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The AIDS Pandemic at 30 Years: Can It Be Stopped?

Speakers: Michelle Bachelet, Undersecretary General and Executive Director, U.N. Women; Former President of Chile, Paul De Lay, Deputy Executive Director, UNAIDS, and Robert C. Orr, Assistant Secretary General for Strategic Planning, United Nations
Presider: Seth Berkley, President and CEO, International Aids Vaccine Initiative (IAVI)
June 6, 2011
Council on Foreign Relations

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SETH BERKLEY: So good evening, everybody. My name is Seth Berkley. I'm the president and CEO of the International AIDS Vaccine Initiative, and I'd like to welcome you to this meeting.

First of all, the next meeting is going to be the World Economic Update, which is going to happen tomorrow morning.

For all of you who come to a lot of meetings here, the usual request: Please turn off your communication devices. Don't just put them on vibrate; turn them off, to avoid interference with the sound system.

And I'd like to remind all of you that this particular session is going to be on the record.

You all know that -- the statistics about AIDS as a disease. More than 33 million people are infected today, living with it, and nearly 30 million people have died. There's 7,100 new infections a day.

Now we've had an extraordinary revolution in treatment, where we now have more drugs to treat HIV than all other viruses put together. And we've had enormous progress on getting treatment out to people who need it. Today there's about 6.6 million people on treatment.

But there's also 9 million people who need treatment who aren't getting it. And for every three people put on treatment, there's five new infections.

Now it's been a pretty extraordinary and unprecedented response to AIDS, and we're going to talk about that today, because we have a fabulous panel. But to put that into perceptive, there's going to be in the next few days, from the 8th to 10th of June, a high-level meeting of the U.N. General Assembly on HIV/AIDS. And this particular meeting is going to mark the 30th anniversary of the original reports of HIV in a cluster of gay men in Los Angeles. It also is 10 years since the landmark meeting that was hosted by the -- by the General Assembly on HIV/AIDS, the first time the General Assembly had taken a health issue like this forward.

Since that time, a lot of things have happened. We've had HIV/AIDS as the specific target of the MDGs, and we've also had a -- an unbelievable political commitment, starting out in the Labour government of the U.K. and then at the Gleneagles G-8 summit, where they adopted a goal of universal access by 2010, which we did not make.

So today we're going to talk about AIDS at 30 and is this an epidemic that we can stop. And to talk about it, we've got this fabulous panel.

To my left is Michelle Bachelet, who's the first undersecretary general and executive director of U.N. Women, which was established on July 2nd, 2010. Former to that, she served as president of Chile, from 2006 to '10, and had the amazing ability to serve both as a minister of defense and a minister of health of that country.

To her left is Paul De Lay, who's replacing my good friend Michel Sidibe, and he's picked a(n) excellent substitute. Paul joined UNAIDS in February 2003. He was appointed the deputy executive director of the program in 2009. And prior to that, he worked at the Global Program on AIDS at WHO, and the chief of HIV/AIDS at USAID. He's a very experienced physician.

And next to him, at the end, is Robert Orr, who's the assistant secretary-general for planning and policy coordination in the executive office of the secretary-general since 2004. He runs the secretary-general's policy committee, and he's the principal policy adviser to the secretary-general on climate change, food security, global health, counterterrorism, and U.N. reform. Quite a big set of tasks there.

So I'm going to start with a series of questions, and then obviously we'll open it to the members.

UNAIDS has adopted a very bold platform. They've said zero HIV infections, zero HIV discrimination and zero AIDS death. And in the last two years, we've seen tremendous in breakthroughs in biomedical prevention. We've seen proof of concept of a vaccine. We've seen successful clinical trials of a microbicide. We've seen that if you give anti-retroviral drugs for prevention, you can block transmission to men who have sex with men. And most recently, data to show that if you treat discordant couples, you can block transmission.

So very exciting new science coming. We also know that over the last few years, we've begun to see rates of HIV drop in a number of countries, and we've got more people on anti-retrovirals than ever before. But we also know that donor governments have become less willing and less able to sustain the levels of existing funding for anti-retroviral therapy and for prevention research. So we could be on the threshold of ending the pandemic, or we could lose the ground we've gained.

So can we keep the momentum going and stop the pandemic? So let me start with you, Paul.

PAUL DE LAY: Seth, thank you. And again, I am grateful to be here, and I do want to extend the apologies of our executive director, Michel Sidibe. He was planning to come, but at the last minute was -- had to meet with the secretary-general to prepare for the high-level meeting. We're negotiating a declaration, which is a critical document that we may talk a little bit about before.

