11th Conference on Retroviruses and Opportunistic Infections

Allow me to set the stage for my remarks in this fashion: last Monday night, in London, I was privileged to attend a preview showing for the United Kingdom of the film “Angels in America. ” Doubtless there are those in this audience who have seen it; it's a brilliant piece of film-making. It deals, as you know, with the early days of AIDS in America, and the dehumanizing process of death of one of the male leads, mid-way through the movie, is as harrowing and numbing an episode of horror as I've ever seen in the cinema. The audience was laid waste. It was of course a faithful rendering of the way death from AIDS used to be in this country, and is no longer. But I must say that I sat in the theatre, emotionally clobbered, and thought to myself, “That's the way people die in Africa, now, at this very moment, day upon day upon day. ” How do we get the world to understand? I've been in the UN Envoy role now for something more than two and a half years. You will understand when I say that to visit Africa repeatedly, and to observe the unraveling of so much of the continent, is heartbreaking. There are simply no words, in the lexicon of non-fiction, to describe the human carnage. I have heard, from African leaders and social commentators alike, language that startles and terrifies—holocaust, genocide, extermination, annihilation—and I want to say that on the ground, at community level, watching the agony, the language is not hyperbolic. And what makes it even worse is the tremendous resilience and courage and effort and compassion with which the entire population, especially the women, attempt to withstand the pandemic. The individual and collective work, therefore, of people attending this conference, is truly invaluable. That's not a flippant or gratuitous remark: it's important for everyone here to recognize that you're part of the most significant battle against a disease that has ever been waged in human history … and when you're consumed in your laboratories, or wrestling with the esoterica of science, at the end of that long exploratory road there lies the whole fabric of the human family fighting for survival, searching, desperately, for hope. The grieving villages, the funerals, the hospital wards, the orphans, the women at the clinics—it's an hallucinatory nightmare; it should never have come to this. Your work can bring it to an end. What I want to try to do in these remarks is to flag the signals of hope as we enter 2004, and to look at some other related issues as well. The items are six in number; I shall deal with some elaborately, and others more briefly. First, the single most dramatic development that has happened in years around HIV/AIDS is the decision, by the World Health Organization, in conjunction with UNAIDS, to achieve the goal of three million people in treatment by the year 2005: “3 by 5” as it's colloquially known. It has the potential to revolutionize the struggle against the pandemic. Until now, large numbers of people have resisted testing for the obvious reason that confirmation of a fatal disease, without any promise that the information would improve or prolong life, made no sense, had no appeal. Finding out that you were HIV positive simply intensified, for many, the risk of depression and stigma. A prognosis of death, without hope, is hardly an inducement to seek the prognosis. All of that is about to change. Give people hope through treatment, and with well-designed programmes, they will seek to get tested in ever greater numbers. And if stigma proves so powerful as to limit the uptake of testing, there is always the alternative of doing what Botswana is now doing until testing becomes de rigeur: require routine testing for HIV whenever someone presents at a medical facility, with the option of course to opt out. The new leadership of WHO, under Dr. J. W. Lee, is absolutely bound and determined to pull off 3 by 5. It's amazing to see the depth of commitment; it's as though WHO had undergone some religious metamorphosis—they are collectively possessed. I almost expected to see flashing iridescent lights and hear celestial thunder when I visited WHO headquarters in Geneva ten days ago. I'm not going to go into detail of 3 by 5—there are handbooks and monographs available—but it is worth emphasizing that WHO sees the entire initiative as “the antiretroviral treatment gap emergency”; that emergency teams are already evaluating needs in high prevalence countries; that WHO is working with multiple partners, for example partnering with those doing the Prevention of Mother to Child Transmission Plus, where the “Plus” represents treatment for the woman and her family; that the improvement of health systems and human capacity is a sine qua non of the goal; that the logistics of drug distribution and delivery are very much a part of implementation; that the principle of equity of access will be determinedly followed, women–men, rural–urban, rich and poor; that a secure supply of medicines and diagnostics will be pursued; and that this is just the beginning. In its publication on 3 by 5, titled Making it Happen, WHO writes: This Initiative does not end in 2005. Antiretroviral therapy does not cure infection and must be taken for life. . . withdrawing or ending treatment will lead to the recurrences of illness and with it the inevitability of premature death. Lifelong provision of therapy must be guaranteed to everyone who has started antiretroviral therapy. Thus, 3 by 5 is just the beginning of antiretroviral therapy scale-up and strengthening of health systems. And so it must surely be. On the continent of Africa, it is estimated that 4. 