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
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 twenty countries, with excellent therapeutic results and excellent adherence 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”. 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 $132 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 30th, 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 fifteen to nearly forty per cent? It’s the Global Fund that stands ready to be called upon. With 3 by 5, the presence of a coherent and rational funding body, for all regions of the world, is surely vital.
It’s been a heavy blow, then, to see how inadequately-funded the Global Fund has been. In fact, I think I should stop pulling my words: in my respectful submission the Global Fund has been abysmally resourced. You might think that the industrial nations would compensate for a decade of financial abstinence by embracing the Global Fund as the obvious vehicle for resource-constrained countries. But that hasn’t been the case. At this moment in time, the Fund is several hundred million dollars short for this year, and almost three billion short for next. Nor are the omens auspicious. The administration of the United States has asked for only $200 million for the Fund for 2005, some $350 million less than 2004, and a billion short of what many active observers feel would be an equitable contribution. The rule of thumb, based on gross world product, is one-third from the United States, one-third from Europe and one-third from everyone else --- everyone else comprising vast powers like Japan to sweetly diminutive states like Canada. In 2005, the Fund will need a minimum of $3.6 billion … hence $1.2 billion from the United States. This is not higher calculus: the arithmetic is clear. And let me add a footnote: of the $3.6 billion required for 2005, $1.6 billion represents money needed to extend existing programmes … that is, those that were approved in years one and two. If that money is not forthcoming, the programmes cannot be extended, and people who have been put on treatment with that money will have their regimen severed, posing serious mortal risk. On the other hand, it must be said that no country, my own included, is paying an adequate share based on any reasonable formula. And that, quite simply, is shocking. Worse, it deters developing countries from asking for what they truly need because they don’t believe they can get it. People are dying at a rate of three million a year, and we have the capacity to keep them alive, and we can’t summon sufficient resources. Overall, some $4.7 billion was spent in the global response to AIDS in 2003. UNAIDS says a minimum of $10.5 billion is required by 2005, and $15.5 billion by 2007. Where will the dollars come from? Third, this constant struggle for funding bedevils everything, including the critical quest for a microbicide. But before I address the question of microbicides, allow me to make a simple point. The developed world has endorsed time and time again, at conference after conference ad nauseam, the target of .7 per cent of GNP --- seven-tenths of one per cent of GNP --- for foreign aid. The only countries that have regularly reached or surpassed it are, predictably, Norway, Denmark, Sweden and the Netherlands. Our present annual official development assistance, from the OECD countries, approximates $57 billion. According to Columbia University’s Dr.Jeffrey Sachs in his study on Macroeconomics and Health, were we to reach an average of .7 of GNP, we would be at $175 billion now, and $200 billion by 2007. The only figures I’ve recently seen comparable to those are the cumulative expenditures for Afghanistan and Iraq. Was there ever a double standard more visible and egregious? People are dying in Malthusian numbers for heaven’s sake; people are dying.
And the majority of those people are now women. Hence the scientific search for a microbicide. Women must somehow be given control over a way to protect themselves from HIV, and that way is microbicides.
As more and more research is done on the particular vulnerability of women to infection, we’re learning more about the situations in which risk is paramount. And extraordinarily enough, according to UNAIDS, the risk is particularly high in apparently monogamous marriages and partnerships. Ironically, and lethally, in the age of AIDS in Africa, marriage can be dangerous to women’s health.