The successes -- and I think we can call them successes -- that Seth has referred to that have occurred over the last 10 years certainly started from a period of time of extreme skepticism. In 2000, no one thought we could put people on complicated anti-retroviral drugs. No one thought we would get the resources from donors. No one thought that we would be able to effectively change risk behaviors and overcome the stigma and discrimination that's particularly associated with this epidemic, unlike most of the other infectious disease epidemics of the world.

And we've proved them wrong. Now, of course, we have naysayers who are saying, well, we can't sustain people on treatment, or the decreases in prevention are not fast enough. We have a 25 percent decline in incident infections since 2001. Well, all of this results from a lot of work, a lot of passion, a lot of community engagement, and money. We are now at about $16 billion U.S. being spent in middle and low-income countries. We never thought we'd get to that level. It's probably not enough. But it was at least enough to be able to broaden from what we were calling "boutique programs" back in the '90s that only served hundreds of thousands of people, to programs that truly served millions of people, both on the treatment side and on the prevention side.

And the successes -- and I will close now -- that we've seen thus far have primarily been what we used to call the old ABCs: abstinence, be faithful to your partner, and use condoms. We are just now on the verge of seeing the effects of male circumcision and the increasing number of people who are being treated and are therefore less infectious.

So the last 10 years really was a proof of concept that risk behaviors could be changed. And I think that's a positive story, as positive and as powerful as the dramatic increases in treatment. Unfortunately, it's not going to be enough. And if we continue the current trend at this rate, we are looking at an epidemic that will last another 30 to 40 years.

BERKLEY: Thank you, Paul.

Bob, the U.N., on this particular issue, has done a really enormously fabulous job. They've created a special program and brought the different U.N. agencies together -- UNAIDS -- and they've also created a funding mechanism. Kofi Annan pushed very hard for that, the Global Fund, which has raised unprecedented amounts of money for HIV and obviously also for malaria and TB.

All of this has said that, you know, AIDS is exceptional. Is there still room for AIDS exceptionalism? And how do you see the future for this effort within the U.N. system, given the priorities that are with us today?

ROBERT ORR: Thank you, Seth, and to the council for the invitation.

I'm really struck at what a difference a decade makes. If you think back just one decade ago, when we were talking about this -- and in the context of, Seth, your question about the U.N. -- this was still taboo. It was still an area where, institutionally, you couldn't really talk about it. But as we are tonight -- literally, the planes are landing at JFK one after the other with heads of state on board -- you couldn't even raise this in polite company with heads of state one decade ago. Diplomatically, this was a dead letter.

In this one decade, not just the scientific advances that Seth mentioned -- and I think that the institutional advance had been that the U.N. became the locus of activity, in many ways, to fill this huge vacuum of leadership. It was not easy. It was not pretty in the early days. But I think -- I remember the initial efforts, when Richard Holbrooke, for whom I worked at the time, tried to drag this into the Security Council -- the visceral reaction that this was wrong. You couldn't do that. This was distorting what the U.N. was. There was an institutional reaction, there was a cultural reaction, there was a political reaction all wrapped into one.

But what's happened in the decade since was that the U.N., I think, both because of some political leadership -- I would credit Kofi Annan and Richard Holbrooke, among others -- but for creating a space within the organization to address this. And then a lot of the pioneers in the area just constantly opening that space in the U.N., and I think the Global Fund -- the fact that Kofi Annan was successful at getting the Global Fund off the ground, but then it had to leave the U.N. -- (chuckles) -- to survive and thrive, I think is -- it shows some of the limits too, the institutional limits.

But I really wanted to pick up your AIDS exceptionalism issue, Seth, because I think here's another area where we really are on the verge of a breakthrough. For a while, it took AIDS exceptionalism to give this issue the attention it deserved. But we've long since outgrown AIDS exceptionalism. For our success on AIDS, we need to break down the barrier of exceptionalism. And for success on a range of other health issues, we need to break that down.

So right now maybe the most exciting, dynamic advancement in the space is the global strategy on women's and children's health. And the big question -- the big question two years ago was, do we have room for a strategy on women's and children's health and the fight against HIV/AIDS. You know, for those of you -- I think just about everyone in this room recognizes that's a crazy question. But that was the question. Do we have enough funding to do women's and children's health and HIV/AIDS?

