AIDS activists need to change not only their tune but their name. What we need is HIV activism, not AIDS activism. Because with the treatments that are now widely available in Western Europe and North America, AIDS is vanishing fast. While it continues to kill millions of people in Sub-Saharan Africa, where two thirds of people with HIV live, in most industrial countries it now kills a few hundred people a year at most. As long as treatment is available and effective, AIDS will remain largely a thing of the past in the rich world. But if drug-resistant strains develop and spread — and there is a real possibility they will — we’ll be back to the carnage of the late 1980s and early 1990s. Only very much worse, because there are so many more people now living with HIV in the West. And there are more people living with HIV in part because people aren’t dying of AIDS any more (a good thing) and in part because we are doing so very badly at prevention (definitely not a good thing). Brand new HIV infections are on the rise again among gay men in Germany, the US, the UK, Australia, Canada, Spain, Switzerland, the Netherlands — just about everywhere we’ve can measure it. That really is shocking.

Does it seem churlish, then, for me to be criticising the new prevention campaign in Germany? Some respondents to a comment I wrote in The Guardian think so. But I’m critical precisely because we need more good prevention that addresses local realities. The local realities in Germany are:

1) we are already effectively preventing AIDS, through treatment
2) we are failing to prevent HIV
3) the vast majority of the sexual transmission of HIV happens between men in anal sex

What Germany needs is campaigns to encourage gay men to avoid an inconvenient life-long infection (HIV) that is expensive to treat and can be most easily prevented by using condoms in sex. That is not what Malawi or Washington DC or Buenos Aires need, but it IS what Germany needs. What the Das Comitee ad gives the German public is a campaign to encourage heterosexual women to avoid a killer disease that in their local reality barely exists. “Shock value” is all very well, but if you are shocking the wrong people about the wrong things, you’re not going to prevent many HIV infections. And that’s what we need to do, now more than ever.

Activists have done a spectacular job in slapping down the price of antiretroviral drugs in the last five years. They’ve rallied big names like Bill Clinton and marshalled huge funders like the Global Fund. Even US-funded PEPFAR, once laughingly known as Purchasing Expensive Pharmaceuticals from American Retailers, is spending money on cheap generic drugs. All the while, Big Pharma has warned that eroding profit margins by pushing prices too low will discourage new investment in research.

Roche has been careful not to make a direct connection between low prices for HIV-related drugs and their decision to stop research in the area, even off the record. And there are good reasons for the decision — they were not a huge player in HIV in the first place; less that 5% o HIV related drug sales are from Roche. Many of their drugs are designed to help people only after other, more common treatments fail. And one of their most effective products is unpopular because it has to be injected rather than swallowed.

Is Roche’s announcement a shot across the bows of advocacy for cheaper drugs? “Stop eroding the profits we want, or we’ll stop inventing the drugs you need?” It’s hard to say, but I am amazed that the question is not ringing loudly around the blogosphere. I support the achievements of groups that have fought to bring down drug prices with every fibre of my body. And I certainly find it hard to feel sorry for an industry that spends far more on marketing than it does on research, and that consistently makes its shareholders richer. But is there a point when we have to start discussing how much is enough when we press commercial firms to lower prices?

One solution to the return-on-investment dilemma of is of course to provide more public funding for the development of drugs that meet the needs of poor people and poor countries. There’s been a fair bit of progress in finding public funding for vaccine research, so it’s especially depressing that yet another vaccine trial has been canceled because researchers think it’s unlikely to produce good news.