The United Nations (UN) has just issued its latest AIDS epidemic update. It is now 20 years since the immunodeficiency syndrome that came to be known as AIDS was first reported. In that time the disease has wrought death and debilitation across the planet. According to the UN in that 20 years more than 60 million people have been infected with the AIDS virus.

Worldwide it is the fourth largest killer, whilst in sub- Saharan Africa it has become the foremost cause of death. The report states that in the year 2001 there are 40 million people living with the disease, five million people became infected and three million people died as a result of AIDS.

The report picks out the course of the disease in various regions of the world. Of the 40 million people with the disease, the majority are in sub-Saharan Africa, which has 28 million, whilst in South and South-East Asia there are over six million people with the disease.

The report says of those in sub-Saharan Africa, "Without adequate treatment and care, most of them [AIDS victims] will not survive the next decade." In surveys of antenatal clinics in Botswana, Swaziland and parts of South Africa, there are HIV prevalence levels of over 30 percent. Five West African countries - Burkina Faso, Cameroon, Cote díIvoire, Nigeria and Togo - have adult prevalence levels in excess of five percent. Apart from some isolated successes the overall picture is devastating.

The report points out that in spite of the dangers of the disease, many young African women are unaware of them. UNICEF has found that 70 percent of adolescent girls in Somalia have not heard of AIDS, corresponding figures for Guinea-Bissau and Sierra Leone are 40 percent. The report says, "AIDS has become the biggest threat to the continentís redevelopment... essential services are being depleted at the same time as state institutions and resources come under greater strain...the risks of social unrest and even socio-political instability should not be underestimated."

Eastern Europe and Central Asia, covering much of the area that formed the Soviet Union and its East European satellite countries, has experienced the fastest rise in levels of HIV infection. The report states that much of this increase is due to drug use among young people, the sharing of needles being commonplace, and the increase in the number of sex workers. It cites a survey, which shows condom use amongst sex workers (aged 17 to 23) in the Russian Federation is "erratic at best." The report says, "Several factors are creating a fertile setting for the epidemic: mass unemployment and economic insecurity beset much of the region... public health services are steadily disintegrating."

South and South East Asia has over six million people living with the disease. Its prevalence is highest among drug users and sex workers. Past experience has shown that these groups can act as reservoirs for the disease which can easily spill out to the rest of the population. The fear is that the prevalence of the disease in this region could overtake that of Africa.

What are described as the high-income countries are also giving cause for concern. The report states that the up-to-now successful use of anti-retroviral drugs to cut AIDS related deaths has led to misplaced perceptions that the disease can be cured. Consequently there has been an increase in high-risk sexual behaviour. Within this region there are variations in the levels of incidence related to racial discrimination and health and income inequalities. It states, "In high-income countries there is evidence that HIV is moving into poorer and more deprived communities." In the USA African-Americans make up 47 percent of the AIDS cases yet represent only 12 percent of the population.

Life expectancy in the worst affected countries is beginning to drop sharply. In sub-Saharan Africa without the impact of AIDS life expectancy would be 66. Instead it is 47. Twelve million children were left orphaned by the disease up to the year 2000 and the figure is expected to double in the next decade. The disease is also a big killer of children. In the Bahamas it is the cause of 60 percent of deaths of under-fives, whilst in Zimbabwe the figure is 70 percent.

In a section "Coping with Crisis" the report says, "Unequal access to affordable treatment and adequate health services is one of the main factors accounting for drastically different survival rates among those living with HIV/AIDS in rich and poor countries and communities... Also indispensable are functioning and affordable health systems. Massive international support is needed to help countries meet that challenge."

Even the production of condoms is below the level needed to prevent the disease spreading. Currently world production of condoms is about eight billion. Experts estimate that to have an impact on AIDS/HIV the world needs to manufacture three- times this amount. UNAIDS estimate only three percent of sexually active people in Africa use condoms.

Figures just released by the Nigerian government show the prevalence of AIDS/HIV in Nigeria to be 5.8 percent of the adult population. Stella Iwuagwu, executive director of the Centre for the Right to Health, warned, "Nigeria is the most populous country to have crossed the five percent prevalence rate. That five percent prevalence rate is called the threshold of disaster, because from that point the epidemic begins to grow at an exponential rate."

Following an international AIDS summit hosted by Nigeria last April, the government announced a programme making anti- retroviral drugs available. There have now been three announcements, but no programme. "They are still planning, they are still verifying, they are still doing a lot of research, meanwhile people are dying," Iwuagwu said.

A group of 60 poor countries known as the Africa Group challenged the World Trade Organisationís Trade Related Intellectual Property agreement (TRIP) at the WTO talks at Doha in November. The Africa Group and its supporters wanted changes to the WTO rules to allow poor countries to buy cheaper generic versions of the vital drugs.

They attacked the hypocrisy of the American government, which has been able to force the pharmaceutical firm Bayer to reduce the cost of Cipro, the anti-anthrax drug, in response to the mailing of infected envelopes, believed to have been carried out by right-wing US extremists.

After extending the planned meeting by an extra day, the WTO offered a limited concession over access to drugs for major epidemics such as HIV/AIDS. The final statement allowed WTO member countries to manufacture their own generic versions of drugs that are essential for combating public health emergencies.

