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The philanthropist Bill Gates has complained about the slow pace of progress in fighting AIDS, saying that there is a lack of urgency despite the huge number of deaths.

In his third annual letter, the co-founder of the Bill & Melinda Gates Foundation said clinical trials should take less time and proven approaches should be rolled out faster.

"Given all the lives that are at stake, I am willing to be viewed as a troublemaker by people who are happy with the status quo," he said in his letter, published yesterday (31 January).

The fight against HIV/AIDS has made substantial progress over the last decade: both the annual rate of infection and the number of deaths have dropped by around a fifth to fewer than 2.7 million and two million people, respectively.

The two main approaches to fighting the disease are prevention and treatment.

And while treatment has been a "great success story", according to Gates, it is enormously expensive. If everyone living with AIDS today was on the correct drugs the cost would be over US$40 billion a year — over four times the entire international aid budget, he said.

So prevention is the key, yet "there needs to be a sense of urgency that doesn't exist yet".

Gates highlighted three new prevention tools including male circumcision, which "we should be scaling up ten times faster than we are".

Vaginal microbicide gels, which women can use to protect themselves, have been successful in trials. "Now the question is how long it will take before the gel is rolled out on a large scale," he said.

"As someone outside the field, I am surprised at the number of steps it takes," he said, criticising the fact that the steps are done in sequence rather than in parallel.

"And it is only when the entire approval process is complete that the product can be rolled out," he added.

"Even then the process isn't complete because a whole system for delivering the product needs to be put together, and again a lot of these steps proceed in a slow, serial fashion."

"With both microbicides and pre-exposure prophylaxis [a new approach of using AIDS drugs preventively] I think countries with large epidemics should figure out how to do large community trials as soon as possible."

Meanwhile, in the quest for a vaccine, the typical trial cycle is five years: "The field needs to look into how to shorten this so that progress matches the urgency of the problem".

Gates began his letter by urging nations to continue the fight to get rid of the final one per cent of polio cases.

The polio campaign faces a funding gap of US$720 million, but the foundation and the UK government's Department for International Development (DFID) announced last week (28 January) extra funds of US$102 million and US$63.7 million respectively.

This follows a pledge in the same week (27 January) by the Gates Foundation and the crown prince of Abu Dhabi, Sheikh Mohammed bin Zayed Al Nahyan, to give US$37 million to vaccinate children against polio in Afghanistan and Pakistan.

Link to full letter [5.85MB]