1 million people need treatment now (i. e. , their CD4 counts are below 200) and approximately 70, 000 to 100, 000 are actually in treatment, or roughly 2%. Quite frankly, that's an abomination. The total number of people worldwide who should be in treatment measures six million. In other words, even if the target of 3 by 5 is reached, some 3 million people—50% of those eligible—will continue to be in desperate straits come 2005, with the numbers growing daily. What I was reminded of today, at an earlier press conference, by Dr. Alex Coutinho of Uganda, is that tens of millions more, who are now infected, will inevitably require treatment at some point in the future. When we talk of 3 by 5 then, it's the signal of what's to come. It's also the symbol of the untold numbers of children, whose parents will remain alive, and who will therefore not be prematurely orphaned. That's why the WHO initiative is of such enormous import. It has unleashed huge expectations, great hope, and it's based on the recognition that prevention is profoundly strengthened when treatment takes hold. It cannot be allowed to fail. I repeat: it cannot fail, or we will have given the pandemic a license of unbridled human decimation greater even than that which presently exists. To those sentiments should be added the lead words of the handbook, under the heading Guiding Principles. They read: “Immediate action is needed to avert millions of needless deaths. ” There is, to be sure, a certain other-worldly, Ionesco quality to all of this. We have all the will and money in the world to fight the war against terrorism; what happened to the will and the money to fight the war against AIDS? Why conflict and not compassion? We're over 20 million dead, and counting. With that in mind, there are four issues related to 3 by 5 which I'd like to address: 1. The World Health Organization needs up to 200 million, centrally, over and above its existing budget, to implement 3 by 5. They need it for 2004 and 2005. They need it now. They need to train 100, 000 people at country level; they need to hire teams of experts and dispatch them to the field, they need to put the whole elaborate logistical mechanism of drugs, capacity and infrastructure in place; they need to be the technical assistance providers of first resort. They will not succeed without the money. They don't have it. And though they have tried, they can't seem to get it. Frankly, I don't really care where the money comes from; it just must come. The obvious and appropriate source would be individual donor governments. There's just no way around it: rich countries should provide the funds, and frankly, 200 million is a laughable pittance when compared to what the world spends its money on these days. If for perverse reasons, that doesn't prove possible, then the Global Fund on AIDS, Tuberculosis and Malaria, becomes an alternative conduit. It would differ from what the Global Fund has done up till now, but it's clearly an integral part of everything for which the Global Fund was created. But whatever the ultimate nature of the bank account, if WHO does not get the resources, it constitutes an unimaginable setback in the battle against AIDS. 2. What clearly makes the best sense, if 3 by 5 is to succeed, is the WHO pre-qualified triple fixed-dose combination; one pill taken twice a day, available only from generic manufacturers. It's noteworthy that Medecins sans Frontieres uses this drug with several thousand clients, in 20 countries, with excellent therapeutic results and excellent adherence rates. In order for us to find the money to put huge numbers of people into treatment, and scale up dramatically, this is the drug regimen of first-line choice. It is surely of significance that the Clinton Foundation has negotiated, in India, a reduction in the price of this fixed dose combination to 139 per person per year. No one would have thought that possible, even six months ago. The international community, through the World Health Assembly, has bestowed upon WHO the responsibility for approving, and providing guidance in safety and efficacy for a vast array of medications. They do so with consummate science, fidelity and integrity. Fundamentally, evaluations carried out by the WHO pre-qualification team provide assurance that international quality standards obtain. One of the great strengths of multilateralism is that we have the World Health Organization to do this work. There may be individual countries who wish to pursue a different tack. But when WHO has identified and pre-qualified generic drugs, at low cost, to prolong millions of lives, that's the route the international community, without caveats, should follow. As a Canadian, I'm particularly sensitive to this reality. The Government of Canada—deserving of both recognition and plaudits—is about to amend patent legislation, in relation to AIDS and other diseases, to permit the manufacture and export of generic drugs, consistent with the WTO agreement reached August 30, last. The Government of Canada will undoubtedly accept the purview of the World Health Organization. 