Kampala — THE HIV implementers meeting that ended on Saturday in Kampala had all the trappings of big money: rich donors like the US government, the Global Fund and the World Bank, 1,700 participants, media from around the world, the luxurious surroundings of two expensive hotels and a stunning menu of well-funded research on every imaginable aspect of HIV/AIDS.

Yet one conclusion was inescapable: we are not winning the war against HIV.

Some prominent speakers acknowledged that more money was yet to provide a positive answer.

"Many of our most trusted interventions are at best unproven, at worst disproved," noted David Wilson of the World Bank's Global AIDS team.

"The best preventive intervention in the history of the epidemic, male circumcision, is barely advancing."

"Much as reducing the number of sexual partners has been the major contributor to reducing HIV transmission, except for Uganda early in the epidemic, that happened but not because of formal programmes," he added.

Wilson spoke against a backdrop of steadily rising HIV/AIDS funding. Under the US Presidential Emergency Plan for AIDS Relief, funding shot to $6b in 2008 compared to the $2.3b in 2004, according to Dr. Thomas Kenyon, an official.

In Uganda, the plan has pledged $283m this year, compared to $236m in 2007. Also, the six-year-old Global Fund has committed more than $11b in 136 AIDS-affected countries in the developing world, with 60% of the funds going to African countries.

Ironically, progress was more dramatic 25 years ago when there was little funding. The UNAIDS boss, Dr. Peter Piot, said with every two people on treatment worldwide, five people were becoming infected with HIV daily.

First Lady Janet Museveni explained it this way: "In the late 1980s and the early 90s, there was a sense of urgency to stop AIDS and we had many volunteers.

"At that time, there were no financial rewards. Then money started coming in and we lost volunteers when we institutionalised recruitment."

Today, the rate of new infections in Uganda is rising by as much as 2% in some areas.

Various arguments are offered to explain why the dramatic rise in spending has brought a less-than-dramatic reduction in the rates of HIV-infections.

Some say the easy battles have all been won. Others blame changing morals or complacency. But others ask whether the huge establishment created by HIV spending is losing sight of simple things that make a difference.

As Wilson put it: "We must understand, but not overcomplicate."

That may be hard because the HIV/AIDS sector has become a massive industry, sometimes concerned with perpetuating itself. In fact, conference sponsors already were thinking about the next big AIDS gathering.

During last week's meeting, they refused to release research papers to the media because the same presentations will be made at the International AIDS conference to take place from August 3 to 8 in Mexico City. Apparently, they did not want the Kampala meeting to pre-empt the Mexico agenda.

Meanwhile, the HIV/AIDS sector's size has brought duplication of services, donor programmes and poor coordination of activities.

The donor market, dedicated to combating HIV/AIDS, is crowded and agencies have begun fighting for attention and space, observed the UNAIDS deputy executive director, Michel Sidibe.

"We are trying to deal with the magnitude of the epidemic. But on many occasions, we have been doing it in an uncoordinated manner," Sidibe said. "We need to simplify and coordinate the aid money."

The World Bank's operations adviser, Jonathan Brown, agreed that duplication and competition of donor activities was alive but perhaps natural.

In the competition for funds, some anti-HIV activists feel squeezed out.

Phillip Mitchell, who is a director of Hope Clinic in Kampala, said the implementers meeting did not guide small NGOs on how to access funds.

"To scale up, you have to bring in more people. There are large multi-national companies that have money. But they are not bringing in new organisations. Donors should make it easier for new implementers to get into the system," said Mitchell.

These problems are not limited to Uganda. In Rwanda, Agnes Binagwaho, the executive secretary of the National AIDS Control Commission, said lack of coordination had led to fragmentation of donor programmes. "Aid is lost in overhead costs and funding, which is unpredictable, comes late."

The anti-HIV effort also suffers because donors sometimes do not have the same priorities as beneficiaries. Several African countries have weak, non-functional health systems and keep requesting for technical support for infrastructure development - to increase capacity and systems of storage for donated drugs, for instance.

Primary health care state minister Emmanuel Otaala said: "Donors cannot allow us to put up infrastructure or train human resource. In the end, we only distribute drugs but lack human resource."

While health officials deal with such questions, there are ominous signs that the HIV epidemic could become worse.

According to Dr. Peter Piot, AIDS remains the first cause of death after malaria and respiratory tract infections.

Today, three million people living in the developing world are on ARV treatment and another six million need ARVs.

Health experts forecast that by the year 2010, the number of people in need of ARV treatment will be 10 million worldwide.

Still, universal access to ARVs cannot be achieved by 2010, given that only 20% of people worldwide, know their HIV status, which is prerequisite to accessing treatment.