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The big question hanging over the International AIDS Conference this week is whether all 34 million people in the world with HIV can possibly get antiviral drug treatment.
New guidelines released at the Washington meeting call for everybody with HIV to be started on anti-retroviral drugs as soon as they test positive for the virus. New research shows that's better for their long-term health, and it will help end the pandemic because people in treatment are less likely to infect others.
But it's probably safe to say that all 22,000 people attending the biennial meeting in Washington, D.C., have been thinking and talking all week about just whether the goal is achievable, and who would pay for this enormous expansion in treatment.
Right now about 8 million people across the world are getting treated for HIV at a cost of around $17 billion a year. Universal treatment would cost another $22 billion, by some estimates.
"Who should pay for it? The rich countries, probably," says Martine Collumbien of the London School of Hygiene and Tropical Medicine. "But we know in this current climate, that's not going to happen."
Henry Luyombya, a Ugandan with the Committee for Accessible AIDS Treatment in Toronto, is also doubtful.
"It's good to have a goal," he told Shots. "That's a goal that's a little bit ambitious."
But Dr. Batsirai Makunike from the University of Zimbabwe is upbeat.
"It has to happen," she says. "I think we can."
Dr. Bernhard Schwartlaender of UNAIDS is convinced it can be done. He pointed out in a plenary session speech that the economies of many of the world's poorest countries are growing.
"In just eight years from now, the number of poor countries will have declined from 73 to 20," he notes.
"Let us not accept the notion that we cannot find the relatively humble resources to pay for the basic services that mean life for those in greatest need," Schwartlaender told his audience. "The world overall is getting richer. We have to make it fairer."
Schwartlaender offered up several possible ways to raise the money. A tax on shipping and aviation fuel could raise $64 billion — and help reduce global warming at the same time. A levy on financial transactions — some call it a Robin Hood tax — could raise $150 billion (but has been blocked so far by the U.K. and other wealthy nations).
Schwartlaender also proposes tapping the fines levied on big pharmaceutical companies for their marketing practices.
"A few weeks ago, a single multinational company paid $3 billion in fines," he said. "$3 billion could easily pay for a year of drugs for all those in treatment today."
Another conference speaker, Dr. Andrew Hill of Liverpool University in England, made a strong pitch for the same kind of taxes that many U.S. states already impose on alcohol and tobacco.
Hill says money collected this way could solve a dire problem many countries will face as the U.S. and other wealthy nations pull back on AIDS funding.
The tax could be as little as 1.5 cents on a bottle of beer and 10 cents on a pack of cigarettes.
"The money collected would be enough to achieve universal access to HIV treatment in 10 of the worst-afflicted countries in the world — Russia, China, India, Brazil, Vietnam, Thailand, Ukraine — there are other examples," Hill told Shots. "So it could go a long way. And it's actually a very small increase [in] tax."
In many countries with big HIV problems, there's a lot of room to raise alcohol and tobacco taxes.
"The taxes on cigarettes and alcohol in Africa and Asia are very low compared to Europe and North America," he says.
And these taxes are easier to collect than many.
"It's a very powerful way of collecting money, a very simple way," Hill says, "because you only need to collect it from a small number of tobacco producers and breweries at the point that cigarettes and alcohol leave the factory. And the sheer numbers involved — you could collect billions."
Still, many say the enormity of the need might require a combination of different and creative funding mechanisms.
The difficulty is that many of these taxes would need to be enacted country by country. That would take a lot of persuading. But Schwartlaender of UNAIDS says it's actually more feasible to do it that way than to forge a global agreement on new taxes.