How could you see these two things as somehow competing with each other, when the overlap is so dramatic -- but also the model of how you -- how we've had some success against HIV/AIDS; bringing in multistakeholder communities, scaling up, going up the cultural issues and the political issues, as well as the technical and the health issues.

So I think we can not only say that AIDS exceptionalism is no longer needed, it really is something that we are going to get much further by integrating our HIV/AIDS interventions in a broader set. And just coming from Nigeria and Ethiopia, and in the last week with the secretary-general where we saw, at the village level, things happening on women's and children's health, and HIV/AIDS kind of seamlessly meshed into those programs -- that's where we want to be. We just need to get it out there further and farther.

BERKLEY: Thank you, Bob. And for President Bachelet, women have steadily borne more of the brunt of the epidemic worldwide. And yet, culturally they often can't control their own sexual situation, their sexual relationships. You know, what can be done to empower women and reduce their risk of infection particularly?

And I personally want to congratulate you on your new role at U.N. Women, and I suspect that many of the members don't know fully what U.N. Women is, so you might just want to take a minute to say something about the new agency -- if I can call it an agency -- and how that is going to play a role around HIV.

MICHELLE BACHELET: Well, thank you Mr. Berkley. I'm happy to be here again in the council today in my new capacity as the executive director of U.N. Women. But also because I'm here is because I -- last year Michel Sibide asked me to be an advocate, as a former epidemiologist, of the national commission of HIV/AIDS for my country.

The foreign minister, as the head of delegation of the UNGASS meeting 10 years ago, where all what you have been saying, I lived it there -- where just putting in a declaration, a final statement, people who are sex workers or men who have sex with men, was really a very complicated situation to do at the general assembly.

So of course, I have to say I've seen and I agree with what I've heard -- but on the other hand, I have to say, or we improve women's capacities, we empower women, or we're not going to be able to be completely successful because in Africa, of course, and not only in Africa, also in the Pacific area, and still in some parts of the Caribbean, the HIV epidemic still has the face of a woman.

And women in many of those places are first -- they'll have, as you mentioned, all the capacity of putting the conditions in a sexual intercourse, in a relation, but also not only with intimate partners, but also in many places where rape is used a -- or as a means of war, in the case of conflict or post-conflict countries, where you can end the conflict, but rape doesn't end, unfortunately. Maintains as a way of, I would say, of a relation between power between men and women.

On the other hand, we see women who do not have access to -- attention to IRV (ph), to health care. And also women, in my experience in HIV/AIDS commission, but I have spoken to my friends in the UNAIDS and many other places, usually they are the ones who -- how can I say -- they sacrifice for the rest. If there are few treatments they would prefer that her husband or her children receive the treatment and they are always there. They never go to the health site for care, attention or so on.

So why I mention all this? It's not anecdotic (ph). It's concrete of the difficulties that we find in fighting with HIV/AIDS and not looking at the specificities of women. So what do we need to do? First of all, we need to empower women as agents of change. We need much more women leaders in terms of women living with HIV/AIDS, or women ensuring that there is sort of a mainstreaming in the health quality that can ensure that women really are receiving the treatment, the care, or the information so they can prevent and avoid getting an HIV infection.

I have to say that one of the things that I was taking with Michel Sibide, and of course with Dr. Babatunde from UNFPA is how we deal with the issue that a woman is a mother, but not only a mother. And because if you see many -- I have some data here, that in 2009 53 percent of pregnant women living with (HIV?) received the antiretrovirals to prevent mother-to-child transmission in low- and middle-income countries.

And they -- (inaudible) -- up from 15 percent. I mean, from 15 percent, 2005, to 53 in 2009. It looks like a great improvement. But only 26 percent of pregnancy women receive HIV testing and counseling. So we're not -- first of all we do not know exactly how many women are living with HIV/AIDS.

And then they receive the treatment -- but in some places because of a lack of funding, because of the perspective of women as mother, trying to avoid vertical transmission, when the children is -- the child is about three months old, they cut the treatment. And then, the children can avoid the transmission, but what about breastfeeding? What about the women who then could die afterwards because spontaneously the infection -- and can die of AIDS.

So we have to continue working empowering women. Second, we need to ensure that women have access to prevention, treatment and care services. So we need to ensure particular earmarked fundings for women's access to all of this, because otherwise they won't be prioritized. And so there is an incredible, I would say, correlation between violence against women and HIV and AIDS. So we have to fight very strongly against violence against women. And I'm talking from domestic violence that can be linked to gender based violence, to of course conflict and post-conflict countries.

