AFRO-NETS> Breaking the Silence, One Year Later: Reflections on the Durban Conference

[Dieter Neuvians MD <neuvians@mweb.co.zw>]

Breaking the Silence, One Year Later: Reflections on the Durban Conference
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Salim S. Abdool Karim, MBChB, PhD, and Quarraisha Abdool Karim, PhD 

AIDS Clinical Care, July 2001

[re-printed with permission from AIDS Clinical Care and the Massachu-
setts Medical Society]

The 13th International AIDS Conference in Durban, South Africa in July 
of last year marked the first time that the world's premier AIDS meet-
ing had been held in the heart of the epidemic: Sub-Saharan Africa. One 
year later, we pause to consider the effects of the conference in South 
Africa and beyond and provide an update on the epidemic itself and the 
institutional responses to it.

FEATURE

Since the first International AIDS Conference was hosted by the CDC in 
Atlanta in 1985, the meeting has grown in size and scope to become the 
world's premier AIDS event. In July 2000, the conference was held in 
Durban, South Africa, marking the first time that it was hosted in the 
developing world. The significance of the journey to South Africa was 
not lost on the thousands of participants. Sub-Saharan Africa has 70% 
of all HIV-infected people, although it has only 10% of the world's 
population. Within this region, South Africa has the largest number of 
HIV-infected people (4.2 million as of July 2000) and one of the fast-
est growing HIV epidemics. At last, the conference was being held in 
the midst of the epidemic. In addition, the South African government's 
inaction on the provision of antiretrovirals to reduce perinatal trans-
mission because of concerns about cost and drug toxicity brought the 
ethical dilemmas and contradictions between rich and poor countries 
into stark relief. This backdrop served to heighten the sense of ur-
gency and the need for action to redress the many inequities high-
lighted by AIDS.

DURBAN -- THE EXPERIENCE OF "UBUNTU"

The conference was a milestone in both the South African and global re-
sponses to the HIV/AIDS pandemic. It is remembered simply as the "Dur-
ban Conference" because the host city provided the unique melting pot 
of cultures and hospitality that permeated throughout the proceedings 
and among the delegates, creating a sense of "ubuntu," a Nguni word 
that simultaneously conveys togetherness and recognition of each per-
son's interdependence within a community; it can be translated as "I am 
because you are."

The schism between scientific innovation and community aspiration was 
successfully bridged in an unthreatening manner at the Durban Confer-
ence. Participants experienced a true understanding of the devastation 
and pain caused by AIDS, which served to rejuvenate flagging spirits 
and create a new impetus to struggle against the pandemic. A common 
purpose was born amidst the diversity of conference attendees. Scien-
tists, community activists, donors, businessmen, clinicians, social 
workers, and the many other participants felt the spirit of the inter-
national solidarity and the shared commitment. The success and spirit 
of the South African antiapartheid struggle further infused hope and 
vibrancy into the conference. Surely no enemy could be worse than 
apartheid; and South Africa had shown that success against such a for-
midable enemy was possible. South Africa has been a beacon of hope for 
the rest of sub-Saharan Africa, and it played a similar role among the 
conference delegates - reminding them that, with struggle and faith, 
success is within our grasp. This made the Durban Conference an inspi-
rational turning point.

AMIDST THREATS OF BOYCOTTS, A DEVELOPING COUNTRY SUCCESSFULLY ORGANISES 
THE WORLD'S PREMIER AIDS CONFERENCE

In the months preceding the conference, several threats of boycotts 
were made by senior scientists and academics over the South African 
government's stance on providing AZT for mother-to child transmission 
and President Mbeki's interactions with "AIDS dissidents." The detrac-
tors of the Durban Conference questioned the ability of any developing 
country to host the premier AIDS conference and, in particular, the 
adequacy of the City of Durban's infrastructure to cope with large num-
bers of delegates. Concerns were also raised about the quality of the 
scientific program, the general availability of accommodations - spe-
cifically the lack of five-star hotels - and the high crime rate. How-
ever, 2 weeks before the conference, it became clear that these con-
cerns were articulated by a minority and that most scientists, academ-
ics, donors, activists, community members, government officials, phar-
maceutical companies, and international agencies would attend.

