Keynote lecture by Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa
11th Conference on Retroviruses and Opportunistic Infections 8 February 2004, San Francisco, United States
Mr. Chairperson, Ladies and Gentlemen: I want you all to know how much I appreciate the invitation to speak to this auspicious gathering, even though I stand before you with no scientific credentials whatsoever.
Allow me to set the stage for my remarks in 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 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. Up 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 … ie, their CD4 counts are below 200 … and approximately 70,000 to 100,000 are actually in treatment, or roughly two per cent. 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 three million people --- fifty per cent 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 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. 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 twenty 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.