If we don't work on that, I think, all our successes in terms of all kinds of medical treatment and so on will not be enough because many of the women who are victims of violence and then they are raped, they can get infected by their partners. We all know that women are less -- how could I say -- they transmit less their HIVs.

They are the ones who carry it to men, then men to women. So, we really -- I'm really convinced, and not because now I'm the head of the -- of U.N. Women, I'm always been convinced of this, because I'm a medical doctor and I study these things.

So just to end saying that if we do not focus on women on this next step, we will be having this trend. I mean, this trend maybe will not go as fast as we should in terms of trying to prevent and to improve the quality of life of people living with HIV/AIDS.

Two words about UN Women -- new agency, new entity of the United Nations. After five years in negotiations, they acknowledge that even though all the efforts done on the U.N. system for women, for gender equality and women's empowerment, all the indicators linked to women's issues and women's life were the ones who progressed the slower. And if we only go into the -- into the Millennium Development Goals, we see that empowerment of women, maternal mortality, HIV/AIDS and so on -- of course, poverty has the face of a woman and is still very high.

So there was this political decision that women should have their relevance, if I may say, as apart from other kinds of global (challenge?) like climate change, poverty, and so on. So this new entity is working for the women and girls of the world, will be producing the coordination synergies within the U.N. system, is probably the first child of the reform of the United Nations because it's -- what looks after is to produce synergies, coordination, and not duplicate efforts, and have five main priorities as leading agency, because there are many other areas where women are important, but were not the leading ones.

And HIV/AIDS, of course, our friends here are the leading ones, but it's economical and political empowerment that's -- (inaudible) -- first two priorities -- understanding that if women cannot have autonomy, economic autonomy, we'll never have equal rights, and that we need -- for example, when we're talking about HIV -- the women's voices to be heard so we really can give the relevance and the importance to women's issues. Otherwise, usually, they're not in the DNA of the decision-makers -- very difficult, that they really consider special measures for women.

Third, ending violence against women, that's a third priority. And fourth, it's women in the heart of peace and security agenda for 1325, as you all know, and not only as usually be seen, and probably what we have advanced more, is looking at how we can prevent violent -- again, the violence against women in conflict and post-conflict countries, but what we have been, I would say -- I mean, when I say "we," I say the whole world, the community, the international community. Very slow, if in the other part of 1325 that last year celebrated 10 years, it is looking at women and incentive and encouraging women's involvement in the peace building and peacemaking process. This will mean women at the peace talks, women at the peace agreement.

This has been very slow, very slow, and we're going to work very strong on that. How? Through national capacity building, in national action planning, but also budgeting, because only planning without money is only music and is not important, and of course, statistic that can show us an indicators and follow-up of indicators that can show us, you are really progressing or not.

Education, health, and so on, migration, domestic workers -- all of those areas, we will be working on that and many others as you can imagine, but we will be building partnership with the rest of our colleagues on the U.N., because we want to work to do that, not duplicate what they have been doing so long.

Oh, and last -- sorry. Really, I shut up immediately. (Laughter.)

But it's so linked to this issue, because I was 10 years ago in the UNGASS in the -- (inaudible) -- delegation in my country. But still now, in -- (inaudible) -- to include an article about sexual education was a fight. I mean, today, in -- 50 years ago in -- (inaudible) -- it was talked about sexual and reproductive rights. But today, nobody's also talking about that. Family planning is a revolutionary word; that was in the '60s.

And I don't -- I'm not crazy. I'm mentioning this because one of the issues -- (inaudible) -- on how we really can combat and work in a better with HIV/AIDS is how we ensure -- and with maternal mortality, with early forced marriage, with pregnancy, it's through really have sexual reproductive services linked to HIV and AIDS services. Otherwise, we're having a lot of problems in many places facing how we can ensure, really, health care and health attention to women and girls and boys and men. Thank you.

BERKLEY: OK. Thank you very much, both for your comments on women, and then a brief view of U.N. Women.

For either Bob or Paul, this week is the high-level meeting. We're going to see people -- 40 heads of state, civil society representatives, activists are going to convene at the United Nations to see where we go from here. Are we going to be able to end the pandemic?

And we understand that there is some areas of disagreement that are going on now. Maybe you can highlight what you think are some of the main issues of disagreement, what coalitions are driving these debates, and how you see those playing out. For some, there is some concern that we're, in fact, moving backwards on some of the major concerns towards stigma and other issues that President Bachelet has just talked about.