3. If there's one thing we've learned about testing and treatment, it's that the involvement of the community is decisive. If 3 by 5 is to make the intended impact, it must call on the community for help, and jettison the lip-service to which so many are addicted. And the key element of the community are the people living with HIV/AIDS, who are the real experts, and must be acknowledged as such. They should be consulted on every aspect of the treatment process, and they should be seen as helping to mobilize the community to work, in an equal partnership, with the medical facility dispensing the treatment. Wherever this formula has been genuinely applied, testing increases exponentially, stigma and discrimination drop significantly, and adherence rates are generally higher—I repeat, higher—than they are in this city of San Francisco. 4. Finally, you can't achieve equity in 3 by 5 without opening the doors to women. I'll have more to say about that shortly, but at this stage let me simply point out that the disproportionate numbers of women infected in Africa, requires a similarly disproportionate access to treatment. It is matter of bewildering shame that even an insatiable pandemic, malevolently targeting women, has failed to demonstrate, once and for all, the size of the gender gap, and the deadly risk we run by failing to close it. That brings me to my second omnibus point. Any discussion of treatment necessarily focuses, in large measure, on funding, and funding inevitably leads to the Global Fund on AIDS, Tuberculosis and Malaria. So allow me to deal with it. It's time for the world to embrace the Fund, without all the carping to which it has been—often mindlessly—subject. No one pretends the Fund is perfect, including its own Secretariat. But it is emerging as one of the most inspired multilateral financial instruments that the world has latterly fashioned. And I, for one, am nonplussed by the refusal to fund the Fund at levels which would save and prolong millions of lives. There's something nuts about holding out a begging bowl for an organization dedicated to confronting and subduing the AIDS pandemic. I am reminded of the 1980s, when members of the international community were reduced to groveling on behalf of financing the United Nations, in order for the world body to function in the interests of humankind. Where would we be without it today—you'll note that there seem to be countries who suddenly need it—if its capacity for intervention had been eroded by the Scrooges of the planet? The Global Fund is largely past the inevitable hiccups associated with launching a new and complex international mechanism. It has sophisticated and useful processes in place. The innovations of the so-called CCM—the country coordinating mechanism—and the Technical Review panels are working pretty effectively at country level and at the centre. The Board, with its unique representative nature, is functioning well, and the Fund is now disbursing money rather more quickly than certain other international financial institutions that have been around forever. This isn't some blanket apologia. I myself have occasionally been critical of the Global Fund and have raised with them some of the frustrations felt by recipient countries. But let's keep perspective here. In barely more than two years, we have an entirely new international construct up and running, admirably serving the interests for which it was intended, and getting money to the grass-roots of AIDS-plagued countries where it is so desperately needed. That's one of the most admirable things about the Fund: because the proposals come from the bottom, the money can get to the bottom. The Fund was the brain-child of the Secretary-General of the United Nations. It was an excellent cerebral birth. It can become the kind of international coordinating body which we must have to defeat the three communicable diseases that constitute its mandate. I have nothing but regard for the work of the Clinton Foundation in the four countries where it is most in evidence: Tanzania, Rwanda, Mozambique and South Africa. And I'm delighted by the prospect of President Bush's enterprise bringing hefty resources into twelve of the countries of Africa. But what of the countries that are left out of those initiatives? What of Swaziland and Lesotho and Zimbabwe and Malawi, whose collective prevalence rates range from 15% to nearly 40%? It's the Global Fund that stands ready to be called upon. With 3 by 5, the of a and funding for all of the is surely It's been a then, to see the Global Fund has In I I should my in my the Global Fund has been You that the would for a of financial by the Global Fund as the obvious for countries. But that been the this in the Fund is several million for this and almost three for are the The of the United has for only 200 million for the Fund for 2005, some million than 2004, and a of what many would be an The of based on world is from the United from and from everyone vast like to like In 2005, the Fund will need a of. . . from the United This is not the is And let me a of the for 2005, represents money needed to existing is, those that were in years one and If that money is not the cannot be and people who have been put on treatment with that money will have their regimen On the other it must be that no country, my own is an based on any And is it countries from for what they truly need because they don't they can get it. are at a of three million a and we have the capacity to keep them alive, and we can't some was in the to AIDS in a of is by 2005, and by Where will the come this struggle for funding including the critical for a But I the of allow me to make a point. The world has time and time at the target of of