We read and hear so frequently the numbers of people infected with HIV worldwide that it's easy to become impervious to the scale of the epidemic. Nearly 35 million are infected globally. However, at last month's World AIDS Conference in Durban, a new and sobering statistic shocked even the most jaded readers: demographer, Kevin De Cock of the US Center for Disease Control and Protection, predicts that by 2003 South Africa, Zimbabwe and Botswana will experience a negative population growth of one to three percent. Unfortunately, not even this information has awoken the South African government from its torpor.

The World AIDS Conference is more a meeting devoted to addressing the social, political and economic factors that give rise to the global inequity of the disease, than it is a scientific forum. It is one of the few medical conferences to receive widespread publicity through the world's media. Thus, the announcement over two years ago that the next venue for this biennial meeting would be in Durban, South Africa—which has the largest number of infected people in the world, 4.2 millionFootnote 1—was greeted enthusiastically by all those with an interest in HIV/AIDS.

Initial rumblings of a threatened boycott of the conference by HIV researchers because of the South African government's policy of not providing AZT or nevirapine to pregnant mothers, were thankfully forgotten. Instead, positive new initiatives were announced such as US president Bill Clinton's Executive Order allowing sub-Saharan Africa to import patented AIDS drugs at a cheaper price from other countries; Boehringer Ingelheim's offer to provide nevirapine free of charge for the prevention of mother-to-child-transmission (MTCT) in developing countries; Abbott Laboratories initiative to improve medical care and provide testing kits to help diagnose HIV in AIDS orphans in Tanzania and Burkina Faso; and the Gates Foundation gift of $90M in grants to decrease infection rate through microbicide use and MTCT through drug use in Africa.

Although some of these initiatives have met with inevitable criticism by activist groups that they are too little too late—complaints targeted at pharmaceutical companies who offer free drugs rather than the United Nations Security Council whose conference gesture was to pass a resolution against the disease—they far exceed efforts made by the South African government to come to terms with the epidemic.

In the two-year period prior to the Durban meeting, the South African government denounced AZT as being too expensive and then too toxic, insisted on testing nevirapine in their own country despite positive results from neighboring Uganda, and the president himself has questioned the etiology of AIDS and spent time and money soliciting the advice of dissident scientists whose ideas have long since been dismissed in the West. The latter led top HIV researcher David Ho of the Aaron Diamond AIDS Research Center in New York to open his presentation with the redundant statement, “HIV causes AIDS,” which was met with rapturous applause.

Presented with the opportunity to redeem himself at the opening ceremony in Durban (page 843) and demonstrate that the government is taking the threat of HIV seriously, South African President, Thabo Mbeki, ducked the opportunity. He was widely criticized by the world's press and one of the most eloquent attacks came within 24 hours from a white South African High Court judge, Justice Edwin Cameron, who said that his government “…has at almost every conceivable turn mismanaged the epidemic. So grievous has the governmental ineptitude been that South Africa has since 1998 had the fastest-growing HIV epidemic in the world.”

Disruptive demonstrations by activists are as common at the World AIDS Conference as scientific presentations. Gro Harlem Brundtland, director general of the World Health Organization (WHO) witnessed this first-hand in Durban when protesters took over the podium mid-speech blowing horns and shouting that the WHO had “sold out to big pharma.” But here too, the activitsts missed the real opportunity that the conference venue provided. Instead of hitting out solely at the pharmaceutical industry, they should have devoted some energy to lobbying the South African government to change its policies.

Despite the negative political backdrop, the choice of Durban was a positive one for the simple reason that having roughly 12,000 of the most knowledgable and powerful people concerned about alleviating the effects of HIV/AIDS in Durban brought a new awareness to the region. Its people were able to find answers to questions on issues about which their own government has neglected to inform them. A case in point was the local African woman who asked a panel of eminent Western scientists why they simply couldn't give their HIV vaccine to South Africans like her. She learned by their direct response that no such vaccine exists yet.

The 2002 meeting will be held in Barcelona. But once again this seems a missed opportunity to confront the disease. In an effort to continue the focus begun in Durban, perhaps the organizers could have taken the meeting to South East Asia, where 5.6 million people are infected, to Botswana where HIV prevalence in adults is 35.8%, to Latin America where 1.3 million live with HIV, rather than Western Europe, where 520 000 are HIV positive * .