believe it is important to take those lessons and employ them not just for disease-specific programmes but to develop sustainable, integrated strategies for universal healthcare and human development that leave no one behind.

In the 1990s, emaciated and incontinent patients with sores filled the corridors of Kamazu Central Hospital in Malawi’s capital, Lilongwe. As I drove up country, I saw abandoned fields and empty villages.

Attending the funerals of my local colleagues, including those at the British High Commission, was a regular part of my job. My main task – to establish Malawi’s post-colonial healthcare institutions – took a bad knock, as doctors and nurses died faster than they could be trained.

I often used Zambia Airways to travel around Southern Africa until rising HIV infections among its aircrew hastened its demise. As infection rates shot up in the police and military – exact levels were closely guarded secrets – regional instability became a serious concern.

It was heart-breaking to tour crowded orphanages in South Africa as parents died and traditional family support systems were overwhelmed. Older siblings were thrown out to face abuse and exploitation on the streets. I saw worse still in Rwanda, where 70 percent of the 500,000 women raped during the 1994 genocide acquired HIV.

Then a “miracle” happened. In a Zimbabwean hospital, I witnessed an AIDS patient treated with antiretrovirals rise from his deathbed. Overwhelmed, I cried with his family who came singing and dancing to fetch him home.

The AIDS beast was no longer invincible. Suitably inspired, I returned to my office to construct the biggest HIV/AIDS programme for Southern Africa of that time, with the British aid funds at my disposal. However, there was a problem.  Although azidothymidine (AZT), the first HIV treatment, had arrived in 1987, the $8,000 annual cost per patient seemed an insurmountable obstacle.

But I had underestimated the resolve of people living with HIV and AIDS who refused to be marginalised as victims. Joining them were vulnerable populations such as sex workers in Amsterdam and London, migrant labourers in Mumbai and Nairobi, injecting drug users in Melbourne and Mexico City, and gay groups in Rio de Janeiro and Tokyo. They challenged prevailing prejudices with a combination of reason and passion that dominated the agenda-setting AIDS conferences I attended in Stockholm and San Francisco.

Results followed. Funding for AIDS research skyrocketed and public attitudes began shifting. Even religious orthodoxies started cracking as the ethical case for condoms became stronger.

Such worldwide solidarity was unprecedented in history and Big Pharma could not sustain the immorality of massive profiteering from life-saving antiretrovirals. Led by South Africa and India, developing nations sought flexibility within the 1994 Trade-Related Intellectual Property Rights (TRIPS) Agreement to produce cheaper generic medicines when public health emergencies threatened.

This was finally accomplished with the 2001 Doha Declaration, and the impact was a 99 percent reduction in antiretroviral cost to less than $100 annually in the poorest countries. Innovation flourished with better drug combinations to the point that a treated HIV-infected person can now enjoy an almost normal lifespan. Pre-exposure prophylaxis with antiretrovirals is also highly effective in preventing spread. Today, 75 percent of people with HIV receive antiretroviral therapy.

Nevertheless, there is no room for complacency, because of gross inequalities – the appropriate theme for this year’s World AIDS Day. While primary infections have stabilised elsewhere, they have increased in the Middle East and North Africa, Eastern Europe and Central Asia. Previous progress has slowed, with 1.5 million new HIV infections and 650,000 deaths last year. Reinvigorating the fight in low- and middle-income countries, especially to reach marginalised communities, requires $29.3bn by 2025.

The good news? Those of us who have fought AIDS for decades know it can be done — and can serve as a model for how we deal with other public health threats such as COVID-19, Ebola, malaria, tuberculosis, and major noncommunicable diseases.

For example, it was the massive AIDS-triggered investments in fundamental sciences that paved the way for progress on many deadly cancers, turning them into liveable conditions. The technologies invented around AIDS management helped with the super-speedy invention of COVID-19 vaccines and medicines, and recently, the first working vaccine against humanity’s ancient scourge, malaria.

Today’s struggles against our biggest killers, diabetes and cardiovascular diseases, draw on the social mobilisation and educational techniques pioneered by AIDS activists. They also helped us develop the skills to counter stigma and fear — invaluable against conditions as varied as Ebola and schizophrenia.

The most profound impact still has come from the bold vision that all HIV-positive people have a basic human right to access antiretrovirals. That has morphed into today’s universal healthcare movement to cover significant preventive, curative, rehabilitation, and palliative care, from cradle to grave.

But more needs to be done. We need renewed creativity and adaptation to ensure that the lessons from the fight against AIDS serve future generations. For instance, countries like India and South Africa — which successfully secured patent waivers on COVID-19 vaccines — must not stop there. They must push to obtain similar deals for drugs and diagnostics for COVID-19. Just like the waivers for antiretrovirals two decades ago, such success in the coronavirus era would set an example for future public health crises.

Our successes against AIDS will not mean as much if we don’t use them to also try to take on other conditions.

The experience of tackling AIDS has profoundly changed science, society and politics. Those who struggled through its darkest days know that today’s tough world — including additional challenges from climate change and numerous conflicts — is not cause for pessimism.

If we need inspiration, a visit to the carpenters on the Entebbe-Kampala Road should help. Antiretrovirals ended their coffins business, but they are busier than ever making beautiful furniture — for the living.