The Lancet Infectious Diseases, 9/2/2024 - This year's XV International AIDS conference–Access for All (July 9–16) was held in Bangkok, Thailand. Like the Durban conference in 2000, which awoke the world to AIDS in Africa, Bangkok put the spotlight on AIDS in Asia, where one in four new infections occurred last year. This year's meeting had a record number of attendees with nearly 20 000 delegates. It was like being in an international airport with a mixture of scientists, world leaders, bureaucrats, donors, activists, community leaders, and representatives of many of the stigmatised groups in society passing through. Such a colourful display of people provides a unique setting for a scientific meeting. But then AIDS is a unique disease. No longer just a medical and scientific problem, it has become one of the world's biggest political, economic, and societal burdens. But can a single conference really play host to such a diverse set of agendas, and expect to get the balance right?

What started out in Atlanta in 1985 as an annual meeting for scientists has shifted to a meeting where issues of policy and protests by activists have grabbed the limelight. The AIDS conferences have almost become a movement gradually including more and more sectors of society. Perhaps 20 years ago it was too much of a researchers meeting, and the focus needed to shift. But in Bangkok, it seemed the pendulum had swung too far the other way, and the good science, or what little there was of it, was overshadowed by politics. Many US researchers did not make it to the meeting and were heavily criticised, suggesting this was a political move on the part of the US government. But perhaps the reality is that the researchers who are doing cutting edge science don't see this meeting as a place to present their data anymore.

Much of the agenda at recent meetings has been determined by what the activists deem as “hot”. Well-informed and motivated, if it was not for their relentless lobbying we probably would not have the drugs we have today, or be able to afford them. But lately we are seeing a new brand of activism that is rooted in misinformation, and could be counter-productive to progress. Every time an influential leader from a high-income country comes to these meetings, they are met with heckling and protest. In 2002 in Barcelona, US Health and Human Services secretary Tommy G Thompson's speech was drowned out by chanting protesters. In Bangkok, Randall Tobias, the co-ordinator of President Bush's AIDS relief plan received the same reception. Is it any wonder then that Thompson and the rest of his department did not show up in Bangkok?

Furthermore, pharmaceutical companies, who have been major supporters of these conferences, ought to be able to feel that they can attend and not have their stands sabotaged. Attacking them is very short-sighted because in 10 years we might not have the variety of AIDS drugs we have today. Studies in USA and Europe have long been warning of the resistance threat—nearly 30% of new HIV infections in the USA involve drug-resistant strains of the virus. Faced with constant denigration, no company is going to invest massive resources in new drugs for highly resistant strains, where the market will be small and the price huge.

The trouble with the activists’ agenda is that it is focused too much on the short-term needs of treatment, prevention, and care. Long-term strategies that require research such as vaccine and microbicide development, better diagnostics, and new generations of drugs generate the least amount of advocacy. But one of the issues highlighted in Bangkok was the plight of women in the epidemic. Women account for about a half of all infections, and in Africa two-thirds of the infection are in women aged 15–24 years. If we are to really help these women, vaccines and microbicides are the way forward. In Bangkok, we heard there is a rich pipeline of vaccines being tested or awaiting testing, but they all have a similar approach that may not work. With only US$650 million spent annually on vaccine research and development, the International AIDS Vaccine Initiative needs an urgent doubling of funds. The microbicide field is similar, and is calling for a US$1 billion microbicide research project. Activists should direct their energies to prioritising the development of these products in the same way they pushed for drugs back in the early 1990s.

There was no major groundbreaking science in Bangkok, as seen in the first decade of this epidemic, but that is to be expected. What we saw in Bangkok, and will continue to see is more incremental progress, with hopefully breakthroughs in applying what we know already. As for striking the balance between science and politics in Toronto in 2006, we need to ensure that all voices are heard at the table. These include scientists, policy makers, donor nations, and pharmaceutical companies, because if we start to exclude our partners, we risk losing momentum, and not taking advantage of the progress that has truly been made.

The Lancet Infectious Diseases