This confirms the existing arrangements the USA authorities used to force Bayer to sell them Cipro at a reduced rate. The new feature is that AIDS/HIV is explicitly named as a disease that might be considered a public health emergency. In practice, however, the new provision will have little effect on the availability of drugs in most poor countries because they do not have their own drug industries. The principal effect of the declaration will to be to avoid a high-profile court case between the drug companies and manufacturers of cheaper generic versions of drugs in India and Brazil, which would have further damaged the already tarnished image of the pharmaceutical industry.

Discussion of whether India and Brazil can legally export generic drugs to other countries was postponed until next year. The only country in sub-Saharan Africa with the ability to produce generic AIDS/HIV drugs is South Africa. Even if the South African industry began producing its own generics, other African countries could not at present import them.

In an attempt to improve their public image some pharmaceutical companies have begun to offer cut-price drugs to African countries. But even then many of them are still too expensive. In Kenya the government passed a law in June this year with the intention of increasing availability of vital drugs, but even now the daily cost of anti retroviral drugs (ARVs) in Kenya is between US$2.50 and US$5.00. The average income of a Kenyan is a dollar a day. Dr Chris Ouma, of the NGO Action Aid working in Kenya, says that since the law on access to cheaper drugs was passed 800,000 have died of AIDS. Last year Merck began to offer its AIDS/HIV drugs Crixivan and Stocrin to 100 countries for $600 and $500 a year per person. In the US Crixivan costs about $6,000 a year per person and Stocrin about $4,700. Charities and private insurers have taken up the Merck program in Kenya and South Africa. Both have seen dramatic increases in the number of people being treated. But the figures only emphasise the appalling low levels of those receiving the appropriate drugs. In Kenya there has been a fivefold increase in the number of people receiving drug therapy, but that has only taken the number to 1,000. In South Africa only 5,000 people have benefited from the scheme, but this is 20 times the previous figure.

The Kenya Coalition for Access to Essential Medicines (KCAEM) wants the life-saving treatment to be made available for all the Kenyans that need it. Even at the reduced price, this would mean spending one fifth of the entire Kenyan health ministryís budget and cutting other programs, according to Health Minister Sam Ongeri.

In South Africa, the legal action begun in August this year by the Treatment Action Campaign received a boost this week when the judge hearing the case said that he thought the anti-HIV drug Nevirapine should be freely available.

The drug helps reduce the spread of the infection from mother to unborn child. A German pharmaceutical firm, Boehringer, has offered to provide it free of charge, but the South African government has refused to accept the offer.

The use of Nevirapine would help reduce current numbers of around 70,000 HIV positive children born each year. Even so, the near five million adults and young people with HIV in South Africa would still not receive the necessary drugs and treatment.

In April this year a Global Fund to fight AIDS, Tuberculosis and Malaria was launched with a great fanfare of publicity. Most experts agree that to combat these major killer diseases, it would require an annual budget of $7-10 billion. Since its launch, $1.5 billion has been pledged to the fund and most of that has still not materialised.

The US Congress originally agreed to allocate $1bn to the fund, but this figure has now been cut to $190 million. Since the US launched it so-called war against terror, the entire fund is under threat and may be abandoned.

Six months after its launch the fund has no administrative structures and has disbursed no money. Mark Curtis, Head of Policy at the charity Christian Aid, has attacked the fund, pointing out that it is "not delivering new money... money is being diverted from existing aid budgets. Worse than that, as the pledged money remains unspent, it is actually reducing the money available."

A meeting of a consultative body of the fund in Baltimore in October concluded that anti-AIDS drugs alone would not be enough without an AIDS prevention program and public health services. Dr John G Bartlett, chief of infectious diseases at the John Hopkins School of Medicine, explained that anti-viral drugs were needed, but "we canít just dump therapy" on these countries. Trained workers are needed to ensure patients take their medicine, for preventative measures, to stop mother to child infection and for palliative care. "The UN has identified AIDS as the greatest health crisis on Earth, and the epidemic of AIDS threatens the political, social and economic fabric of a substantial part of the world," he said.

In the face of this disaster ministers from over 40 sub-Saharan African countries met with top US government representatives at the end of October. Instead of being offered debt relief or an increase in the AIDS fund, they were subjected to lecturers from President Bush and his top advisors.

The occasion was a forum meeting under the auspices of the Africa Growth and Opportunity Act (AGOA) passed last year by the US government. The measures of AGOA give duty free access to the US for African goods. However, to be eligible countries have to apply IMF adjustment programmes and allow US companies to penetrate home markets.

The charity Global AIDS Alliance has calculated that to tackle AIDS in sub-Saharan Africa alone would cost US$15bn a year. This is only a little more than the $14.5bn that these countries pay out each year to service their debts. Far from offering help to the countries worst hit by AIDS, Western banks, governments and the international financial institutions are actually depriving sub-Saharan African countries of the resources they need to combat the epidemic.  

World leaders have written off the lives of millions of people. Britainís International Development Secretary Clare Short argues that the Global AIDS fund should only be used for preventative measures and not spent on drugs. She is prepared to deny the right to life to all those already infected. Not only is this an offence against these peopleís democratic rights, it is an ineffective approach to combating the disease. The French charity Medecins sans Frontieres argues that prevention must be linked with treatment. Unless treatment is made available, there will be no incentive for potential victims to come forward for testing.