Registration exceeded both expectation and past attendance records with 
12,500 delegates from 160 countries. Durban and its International Con-
vention Center were no only up to the task of accommodating 12,500 
delegates, but were able to do so competently and efficiently. Fears of 
crime and for personal safety proved unfounded. The scientific and com-
munity programs were exceptionally well received; the conference 
evaluation survey of 3304 delegates found that 70% felt that the sci-
ence/community balance was appropriate. Only 16% felt that there was 
too much science and 9% too much community activity.

Disappointment with President Mbeki's speech at the opening ceremony 
was quickly dispelled by a rousing Jonathan Mann Memorial Lecture de-
livered by Justice Cameron in the opening plenary session. His call to 
hold decision-makers and governments accountable for their actions or 
inaction in dealing with AIDS set the tone for the rest of the meeting. 
Speaker after speaker challenged the silence of complacency until Nel-
son R. Mandela closed the conference saying, "Let us not equivocate: a 
tragedy of unprecedented proportions is unfolding. The challenge is to 
move from rhetoric to action, and action at an unprecedented intensity 
and scale." Mandela's words instilled in each person a deep feeling of 
moral commitment to redouble the effort against AIDS. In the end, the 
conference boycotters were the only losers.

BREAKING THE SILENCE, ONE YEAR LATER THE EXPLOSIVE SOUTH AFRICAN 
HIV/AIDS EPIDEMIC CONTINUES

Antenatal surveillance in October 2000 showed that the explosive South 
African HIV epidemic has continued unabated. Although the conference 
could not be expected to directly affect its course in South Africa, 
the harsh reality is that the HIV/AIDS epidemic that confronted all who 
attended the Durban Conference is getting worse. Over the past decade, 
the HIV seroprevalence among first-time antenatal clinic attendees in 
South Africa rose from 0.76% in 1990 to 10.44% in 1995 to 24.2% in 
2000, with no signs of having plateaued. Based on these surveys, 4.7 
million South Africans are currently estimated to be infected with HIV. 
The highest incidence rates continue to be among young women: 29.1% of 
20- to 24-year-old women were infected as of October 2000. Not only are 
women carrying a higher burden of HIV infection compared with men, but 
they are also experiencing a disproportionate burden of AIDS-related 
morbidity and mortality. The gender differences in HIV-related mortal-
ity are even starker: In the past 5 years, the crude mortality rate 
among young women has risen by more than 300% compared with an increase 
of about 50% among young men.

Funerals have replaced weddings as the most common social events within 
many AIDS-ravaged communities in South Africa, and funeral attendance 
is replacing shopping as the predominant Saturday pastime. The rapidly 
advancing HIV epidemic that remained largely hidden until around 1999 
is now a public AIDS epidemic as it takes its toll on the young, espe-
cially young women. Only those blinded by denial fail to see the scale 
of the AIDS tragedy in South Africa.

MBEKI PANEL RELEGATED TO OBSCURITY

President Mbeki aroused the ire of the AIDS community when they learned 
that he was having discussions with prominent AIDS dissident David Ras-
nick and had sought his advice by sending him a list of questions about 
AIDS. In the run-up to the conference, President Mbeki established a 
panel with equal numbers of AIDS dissidents and mainstream scientists 
who accept the etiology of AIDS to advise him on the cause of AIDS and 
offer recommendations for prevention and treatment. The underlying as-
sumption in creating the panel was that scientific discourse between 
the two sides is possible and that at least some common ground can be 
established. Although this approach to negotiation may be appropriate 
in politics, the panel initiators did not appreciate that scientists 
are willing to debate the interpretation of evidence but not basic sci-
entific facts. During the Durban Conference, the epidemic became the 
focal point of national attention. Any doubts created by President 
Mbeki's comments quickly faded as the conference continuously high-
lighted the reality of the devastation. Although not directly linked to 
the conference, the Durban Declaration (www.durbandeclaration.org) pre-
sented a unified scientific view of AIDS. Signed by more than 5000 phy-
sicians and scientists from 84 countries, this document makes a power-
ful evidence-based statement on (1) the scientific certainty that HIV 
causes AIDS and (2) the challenges and priorities in fighting the dis-
ease. The Durban Conference relegated the Mbeki panel to obscurity or, 
at best, to being an irrelevant sideshow. The panel's report, which was 
released in March 2001, stirred little positive interest and was her-
alded as "a waste of taxpayer's money."