of of The only countries that have reached or it and the development from the countries, to Dr. in on and were we to an of of we would be at now, and 200 by The only I've seen to those are the for and there ever a more and are in numbers for people are And the of those people are now women. the for a must be given over a way to from and that way is As more and more is done on the of women to more about the in which risk is And to UNAIDS, the risk is particularly high in and and in the of AIDS in Africa, can be to In the of partners, is very can it be In representative of women in African countries, it was that only in the last with their The is that or is the way in which women are The is There is a growing body of to that a significant number of infected women in Africa have been infected by their or There is no against that the in is great to permit or to the of it is that the intervention doesn't work in the one where the risk for the woman may be without is not is it in is not faithful is is at A way must be to allow the woman to of male are one but they are very and they require And of course they as to The most prospect that we have on the and social is a I recognize that this is an audience of vast and but let me simply for that a can be as a or that be used for months at a It would to the woman the to from HIV in the of a It would the of at 5 years from a But with and there are in the testing now to achieve the in that time The to the development of a that the is in the of million. the end of and development funding million. the is in the of million. It may be In of the Global HIV Prevention an of But it's of a or a it's in the vast of international financial at the of and that a of even used by only of women in with health the numbers of by It's of the under development are to be as as others will be for disease As we potential have into human safety and some may enter in there's a long way to but it's not without hope. But we must have the money. The is so the related to HIV and and are in the of you have to what kind of has into the process of human we to pull out all the and get of and levels of to the we a significant of to the women of Africa and millions of HIV and the millions of premature that and the millions of left in this to me why that be one of the of brings me to the is not the for a It's to me the for an AIDS is also around issues of funding, and is in by the of care and prevention and treatment. this is It's for the world to on a when millions of people are for treatment. But just because a is a and very science, it it must not be of the pandemic are not There will be to as there will be to but a as the ultimate to the must be with an almost There should not be the around The of that roughly ten per of the resources in the battle against AIDS should go to and That's not the greater the number of the greater the prospect of If ever a in it's for an AIDS of are part of a of work, from the and done by so many in this through to development and the And it must on the needs of the world and and in access for all will be when a is It's important to note that there are more potential in the than ever and that are on six of this is by the AIDS and of course But we need more, much more, from and are and from and I with the of not long ago. was the that is was not a is also a A to some even a would to women the ultimate from HIV infection without the male or any involvement The best prospect of course for women, is to have access to both a and the one the We're 3 million people a year. will but not the carnage. There are new daily. If 5 to years from or there's a desperate human to be now and let the world to the prospect of bringing this to an end than And that working on every on emergency treatment, It was the of who that HIV/AIDS the single to the world So I is the world And that brings me to the two issues I want to which I shall not because I have with them on They from what has already been They are rather more than There is one more than any other that me in doing the it's the of the on women. We're a and price for the refusal of the international community, every of the community without to embrace gender And in so many of the gender and AIDS is a of death. There's nothing new in It's in The the the the the male. . . it's as though had this into a of death for women. last 2004, I the first in London, of the of the Global on and AIDS, a I of and a several of whose members are women living with HIV and AIDS. The heading on the press to read: Prevention and are and. . . women are infected by and HIV prevention And then, the the day, the of a that women at deadly in a million years would I the or of the Global entirely of the lies in the the and what's on the I the by and I that the gap and can be no longer. In the last two and a half years, on the African continent, I have seen no improvement in the of women. It's for It makes me almost I have come to the I it's it's truly and to off the It's time for the UN community, for on the in countries, to with the and fighting for to the that are needed. It's time to the It's time to the like which to by that a process the women It's not In Africa, of the million people living with HIV/AIDS the of and nearly are women and to me what is The time has come to and that they or amend the on and It's time to put people in for a long of life, for If leads to HIV and death, then it's time to the entire of the to against to the on the woman to fight off male and in on the with a If male