There are nearly 40 million people living with HIV in the world right now. Today alone, about 12,000 more individuals will become infected and 8,000 people with AIDS will die. We are confronting a global pandemic with devastating momentum, but not because life-saving treatments don’t exist, not because the necessary resources are impossible to provide, nor because effective prevention methods are unknown.

Tragically, the harrowing words of Vito Russo, an HIV-positive activist of the late 80s, still ring true today: “If I’m dying from anything, I’m dying from homophobia. If I’m dying from anything, I’m dying from racism. If I’m dying from anything, it’s from indifference and red tape.” As the AIDS pandemic blazes on today through marginalized communities of people of color, drug users, and women throughout the US and across the globe, it is obvious that what we are facing is a deadly failure of political will, undeniably aligned with the forces of oppression in our society.

Yet, global AIDS is one of the only areas in which George Bush is able to still squeeze political mileage out of his all-but-extinct image as a “compassionate conservative.” Listening to the fanfare from the White House, one could be led to believe that Bush is leading us down the road to a world free of the threat of AIDS. In 2003, the Bush administration launched the President’s Emergency Plan For AIDS Relief (PEPFAR) with a five year, $15 billion commitment to fight AIDS in 15 focus countries.

In 2005, Bush joined other leaders at the G8 Summit in Gleneagles in the goal of achieving universal access to HIV treatment by 2010. Most recently, this May, Bush proposed reauthorizing PEPFAR for another five years with $30 billion. In touting his call “to double our initial commitment”, Bush remarked, “The generosity of the American people is one of the great untold stories of our time.”

There is a different, far less rosy, untold story at work here though. First, because the initial five years of PEPFAR funding has increased each year and will now total an estimated $5.95 billion in 2008, the $30 billion proposal over the next five years actually represents a plan to flat-fund US contributions to fighting global AIDS. When dealing with an expanding pandemic, flat-funding means that the US will progressively fall further and further behind its fair share of funding, and that more and more people with AIDS will needlessly die. In fact, public health experts in fact estimate that to provide the necessary treatment, prevention, and care to adequately keep pace with the pandemic, the US’s fair share of funding is at least $50 billion over the next five years.

Unfortunately however, ending the AIDS crisis will take much more than getting the US and other governments to simply spend enough money. The challenges of AIDS are completely intertwined with the prevailing injustices of our society, and it will take progress on multiple fronts of combating racism, sexism, and globalization in order to gain an adequate foothold for overcoming AIDS. Beneath the veneer of Bush’s funding commitments lies a nexus of neo-colonial policies, special interests spending, and judgmental ideology that blatantly detract from his expressed goals for fighting AIDS and reveal the insincerity of his political rhetoric of compassion.

Shifting goals

PEPFAR’s prevention program is widely recognized to undermine itself with ideologically driven conditions that supplant scientifically-proven prevention strategies. Likewise, a closer examination of treatment efforts, where Bush gets the most accolades, shows similarly contradictory approaches. When Bush first proposed PEPFAR in 2003, many people in the US had come to see HIV as a manageable chronic condition rather than a death sentence due to the increasing availability of effective antiretroviral drugs. Yet at that time only 5% of people in the developing world in clinical need of HIV treatment were receiving these medications.

Activists have been able to push leaders to begin addressing these alarming circumstances, and today about 2 million people are receiving HIV treatment. However, over 7 million people living with HIV have progressed to the clinical stage of needing treatment—meaning that present efforts still leave over 70% of individuals without access to the medication that could save their lives. Of those on treatment today, the Bush administration claims that PEPFAR is supporting treatment for 1.1 million with the goal of supporting 2 million people on treatment by 2008.

The major milestone on the horizon is the all-important universal access to HIV treatment by 2010 which Bush and leaders of the G8 finally committed to in 2005. UNAIDS projects that to achieve universal access in 2010, at least 9.8 million people will need to be on treatment. However, Bush’s proposal for reauthorizing PEPFAR only aims for an additional 500,000 people on treatment. This would amount to the US supporting a total of 2.5 million people on treatment, and not until 2013. This is nowhere near the fair share of support the US must provide to be serious about the goal of universal access by 2010.

Distressingly, soon after the Bush administration lowered the bar, the G8 followed suit, announcing at its June summit a reworded goal that would aim to support treatment for 5 million people “over the next few years”. If this trend of lackluster treatment scale-up and apparent back-tracking in goals continues, the much heralded 2005 commitment to achieving universal treatment access might go down in history as a promise that was dead-on-arrival, with tragic consequences for millions with HIV.

Brand-name pharmaceuticals

One of the main barriers to increasing the numbers of people on treatment is the high cost of antiretroviral medicines. Treatment regimens produced by brand name pharmaceutical corporations are sold for several thousands of dollars per year, prices nowhere near the realm of affordability in the developing world. The past several years have seen a hopeful shift with the introduction of generic versions of HIV medicines which create market competition and drive down the cost of treating HIV.

