In contrast the Durban World AIDS Conference in 2000 felt like a genuinely pivotal event. The first to be held in a developing country, its opening and demonstrations that took place around that opening introduced many developed-world AIDS workers for the first time to a new breed of AIDS Activist and a new set of demands.

South Africa’s Treatment Action Campaign, prominent at the conference in purple T-shirts bearing the words HIV POSITIVE, were only the most prominent of a new generation of developing-world equivalents of ACT-UP who shifted the debate on to the possibility of something previously regarded as impossible – the provision of antiretrovirals for people with HIV in poor countries. Other organisations like Thailand’s Thai Drug Users’ Network, the National Guidance and Empowerment Network in Uganda and some of the local branches of GNP+, the Global Network of People Living with HIV and AIDS are only the most prominent of a plethora of local organisations representing people with HIV that do everything from provide basic services to serve as lobbyists to international bodies.

These combined with multilateral organisations like the United Nations, private philanthropic trusts like the Bill and Melinda Gates Foundation and the Open Society Foundation, international NGOs like Médecins Sans Frontières and ActionAid, and existing anti-globalisation lobbyists to force through huge cuts in the price of HIV drugs to the developing world, so that a typical first-line regimen such as AZT/3TC/efavirenz, which costs $10,000 a year in the USA, can be provided for $200-350 a year in developing countries.

HIV drugs cost so much because of the financial structure of the pharmaceutical industry, which enables companies to recoup their enormous development costs by having a monopoly on selling their new drug while it is still under patent protection. A pivotal event was the forcing through of an agreement at the World Trade Organisation talks in Doha in 2001. Normally patent protection rules under TRIPS, the Trade-Related aspects of Intellectual Property Rights agreement, would make it illegal to sell any drug that was still under a patent. However, following the Doha conference, ministers agreed that TRIPS should not prevent members from taking measures to protect the public health of its citizens. It therefore agreed that countries should be able to manufacture generic drugs made before the 1995 introduction of TRIPS and could produce newer drugs under a system called compulsory licensing.

What this meant was that the large pharmaceutical companies had an incentive to cut prices for drugs intended for the developing world because otherwise their business in those regions would be undercut by generics companies that, in the case of countries like India and Brazil, has already been making generic antiretrovirals (and flouting the WTO rules in the process).

In the meantime parallel developments were happening which brought new money and new funding mechanisms onstream to pay for the huge scale-up of HIV treatment provision.

Indeed, it was not just treatment that was scaled up. One finding of the drive towards universal treatment is that spending money on treatment also means providing better HIV prevention too. This is partly because, given hope at last that something can be done about HIV, far more people come forward for testing. Evidence is emerging that ART availability leads to an upsurge in demand for HIV testing and counselling and other prevention services. In one district in Uganda, introduction of ART led to a 27-fold increase in demand for HIV testing and counselling.

Another is that in areas like Africa public health systems had been so starved of investment for so long that they were barely extant, let alone capable of delivering complex drug regimens on a regular band continuing basis to thousands of people. Indeed the numbers that would have to be treated to meet the need of all people with AIDS in the developing world would put rich countries’ health systems under strain.

In terms of institutional change, several pivotal events made the development of a global AIDS initiative possible.