THE MEDIA RISE TO THE CHALLENGE

Although South Africa lives with the daily devastation of AIDS, the 
Durban Conference focused the attention of delegates and the host na-
tion on the problem of HIV/AIDS. This was due, in no small part, to the 
active coverage of the conference by local newspapers, radio stations, 
and television. An exciting innovation was publishing the daily confer-
ence newspaper within Durban's most prominent daily newspaper. Thus, 
local residents were exposed to the same information the delegates were 
receiving and vice versa. The media attention kept the public well in-
formed of conference deliberations and this led to a sustained increase 
in the quantity and quality of AIDS reporting throughout South Africa. 
Thus, the conference helped to counter a most important discrepancy be-
tween the developed and developing worlds: breaking the silence about 
AIDS with the power of information.

NKOSI JOHNSON BECOMES A SYMBOL

Twelve-year-old HIV-infected Nkosi Johnson captured the hearts of many 
around the world as, in the internationally broadcast opening ceremony, 
he called for the distribution of antiretroviral drugs to reduce peri-
natal transmission of HIV. His health deteriorated following the con-
ference, and his plight focused attention on the need for antiretrovi-
ral therapy in South Africa. His courage in the opening ceremony in-
spired millions, and just as importantly, his ebbing life became a sym-
bol of the suffering of those with AIDS. Sadly, Nkosi Johnson died on 
June 1 of this year.

DURBAN "BRIDGES THE GAP" TO CREATE "ONE WORLD, ONE HOPE"

Organizers of the 11th and 12th international AIDS conferences held in 
Vancouver and Geneva, respectively, sought to highlight a major ineq-
uity: those who most need antiretroviral therapy are least able to ac-
cess it. The Durban Conference continued this theme but also marked a 
turning point. The march organized by Treatment Action Campaign that 
preceded the conference and Justice Cameron's plenary address forever 
changed the quiet acceptance of the status quo on the part of both de-
veloped and developing worlds. A threshold was reached and the tide and 
momentum for affordable antiretroviral therapy cannot be turned back. A 
new sense of hope was achieved as the discussion became when and how, 
and not if, antiretroviral drugs are provided in poor countries.

In the aftermath of the conference, South Africa has become a new bat-
tleground for AIDS therapy: the pharmaceutical industry took the South 
African government to court claiming that a new law that sanctioned 
parallel importation and compulsory licensing undermined their intel-
lectual property rights. Cast as the villain putting profit ahead of 
the lives of the poor, the pharmaceutical industry withdrew its legal 
challenge at the 11th hour. Hope for antiretroviral therapy now runs 
high in South Africa. Several private companies are providing the drugs 
to their employees, and several health insurance plans now cover the 
costs of antiretroviral drugs. Since the trial, several pharmaceutical 
manufacturers have drastically reduced the price of antiretroviral 
drugs to below $1 per day. However, in many sub-Saharan countries, 
where the annual per capita expenditure on health is below $100, these 
life-saving therapies remain out of reach. Of note, Botswana, which has 
the highest per capita GDP in sub-Saharan Africa, has partnered with 
the Gates and Merck Foundations to provide antiretrovirals to reduce 
perinatal transmission. The government of Botswana has announced that 
it will provide the drugs to HIV-infected adults in the coming year.

GOVERNMENT ACCOUNTABILITY

The Durban Conference made government complacency untenable. Speaker 
after speaker emphasized the need for governmental accountability. The 
South African government's dithering on providing antiretroviral drugs 
to reduce perinatal transmission of HIV was a contentious issue before 
the conference, developed into a central theme of the meeting, and has 
since become the benchmark for measuring the government's commitment to 
dealing with AIDS. On June 1 of this year, the government implemented 
pilot programs for reducing perinatal HIV transmission throughout South 
Africa. However, it will not be providing antiretroviral therapy to 
HIV-infected individuals in the near future, despite victory in its le-
gal battle with the pharmaceutical industry.