DE LAY: The declaration of commitment that was endorsed by 182 member states in 2001, which was the U.N. General Assembly Special Session, the UNGASS -- which sounds like a Pepto-Bismol type of medicine, but -- (laughter) -- was at the time -- and I'm not sure we appreciated it as much as we do now -- an incredibly courageous document. It dealt with an epidemic that, quite honestly, nobody wanted to deal with. This isn't TB, this isn't malaria, this is an epidemic that gets into the roots of behaviors, sexual and drug-using behaviors, that we don't like to acknowledge.

And it was seen as critical that we have a powerful document that really addressed the profound human rights issues, and specifically access to services. I know of no other infectious disease, epidemic, where people are deliberately excluded from services. It's never happened with bednets or ORS or immunizations. But in AIDS, it happens every single day.

So this was a powerful document. But the document ended, literally, December 31st, 2010. So we now need something that reaffirms that, strengthens it, adds to it, adds the parts that were not well-covered and takes us into the next decade.

And what are the issues we're seeing? And this is where, I think, Seth's comment that we're moving backwards, it's -- why are we talking about human rights? Why are we talking about engaging the most vulnerable and most affected communities? Why are we talking about harm reduction as an intervention that successfully can reduce HIV transmission among drug users? Why are we talking about sex?

And what AIDS did bring, following the comments of President Bachelet, what AIDS brought to the table as far as gender was very specifically the sexual nature of gender, and violence. And that was a major leap forward. I mean, family planning and all never really grappled with sex. Fortunately, we had the technologies that we didn't need to deal with sex.

So what we're hoping for is a document that's going to move us forward. And we do have risks because of the environment we're in. And hopefully tonight we'll have a document and be able to move forward for the next three, four days, to try to figure out what that then means, as far as how do we operationalize it.

BERKLEY: So maybe I can also ask you, Bob, to comment on this. And you've made it a very important part of your tenure to -- about measuring accountability. And so here's the situation: We're going to have a new declaration. Does it matter? And what has to happen to turn this into reality?

ORR: Great question.

We have to look at what business model is going to work in the next decade. If we just talked about the past decade, and where we've made progress and where we haven't -- if there's one area that is absolutely required for the new business model to work, it is accountability at all levels: accountability for results, accountability for money.

Fighting AIDS has been a pretty expensive deal, and this is where these kinds of unnecessary conflicts have been created between women's health and children's health and malaria and HIV. So we do need to be able to account for every dollar, yen, euro -- you name it -- spent. But the accountability is much more fundamental than that.

And so in the women's and children's health strategy, we built into the agreement a plan for an agreed accountability mechanism, which we've not been able to get in broader MBGs (ph). What this can enable is a discussion -- ongoing discussion -- among all the players, for what they're putting in and what they're getting out.

This will be required to keep the momentum up. People hate the term "donor fatigue," but right now, some donors are pretty flat on their back. Trying to keep the money coming out of the -- you know, the blood out of the stone -- that's not how we're going to win this. We have to get leaner, smarter, faster. But we also need to be able to keep the political support that we've seen.

So the accountability mechanisms should not be sector specific. If you don't need a HIV/AIDS accountability mechanism, a malaria mechanism, a dollar mechanism -- you actually need all the information on the table about what you're putting in and what you're getting out, the cost-effectiveness of those interventions.

And what's interesting, by giving this back a human face -- women and children, the most obviously universal experience of everyone; everyone has a mother, and everyone's been a child -- by giving this back a human face, we actually have a chance to make accountability not a bean-counting exercise, but actually a humanizing exercise for this. How many lives did we save this year? Was that the best investment we could make to get those lives?

This is a hard, tough prioritization questions that have always been out there. But rather than pitting one community, the malaria community, against the HIV/AIDS community, if we can kind of bring this together so that we're actually trying to save lives and save money to be able to save even more lives, I think we have a shot at this.

But the last point I would make about the business model -- and I'm glad the issue of stigma has come up multiple times -- there are some things that don't cost a lot of money, but are the hardest things: the cultural attitudes, the inability for politicians to see their way beyond, you know, certain issues, and this will cost me too much.

What we found, though, is tipping points on stigma issues can be swift. When the secretary-general came in, I don't think anyone thought -- they were thinking, oh, post-Kofi Annan, we're in trouble. Kofi Annan knew AIDS. He cared about AIDS. He cared about Africa. Uh-oh, here comes an Asian secretary-general.

