Four world-spanning AIDS activists weigh in on the issues of the day.

What is the biggest breakthrough for HIVers since Durban in 2000?

Hands down, all agreed that expanded access to HAART in developing countries through the introduction of generic drugs was the great leap forward. “Treatment offers people hope and that hope is the basis for social mobilization against HIV,” Health Gap pioneer Alan Berkman, MD, says. In Uganda and elsewhere, public education and pilot treatment programs -- good, old PWA empowerment -- have triggered demand for better health care and other resources. “The mindset of people is changing after seeing that even in Africa, people can have treatment,” says PWA Milly Katana, who singlehandedly represents the entire southern hemisphere at the UN’s global AIDS fund.

What is the biggest barrier you face as an activist?

Funding, stigma, denial and political cowardice still conspire to hinder headway. UNAIDS’s pull-no-punches Peter Piot says that “the recurrent questioning of AIDS as one of the biggest tragedies of the century -- or that AIDS exists at all” -- is the real tragedy. The UN’s global AIDS fund, which took 20 years to birth, goes begging for money. “The most important barrier to our work is the failure of the Bush administration and of Congress to support the fund,” Berkman says. “It’s the best opportunity we have to make serious progress in slowing the pandemic.”

What is the next big thing we must learn as a movement?

“The next big thing is the same old thing: to respect and value each human life across [all] lines,” Berkman says. Veteran Haiti hand Paul Farmer toasts to that, adding, “Equality and social justice have their place in basic-science research. Also, it’s possible to do complex health interventions in poverty. ’Everyone has the right to live,’ to quote the patients here.” A vaccine -- preventive or therapeutic -- and its viable distribution also topped the to-do lists.

Do activists still have a role to play in setting the AIDS research agenda?

A no-brainer for this crowd. Everything from coming out as positive to street demos created the critical mass that is getting HIV meds to the global poor. “Without activists, the epidemic would be even worse today,” Piot says. “Access to treatment would still be largely academic.” But breaking patents and generating generics are only the beginning -- communities must muster the political will to build an infrastructure that combats poverty and disease, let alone distributes HAART. “Activists have been more successful than we ever dreamed and yet not nearly successful enough,” Berkman says.

What will HIV treatment look like for the average patient in five years?

For the wealthy: Kinder, gentler, once-daily-dosing meds. Fewer opportunistic infections (OIs). No pediatric AIDS deaths. More drug resistance. The crystal ball is much cloudier for the poor -- only a few will benefit from scientific advances. Berkman shines his crystal: “Globally, my dream is that 5 million people will be receiving appropriate treatment for OIs and HIV. If we get there, it will be a magnificent achievement.” Then, only 20 million to go.

Alan Berkman, MD, Health Gap, New York City; Paul Farmer, MD, Partners in Health, Haiti; Milly Katana, Global Fund for AIDS, TB and Malaria (GFATM), Uganda; Peter Piot, Executive Director, UNAIDS, Geneva