Global AIDS

Highlights of Special Report by Stephen Lewis, UN Special Envoy, HIV/AIDS in Africa
To Retroviruses Conference, San Francisco - Feb 8, 2004

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; its 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 Ive 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, "Thats the way people die in Africa, now, at this very moment, day upon day upon day. How do we get the world to understand? "

Ive 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. Thats not a flippant or gratuitous remark: its important for everyone here to recognize that youre 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; its 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.

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 its 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.

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, thats 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 are now infected, will inevitably require treatment at some point in the future. When we talk of 3 by 5 then, its the signal of whats to come. Its also the symbol of the untold numbers of children, whose parents will remain alive, and who will therefore not be prematurely orphaned.

Ive 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.

With that in mind, there are four issues related to 3 by 5 which Id 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 dont have it. And though they have tried, they cant seem to get it.
   
   Frankly, I dont really care where the money comes from; it just must come. The obvious and appropriate source would be individual donor governments. Theres 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 doesnt 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 its 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. Its noteworthy that Medecins Sans Frontieres uses this drug with several thousand clients, in twenty 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 $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, thats the route the international community, without caveats, should follow.
   
   As a Canadian, Im 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 theres one thing we've learned about testing and treatment, its 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 cant achieve equity in 3 by 5 without opening the doors to women. Ill 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.

Its 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. Theres 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 Fund was the brain-child of the Secretary-General of the United Nations. It can become the kind of international coordinating body which we must have to defeat the three communicable diseases that constitute its mandate.

Its 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 hasnt 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. 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 dont 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 cant 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. 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, were 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 womens health.

In the situation of intimate partners, condom use is very low. Nor can it be demanded. In representative surveys of women in 14 African countries, it was found that only 7% reported condom use in the last sex act with their regular partner. The prevailing assumption is that commercial or casual sex is the primary way in which women are infected. The assumption is wrong. There is a growing body of evidence to show that a significant number of infected women in Africa have been infected by their husbands or intimate partners. There is virtually no defence against that reality: the power imbalance in marriage is too great to permit or to request the regular use of condoms.

A way must be found to allow the woman to protect herself, independent of male hegemony. Female condoms are one possibility, but they are very expensive, and they require partner consent. And of course they act as barriers to conception. The most exciting prospect that we have on the scientific and social horizon is a microbicide.

Alas, we're still at least five years away from a first-generation microbicide. But with government support and financing, there are enough products in the testing pipeline now to achieve the breakthrough in that timespan. The Rockefeller Foundation, deeply committed to the development of a microbicide, estimates that the cost required is in the vicinity of $775 million. At the end of 2002, research and development funding totaled $343 million. Thus the shortfall is in the vicinity of $400 million. It may be higher. In May of 2003, the Global HIV Prevention Working Group recommended an additional $1 billion of public sector spending. But whether its three-quarters of a billion, or a billion, its peanuts in the vast panorama of international financial architecture.

Using mathematical models, researchers at the London School of Hygiene and Tropical Medicine found that a microbicide, of even 60% effectiveness, used by only 20% of women in contact with local health services, could reduce the numbers of infections by millions. Millions. Its breathtaking.

Some of the products under development are likely to be contraceptive as well as microbicidal; others will be non-contraceptive for disease prevention. As we meet, eleven potential microbicides have advanced into human safety trials, and some may well enter large-scale Phase II/III trials in 2004. Obviously, theres a long way to go, but its not without hope.

Which brings me logically to the fourth item: is not the same true for a vaccine? Its interesting to me how the search for an AIDS vaccine is also struggling around issues of funding, and is often eclipsed, in public debate, by the preoccupations of care and prevention and treatment. Perhaps this is inevitable. Its tough for the world to fix on a vaccine, when millions of people are understandably clamouring for treatment. But just because a vaccine is a long-term proposition, and obviously very tough science, it cannot, it must not be depreciated.

The rule of thumb suggests that roughly ten per cent of the resources allocated in the battle against AIDS should go to vaccines and microbicides. Thats not happening. Yet, the greater the number of vaccine trials, assuming plausible candidates, the greater the prospect of discovery.

We are losing three million people a year. Treatment will slow, but not eliminate the carnage. There are 14,000 new infections daily. If were five to ten years away from microbicides or vaccines, there's a desperate human toll to be faced between now and then.

Just last Monday, February 2nd, 2004, I attended the first meeting, in London, of the newly-constituted Steering Committee of the Global Coalition on Women and AIDS, a Steering committee, I might add, of undisputed intelligence, influence and reach; a Steering Committee, several of whose members are women living with HIV and AIDS. The heading on the press release to stir media interest read: HIV Prevention and Protection Efforts are Failing Women and Girls More young women are becoming infected by husbands and long-tem partners --- female-controlled HIV prevention methods urgently needed.