Which organizations should lead in articulating and promulgating effective global AIDS policy? To my eye the leaders should be UNAIDS, WHO, the World Bank, CDC and the Gates Foundation. How effective are these groups in this policy role? They certainly could be doing much better. For example, recently I searched Google on "Global AIDS Policy". None of these groups came up in search results -- or more precisely, they came up very low:

UNAIDS: #45
CDC: #71
WHO: #191
World Bank: #195
Gates: (not in top 200)

As a rule of thumb, you want to be in the first 20 search results (first screen) on Google or you are essentially "invisible". The groups faring well on Google are mostly smaller NGOs that pay attention to Web and communications issues.

UNAIDS should be the highest profile AIDS policy organization in the World (and in some ways they are as described in a recent IAEN study). I however tried to see if I could find UNAIDS with any search string on Google. I tried:

AIDS policy
AIDS ARV
AIDS orphans
AIDS blood supply
AIDS condoms
AIDS prison
AIDS vaccine

In no case did UNAIDS appear in the top 20 search results. That's disappointing. I haven't looked more closely to see what they are doing wrong with their keywords and search engine optimization -- but apparently neither have they. I don't mean to overstate the importance of Google, but I do think it serves as a reasonable test for an organization's attention to information dissemination, and the most important policy organizations should be doing much better than they are.

In preparation for the Bangkok conference, my colleagues and I were setting up a wiki site for one of the conference sub-topics. Seeing that the conference organizers haven't set up a wiki site for the overall conference (at least we can't find one), we decided to broaden the site to include all conference topics in case any attendees find this a convenient way to post notes and share ideas. The site can be found at http://www.aids2004wiki.org. Please feel free to post to this wiki or write me with any questions.

A wiki, for those of you not familiar with the term, is a simple Web site which allows any user to post and edit content. While this sounds like a recipe for chaos, in many cases they are very effective. The best example of a wiki I've seen is Wikipedia, a public encyclopedia site. Feel free to contact me if you'd like to participate.

As funding increases for global AIDS programs, the "monitoring and evaluation" ("m&e") activities associated with programs will quickly increase in importance for two reasons:

First, programs will need to demonstrate that funds are appropriately expended and that (at least initial) program results are positive in order for funding to continue.

Second, m&e programs themselves will be very large and complex. Most program managers expect 5-10% of project funds to be used for m&e, a level reaffirmed by Richard Feachem of the Global Fund in an interview last year. This suggests hundreds of millions of dollars will be spent per year on m&e.

The best (and essentially only) online resource devoted to global aids m&e with any rigor is the UNAIDS Monitoring and Evaluation subsite which provides program descriptions and various documents of merit. It addresses both the "information" issues of m&e (how to set up programs, appropriate metrics etc.) as well as some "coordination" issues -- which are critical. M&E efforts will fail unless the major donors have some consistency to their programs, lest country-level officers become swamped in having to establish different systems for different donors.

My sense is that m&e coordination hasn't gotten as far as it should, an impression in part due to my involvement with one of the resource groups listed by UNAIDS, but mostly because coordination requires a strong Web presence, and I'm still not able to find any new or in depth resources devoted to global AIDS m&e despite its importance. While I'm at the Bangkok conference, one of my projects will be to compile m&e resources from across the event and try to spin them into something coherent. I'll post a link when information is online.

Today we launched a "Global Dialogue" interview which I conducted recently with Dr. Paul Farmer, director of the Clinique Bon Sauveur in Cange, Haiti (and Harvard professor in his free time). In it he discusses successes and failures of AIDS efforts in Haiti, and how lessons might apply elsewhere. He is particularly passionate about the necessity of integrating prevention and care efforts.

Paul, for those of you not familiar with him, represents astounding scholarship and indefatigable efforts on behalf of the poor, all nicely catalogued in the recent bestseller "Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World". His successes in Cange make it impossible for policymakers to say "it can't be done". Even as a med student (where, incidentally, we were classmates -- although he spent much of his time in Haiti!), he already was proving what progress on health was possible in the most difficult of environments. He probably needs to clone a few more of himself to stay intact (or at least share more of his experiences online...).