I think, to everyone's surprise, this East Asian secretary-general has taken it up as his cause, and he's probably made as much or more progress on stigma issues than anyone else could have. He went straight at his own home country, in Korea, and said, I can't believe you have visa restrictions. This is an embarrassment. It was front-page news across every paper in Korea: Secretary-general berates Korea for its policies on visa restrictions. He did the same in the United States. He did the same in China.

This is generally not a politically winning formula: Go after your big supporters and benefactors. But it tips the discussion in those countries, in certain segments of the population that didn't want to talk about it. So if there's a cost-effective intervention that I could say, universally, we all need to adopt: Go after the stigma issues because that's where you can make the biggest difference for the least amount of money.

BERKLEY: That's a good use of the bully pulpit, and let's hope he doesn't have to use it later on this week if I'm -- regret -- (inaudible).

ORR: (Laughs.) Me and my big mouth, we make them. We have a few of those moments this week.

BERKLEY: So at this time, I'd like to invite the members to join the conversation. There are microphones available. Please wait for the microphone, and speak directly into it. We're going to ask you to stand up, introduce yourself, your name and your affiliation, and to try to keep these to questions and relatively briefly so there's enough time for others to speak.

So the floor is open, please.

QUESTIONER: Thank you very much for the excellent presentation. I'm Natalie Hahn. I worked with the U.N. for many years, mostly UNICEF in Africa.

Can we move the discussion to the field level? Which country in Africa has made the most progress? Who's funding it? Why has it been successful? What head of state? What members of parliament? What women's group? Is the private sector in Africa coming in? Position of the Obama administration? Bill and Melinda Gates Foundation? Where do you see the trends, also on the funding of the programs?

But -- I'm interested in declarations, but I'm more interested in some field examples of what has worked, and why.

BERKLEY: So let me ask for a little bit of a lightning rod -- round, where each one of you can just take a bit of this and take a crack at it.

BACHELET: Well, maybe Paul will speak more widely, but I will mention one great example is Botswana. Botswana president decided to improve that country's economic growth and development, and it had a problem. One of the areas he wanted to develop is tourism. And it didn't work because the trend of -- I mean, probably by many other reasons, but one of the reasons, they had to decide, it was that the trend of HIV/AIDS were going higher and higher and higher and higher. So they -- well, this is not -- I mean, so he, as the president of the republic, decided -- and put a big priority to -- the struggle against HIV/AIDS.

And this is not that one day, he woke up and liked it. I mean, this was a struggle of women's organizations, private sector -- I mean, it was like -- because I've been asking myself: How do we produce shift on those official-making people? And it has to be, though, the task of a lot of people who come together, or to struggle for many years, and then, in this case, the president of the republic -- they said that this is something we have to do.

So he increased tremendously the budget for prevention, for treatment -- and really, it dropped dramatically, the trend of HIV/AIDS. So that's a great example.

BERKLEY: Paul, you want to give a quick example?

DE LAY: South Africa. The -- it's gone from possibly being one of the worst responders to one of the best. They're putting, now, ($)1.5 billion U.S. of their own money annually into the response. They have close to 1.2 million people on treatment. That's almost three times how many people are being treated on this country.

They're investing in mother-to-child transmission. They're producing their own AIDS drugs. So they're transferring technology from India and from China. So they're taking all the right actions. And it is a -- I think, an incredible reversal from what we saw under President Mbeki.

BERKLEY: Do you want to --

ORR: I would love to. Thank you, first, for the question. I love it -- it takes a UNICEF person to bring us back to where it matters, on the ground.

I'd like to give -- those I think are great historical kind of cases. I want to give you a hot-off-the-press what it looks like. We were just in Nigeria 10 days ago. This is one of the countries that's had one of the biggest problems on a whole range of health issues. And for all the money, the oil wealth, never been able to translate it into health outcomes anywhere commensurate with that wealth.

The president, at the time temporary president, Jonathan, came to New York last September and at our Every Woman, Every Child event said he wanted to dedicate a fixed percentage of his oil revenue to addressing women's and children's health issues. Everyone said, yeah right, I'm sure that's going to happen.

The day before we arrived in Abuja, less than two weeks ago, the assembly passed a health bill that earmarks 2 percent of the general revenue fund of Nigeria, which is basically all the oil money, for primary health care. The revolution that that could make -- now I say "could" because that's a lot of money, but it has to get from here to there.

But then we met with all the governors, the governors who control a huge amount of that budget and how it's spent and where it's spent -- and these governors were competing with each other for who was going to get more bang for their buck. And the transparency levels are going up. Civil society is very much enmeshed at every level with this.