Today, for the same cost of providing one person with brand name pharmaceuticals, an average of about five people can receive generic HIV drugs. This has made major international treatment scale-up feasible. Not surprisingly, pharmaceutical corporations scorn these significant public health benefits and try to preserve their highly profitable monopolies by lobbying vigorously to limit the introduction of generic medicines.

From the beginning, it was clear that the Bush administration’s efforts were extensively influenced by pharmaceutical industry motives. For instance, PEPFAR legislation mandates that all medicines purchased must be approved by the US Food and Drug Administration (FDA) instead of the widely-utilized World Health Organization (WHO) pre-qualification program, which includes a broader array of approved generic medicines. Under pressure from activists to increase procurement of more cost-effective generic medicines, the FDA implemented a fast-track approval process for generics. However this still represents an unnecessarily duplicative effort, and the March 2007 Institute of Medicine report reviewing PEPFAR stated that the FDA approval provision limits access to generic drugs. The Institute recommended adopting the WHO process to increase the extent and sustainability of treatment efforts.

Trading away health

The most telling example of Bush’s complicity with the profiteering pharmaceutical industry is his willingness to implement trade policies that directly thwart the supposed goal of scaling up access to HIV treatment. In a number of bilateral free trade agreements (FTAs) implemented over the past several years, his administration has inserted intellectual property rights provisions that reshape trading partner nations’ laws to bolster the profits of pharmaceutical corporations at the cost of the public health within that country.

This policy completely disregards World Trade Organization agreements which clearly and firmly assert that intellectual property protections must not interfere with a country’s “right to protect public health and, in particular, to promote access to medicines for all.” Nevertheless, the Bush administration has strong-armed trading partner nations into relinquishing those rights by including a series of clauses in FTAs that systematically delay the entry of affordable generic drugs into the market.

First, the FTAs include requirements for prolonging patents beyond the 20-year monopolies already enjoyed by pharmaceutical corporations in order to offset any vaguely defined administrative delays. The FTAs also impose restrictions on generic companies within the regulatory approval process through a condition called data exclusivity. Normally, generic medicines have to prove “bio-equivalence” to their brand name counterpart, and then the clinical trial data from that original drug is used to finalize approval for the generic version. Completely re-doing a clinical trial would not only be a waste of time and money, it is highly unethical to set up a test where a sizeable control group would receive a placebo instead of a drug with known therapeutic value.

However, the powerful pharmaceutical lobby has succeeded in pushing five years of data exclusivity into the FTAs, meaning that generic companies seeking approval for a medicine cannot use the clinical trial data from the original drug. This effectively forces generic companies to wait an additional five years to apply for regulatory approval. During that time, access to life-saving medicines remains needlessly suppressed and high-priced brand name drugs face no competition.

The FTAs also implement a barrier known as patent linkage, which requires regulatory agencies to verify any patent infringement claims by pharmaceutical corporations before they can grant marketing approval on generic medicines. Regulatory agencies are unequipped for such patent enforcement and this provision is easily abused to again delay the introduction of competitive generic medicines. Additionally, FTA provisions can be used to block compulsory licensing, an important flexibility, protected in WTO agreements, which allows governments to secure access to low-cost medications.

Overall, the interference of generic availability created by these provisions protects the business interests of pharmaceutical corporations to the detriment of those in need of life-saving medicines. Indeed, a study released by Oxfam this March that evaluated access to medicines in Jordan in the wake of their 2001 FTA with the US found that Jordanian drug prices have increased an average of 20% and that generic competition has been delayed on 79% of newly introduced medicines.

Universal access

The arrival of the Democratic majority to Congress was anticipated by many to be the end of the era of neo-colonial FTAs. However, New York City Congressman Charles Rangel as Chairman of the House Ways and Means Committee has taken up an effort to have a few pending agreements re-negotiated, keeping alive the possibility of their passage. Rangel worked with the Bush administration to craft bipartisan consensus on new texts which rework certain controversial sections of the FTAs.

The new FTAs with Peru and Panama do make some changes to the pro-pharmaceutical industry provisions by allowing but not requiring patent extensions, shifting patent enforcement burdens off regulatory agencies, and providing possibilities to reduce the five-year term of data exclusivity. While these changes reduce trade policy barriers to access to medicines, the new provisions still impose unnecessary restrictions that would threaten the ability of Peru and Panama to protect the public health of their citizens.

As we approach the 2008 elections, the untold story of Bush’s global AIDS leadership illustrates the importance of getting candidates who will confront AIDS as a broad, interwoven social justice issue. We must push not only for the commitment for $50 billion to reauthorizing PEPFAR, but for someone who will boldly empower the marginalized groups most vulnerable to AIDS. We must fulfill the essential goal of universal access to treatment by taking on the structural issue of under-resourced health systems and ending the pro-corporate paradigm dictated by FTAs. It is time to institute trade policies that advance the availability of generic medicines and actively promote international public health. The world cannot afford another President who usurps global AIDS efforts as an attractive package to conceal an oppressive agenda of profits over people.