On June 30th the World Bank, along with a number of key partners, will be launching an "AIDS Media Center". Based in part on the successful "Online Media Briefing Center" run by the World Bank, the AIDS Media Center will be a "credentialed journalist only" resource providing access to embargoed materials, press contacts, multimedia files, training opportunities, and other resources of interest to journalists covering the AIDS epidemic. It strikes me as a very good idea (although I'm biased since I'm assisting with the effort): journalists get easy access to materials which assist their work, while AIDS organizations get journalist contact information which will assist their outreach efforts. I'm hopeful it will take off.

I was pleased to see the call for the Global HIV Vaccine Enterprise, which the White House press release describes as a "virtual consortium to accelerate HIV vaccine development by enhancing coordination, information sharing, and collaboration globally." I'm not clear, however, why not simply support IAVI, which seems to have a similar mandate: "to accelerate the research and development of promising vaccine concepts for the developing world from preliminary laboratory studies to clinical trials in humans". The initiative is apparently based on the recent Science article, which included Seth Berkley of IAVI as a co-author. The initiative has a seed $15 million which should be sufficient for planning, infrastructure -- and sorting through relationships with IAVI and many others.

With the launch of the latest study of the Global HIV Prevention Working Group, the issue of "prevention vs. treatment" has been resurrected. Helene Gayle, Director, HIV, TB and Reproductive Health programs at the Bill & Melinda Gates Foundation, has emerged with an unambiguous call for more attention on prevention. The Wall Street Journal reported yesterday:

"World-wide, prevention expenditures fall below $2 billion. Dr. Gayle urged that spending on prevention be tripled to roughly $6 billion by 2005. If prevention funding isn't increased, she warned that all the world's drug programs will never keep pace with the spread of HIV."

The "prevention vs. treatment" debate came to a head several ago (in great part due to falling drug prices), but then was replaced by calls to "integrate treatment and prevention", suggesting there was no longer tension. Of course treatment and prevention need to be closely integrated (as the report says clearly), but unfortunately health officials still face difficult budget and program decisions everyday. Congratulations to Helene Gayle for promoting a point of view that is both out of vogue and vital.

Which AIDS professionals are most influential on global AIDS policy issues? One way to approach this (probably unanswerable) question is to check Google citations. Google searches in the format ("jim cashel" aids) resulted in the following results:

Name / Organization / Google Citations

Peter Piot / UNAIDS / 25900
Tom Coates / UCLA / 6780
Paul Farmer / Harvard University / 6310
Richard Feachem / Global Fund / 5390
Helene Gayle / Gates Foundation / 4430
Alan Whiteside / University of Natal, South Africa / 3270
Seth Berkley / International AIDS Vaccine Initiative / 2740
Paulo Teixeira / Ministry of Health, Brazil / 2120
John Stover / Futures Group / 1520
Vadim Pokrovsky / Russian Center for AIDS Prevention and Control / 1320
Debrework Zewdie / World Bank / 971
Geeta Rao Gupta/ International Center for Research on Women / 914
Mead Over / World Bank / 748
Marina Mahathir / Malaysian AIDS Council / 721
Catherine Hankins / UNAIDS / 712
Milly Katana / Health Rights Action Group, Uganda / 680
Mechai Viravaidya / Population and Community Development Association, Thailand / 674
Michael Merson / Yale School of Medicine / 651
Salim Abdool Karim / University of Natal, South Africa / 593
William Makgoba / Medical Research Council, South Africa / 579
Zeda Rosenberg / Internation Partnership for Microbicides / 553
David Serwadda / Makere University, Uganda / 530
Bernhard Schwartlander / WHO / 527
Peter Lamptey / Family Health International / 523
Ties Boerma / WHO / 489
Susan Kippax / University of New South Wales, Australia / 443
Rafael Mazin / Pan American Health Organization / 418
Awa Marie Coll-Seck / Ministry of Health, Senegal /301
Yiming Shao / National Center for AIDS/STD Prevention and Control, China / 228

Sorry if there are misspellings or if folks routinely go by more than one name -- but this isn't intended to be published in Science, just to get an idea of whose voices are loudest.

A principal reason for HIV / AIDS being ranked first in the Copenhagen Consensus surely is the outstanding background paper produced by Anne Mills, a professor of Health Economics and Policy at the London School of Hygiene & Tropical Medicine. The paper draws on an enormous amount of material, synthesizes it clearly and soberly, and pushes the analysis very far (including an impressive cost / benefit compilation on page 46) without overstating its case. I found the document to be a real tour de force.