We met not just with the president, but his entire cabinet -- entire cabinet -- across all the different agencies, all the different ministries. And civil society stoking this from below. And then had dinner with the business community which was piling into this now much more organized space. This is what you need -- you need all these stakeholders.

It won't come from one piece or the other. But success can build on itself. And I think a country like Nigeria, which I don't think anyone would accuse of having been an example over the last decade in this area -- watch this space, because I think we have a success in the making if we can translate these major commitments from all sectors of Nigerian society and the international community, if we can get the huge burdens in Nigeria with this kind of resource flow and this kind of organization.

And here the U.N. is a major part of the story. UNICEF, WHO, UNAIDS, the World Bank, UNFPA, U.N. Women -- working together virtually seamlessly on the ground. And for those who know what it looks like on the ground, to say virtually seamlessly, that's a heck of a lot of progress. So the U.N. can provide an organizing pole to work in a coherent manner with the government on these. So it's really an exciting story in the making here.

BACHELET: I just want to make one comment, that I hope that Nigeria is taking into consideration the population trend that is really going very high. And that's already linked to the need to have real, clear family planning strategies because Nigeria has two problems. Its population is increasing dramatically and then on the other hand it's considered a middle-income country. So usually -- never meets the requirements to get federal aid.

And if you look at average, probably has less poor as an average, but probably if you look at absolute numbers it has much more poor people than in many other places. And that's one of the problems we're feeling today in the world, that middle-income countries have more poor than less developed countries in terms of huge calculations.

So just to mention that I hope that in that strategy they do consider that. Otherwise it will be very difficult to tackle it.

BERKLEY: I was just going to say that, you know, it's interesting none of the people here mentioned Uganda, which was always seen as the kind of miracle case. And what's very interesting is Uganda, of course, President Museveni took on HIV because he sent some of his military leaders to Cuba who tested them, and that's when he realized how severe the epidemic was.

What's interesting is the infection rates dropped very quickly there, partially because of the early spread and the openness. But now they're seeing recidivism in young people, because people aren't seeing the deaths around them. And they're also realizing the limits to being able to get treatment to everybody who needs it. They're beginning to see resistance. So you know, there's the positive side of what's happening, but also the limitations are being felt.

Laurie?

QUESTIONER: Thank you. And thank you all for being here today. Laurie Garrett from the Council on Foreign Relations. The major impact of the world financial crisis on global health funding appears not to have been an actual marked decline in the size of the overall amount of money available, but a skewing of it in terms of what the key donor is. So at this point at least for the -- by the end of 2010, well over 50 percent of all public sector giving came from a single source: Washington D.C. And well over 60 percent of all private giving came from one source: Seattle, Washington.

So the two Washingtons are calling the shots. You're the bureaucracy that's implementing, thanks to the largesse of the two Washingtons. Now we have a very different Congress in the United States, we're hitting a real budget crunch, the FY '12 budget promises to be a bloody war -- (chuckles) -- in Washington.

How can we make this next step, one way or the other but hopefully in a positive direction, if one of the two Washingtons radically decreases its contribution?

DE LAY: Great formulation. And thank you, Laurie, for I think being the inspiration for this session today.

The two Washingtons, I've not thought of it that way, but are on everyone's mind because I think everyone knows the two Washingtons in the best case scenario can't do this alone. And the chances for the two Washingtons to not be able to deliver what they're even delivering today is very real.

I think this multistakeholder model that has been developed in the HIV/AIDS community in the fight against AIDS, but also now we're using very aggressively in the broader women's and children's health -- people bidding each other up; watching the corporate community kind of bid each other up, in a positive sense. Competitors looking at each other and saying, you know, actually if we do this together, we could totally cover the need for a given drug. And if we do this together, neither one of us is going to lose anything. So let's do it.

The use of the bully pulpit, not just from traditional donor capitals but from actually countries that came to the table in last September, like Nigeria, that -- when you put that new 2 percent that goes on top of the Nigerian oil revenue, that is more than any kind of funding round we would get from all of the traditional donors trying to inch up a little bit.

But what was maybe most interesting, I think, for many people -- realizing that a lot of the civil society organizations, both the global ones coming in with figures, their own fundraised money in the hundreds and $200 little old ladies sending their checks in was adding up to billions.

This is very exciting because it mobilizes a lot more people than the traditional model does. So you actually not only get the money. You get the involvement and the political support of people that have sent their $100 check in to CARE or in to, you know, Save the Children or World Vision, but then they're also much better political consumers for their own government.

