Why HIV “prevention does not work” has been the subject of recurrent discussions during the past weeks. It all started with a thought-provoking article published online by Frontiers in LA, “a one-stop source of content for Southern California’s LGBT community” (welcome to the Ghetto) by Michael Liberatore who wrote that “if pharmaceutical companies were supplying the cash to develop [HIV/AIDS] treatments, couldn’t they just as easily stall the development of newer, less profit-friendly treatments to assure that their bank accounts continue to swell?”

The article is worth reading and raises some serious questions, and though peripheries is no friend of the “Big pharma”, one cannot always agree with the columnist. Nevertheless, the recurring conversation was about the belief that money or drugs will “make prevention work” and “treat us out of the epidemics”.

Indeed, it is not just about money or the Pharmaceutical industry but about how the money is used. PEPFAR with its numerous and often criticised ties is a good example but there are many others. For example, in an interview for the Singapore-based network Fridae.com Jan Wijngarden emphasises some very important issues on how to do prevention in the MSM population which is more vulnerable than other to HIV infection. Wijngarden’s main point is that prevention has to reach those who are supposed to be reached and I would add something often overlooked, that the target need to have a stake in the fight.

When it comes to Africa where AIDS is “hyperpandemic”, bending the arm of the Big Pharma or throwing money at African Governments or local NGOs to buy drugs is one thing, but if there is no supply chain (from road to clinics and to nurses) or even no identified people to treat,or worse, no political will, it won’t work. We often talk about corporate responsibility but what about non-profit responsibility? It is often “implied and obvious” but how accountability is there in the non-profit sector? The one that goes beyond “we have provided ARV to 3 million people” (Are these people still on ARV? Alive? How is their health? Did that change something in their community? What was the impact on a larger scale?). In a paper on the impact of PEPFAR the authors, carefully underlining their own limitations, concluded that “After 4 years of PEPFAR activity, HIV-related deaths decreased in sub-Saharan African focus countries compared with control countries, but trends in adult prevalence did not differ.”

Accountability in the non-profit sector is finally being recognised and emphasised and it needs to be discussed further and translated into something real. Indeed, there are reasons to be afraid and sceptical when reading statement such as “UNAIDS estimates that the funds needed annually to deliver adequate prevention programs to sub-Saharan Africa alone would be approximately US$2 billion”. Lest we forget, several world economists (and rock stars) have been telling us that for some time that we “only” need to put X million dollars in African country Z to lift it out of poverty. 50 years and 3.5 trillion dollars later, the African people are still waiting for this to work. Meanwhile, GAP, Motorola and Armani are making profit selling (Red) branded products and rock stara are lecturing us, tax payers whose contribution to the World Bank and IMF, constitute the largest amount of money given to fight HIV/AIDS in Africa with various level of success.

We really need to think hard, look at what has been done during the last 25 year, probably throw away most of it and start again from the bottom: Who is most vulnerable ? Strikingly, MSM have just been “officially” recognized (or rediscovered) as most-at-risk at the last AIDS Conference in Mexico. What will make people practice safe sex? What will make someone vulnerable come forward to take an HIV test? What will make them accept to start treatment and adhere to it? How can treatment be delivered and patients reached, then how much will it cost, rather than blanket covering whole population with impersonal messages and dollars hoping the epidemic will treat itself out.

Re-stating the obvious, HIV prevention and treatment is a complex problem and as much as requesting more money to buy more drugs is much more appealing than requesting dollars to built roads, there is little point of shelving drugs that can be distributed or having brand new and shiny clinics in the middle of nowhere with no staff and no road leading to them.

Some governments have started to understand some of this. The UK Department for International Development (DFID) recently recognised that “Trade is critical for generating economic growth and reducing poverty. Without good quality infrastructure – roads, rail, and ports – the cost of trade and transport rises”. DFID Minister of State Gareth Thomas then announced “£100 million for the implementation of an innovative and comprehensive transport and cross-border trade reform programme along the ‘North-South Corridor’, combined with a broader package of regional trade-related reforms.” Recognizing that trade can’t happen without adequaye infrastructure comes late but is welcomed. It is regrettable that the Minister did not go one step further and recognised that the fight against HIV can’t be won without similarly good infracstructure and also aknowledge that trade development could contribute to the HIV/AIDS epidemic (both in a positive and negative way) and then implement along the North South corridor of trade a corridor of HIV prevention and treatment.

This is were mainstreaming HIV/AIDS (and the money to fight the epidemic) comes into the big picture, but we are not there yet. Money and drugs are still needed to fight AIDS, probably more than ever with increasing HIV prevalence, but what you do with it is as important if not more than as how much you get.

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