Government decisions and actions will determine whether the rallying 
cry of the Durban Conference -- antiretroviral therapy for the poor -- 
will be realized in the most visible AIDS-ravaged sub-Saharan coun-
tries. To date, excuses abound. The two most common are (a) the health-
care infrastructure needs to be developed before antiretroviral therapy 
can be provided, and (b) any attempt to provide antiretroviral therapy 
will be excessively inequitable because of the lack of healthcare de-
livery in poor rural areas. While the world awaits concrete action to 
deal with these conundrums, large-scale provision of antiretroviral 
therapy must move forward. The gross inequities between rich and poor, 
urban and rural and the general lack of medical infrastructure are the 
result of years of neglect and cannot be rectified in the short term. 
Plans to address those inequities are needed, but lack of such plans 
cannot become reason for inaction.

The voices promoting access to antiretroviral therapy in Africa con-
tinue to grow stronger. In March of this year, major international 
foundations, including the Rockefeller and Gates foundations, met in 
Uganda to discuss best practices in dealing with AIDS and voiced a com-
mitment to assist in the provision of antiretroviral therapy in Africa. 
Meeting the following month in Nigeria, the Organization of African 
Unity called for a greater commitment of resources on the part of mem-
ber countries to deal with AIDS and improve healthcare infrastructure. 
At this meeting, Kofi Annan, Secretary-General of the United Nations 
and a native of Ghana, called for the creation of a global fund to help 
poor countries with their AIDS programs, including provision of anti-
retroviral therapy.

NEW RESEARCH OPPORTUNITIES

South African research has benefited from its wide exposure during the 
conference. Visiting South Africa created opportunities for senior AIDS 
researchers throughout the world to establish new collaborations with 
African scientists. This development bodes well for South African medi-
cal research, which is trying to recover from years of international 
isolation imposed to punish the apartheid state. One example of local 
support generated by the conference: the Nelson R. Mandela School of 
Medicine at University of Natal in Durban received an endowment to cre-
ate a special Chair for HIV/AIDS studies.

BENEFITS FOR COMMUNITY ACTION

The Durban Conference and its related activities achieved major suc-
cesses in mobilizing South African AIDS service organizations and NGOs. 
The Second National Conference for People Living with HIV/AIDS, a sat-
ellite meeting convened by the Durban Conference's AIDS 2000 Develop-
ment Project, empowered this community, to demand access to antiretro-
viraltherapy and government accountability; these became important 
themes of the conference. The AIDS 2000 Development Project continues 
to strengthen local NGOs. Soon after the conference, it developed a 
lesbian and gay community health center in Durban.

CONCLUSION

Only time will tell whether the initiatives and progress brought to 
South Africa by the Durban Conference will result in long-term, sig-
nificant changes in the approach to the AIDS epidemic. Having the con-
ference in the midst of the HIV/AIDS pandemic certainly brought home to 
many delegates the magnitude and the urgency of the challenges before 
us. The courage, commitment, and persistence of the people of sub-
Saharan Africa have been an inspiration to the world. By creating a new 
spirit and drive for the provision of antiretrovirals, the Durban Con-
ference changed the landscape of the AIDS struggle. At the 14th Inter-
national AIDS Conference in Barcelona next year, we will have further 
opportunities to reflect on the Durban meeting. If Durban did no more 
than break the silence surrounding AIDS, it was well worth the time, 
effort, and money. One small measure of Durban's success, however, is 
the International AIDS Society's decision to move the 2004 conference 
from Toronto to Bangkok, thereby bringing the conference back to the 
developing world.

Dr. Salim S. Abdool Karim was Chairperson: Scientific Program Commit-
tee, 13th International AIDS Conference and is an Associate Editor of 
ACC. 

Dr. Quarraisha Abdool Karim is Director of the Southern African Fogarty 
AIDS Training Program, Adjunct Associate Professor in Clinical Public 
Health at Columbia University in New York, and Honorary Associate Pro-
fessor at the University of Natal in Durban.

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