So I think here, if we pull these stakeholders together, they keep each other honest, but they also bid each other up. And so right now, the potential for an upward spiral in this area to resist the pressure of the natural downward spiral on national budgets -- I think this is the race we're in right now.

BERKLEY: Paul. Quickly.

DE LAY: I don't -- I think whether you're Republican or a Democrat or anything in between, I think what the U.S. wants to see are three things. They want to see domestic expenditures going up in countries to really justify the international contribution. They want to see other donors, other bilateral donors, take more of their share of the responsibility. And the EU, in spite of the economic crisis, is attempting to do that. And that really is a role that the U.N. does play as far as trying to leverage the immense size of the U.S. contribution.

And then the third thing is they want to make sure that their money is well spent. And it gets back to -- I know it sounds boring -- the accountability issue. But if the accountability issue is women saved in childbirth, infants saved from being infected; men and women, parents' lives being prolonged, and you can show that, then the U.S., I'm convinced, will remain a substantial donor.

BERKLEY: So let me just say, it's interesting that the private sector is taking a very different view of the world now. It's not ROW. They realize that the growth in the future is going to be in many of these countries. And so there's a new look at that. And hopefully with that is going to be a changed relationship with how one deals with price tiering and new activities. Recently -- you know, today, there were announcements from a number of companies on vaccine pricing, you know, dramatic drops in vaccine pricing. So we hope to see more of that as well, which will help the sustainability of these efforts.

Please, the gentleman over here. Please wait for the microphone.

QUESTIONER: I'm Allen Hyman from Columbia-Presbyterian. Circumcision was mentioned as one of the few interventions that could prevent the spread of AIDS. And I find it ironic -- perhaps you do as well -- that -- you mentioned 30 years ago, it was in San Francisco that the first cluster was described. And this fall, the prohibition against circumcision is going to be on the ballot. Does the AIDS community have a position on circumcision, and what is it?

MR. : I'm for it, but -- (laughter) --

DE LAY: From the evidence base, it's one of the few prevention/interventions that we know has measurable, significant protective effect. It's a 60 percent protective effect. It's better than a lot of the other things we have.

So I think the AIDS community -- I don't want to speak for every single one -- supports it as -- particularly in hyper-endemic countries. It's going to be critical to reach that tipping point, where we can't get delayed sexual debut or condom use or reduction of multiple concurrent partnerships to achieve high enough levels.

BACHELET: Just for the record, I'm against female genital mutilation. So for men, I'm for it, but not for women. (Laughter.)

BERKLEY: Agreed.

Please.

QUESTIONER: Thanks, everybody. I'm Ann Starrs from Family Care International. And I wanted to pick up on the -- a couple of the comments that have been made. I think we are -- we'll be seeing later this week the launch of the global plan for the elimination of new HIV infections among children by 2015 and keeping their mothers alive, which I think will be a great thing and is an important initiative for bringing together the HIV and the MCH and the reproductive health communities.

But I think -- the question I'd like to ask is, how do you see the future of this effort politically and strategically in terms of strengthening these linkages, particularly, you know, at these high levels but also very much at the ground where services are provided or made available and the importance of meeting women's and children's needs comprehensively, that sort of one-stop-shop approach? How do you do that while still taking into account the fact that there are marginalized populations -- men who have sex with men, commercial sex workers who are women but are not sort of -- you know, picking up on your comment, Bob, just sort of the human face -- this is -- these are a human face of HIV/AIDS as well, but it's not a human face that people want to see plastered on posters very often.

So how -- while we're moving forward with this integration agenda, how do we make sure that those marginalized populations also continue to get the care and the services that they need?

ORR: I'd love to take a whack at that. Thank you, Ann. I think the -- we -- there is attention there of we have to do both. You have to go after the populations that are the hard to reach and the underloved populations, call them, the ones that aren't going to make the posters, because that's where you could make a huge difference.

At the same time, I think the success that we're seeing on the Women's and Children's Health Strategy is in part because that integrated roll-out of services -- everybody can see what they want to see. Those who really want to save babies can save babies, and they can see it and touch it. Those who think that, you know, women have been underserved for far too long and we're finally getting a women-centric roll-out of health services, they can have that.

So I think the global strategy, the reason we're getting the kind of support we are is because we did not force that false choice. We heard all the debate between the health system strengtheners and the high-value interventioners and said wait a minute, folks, we're not arguing against each other, are we?

So we meshed it together knowing that that defers the real challenge to the ground, to where it has to happen. But it's in that context that we're actually seeing both happening. You can build up the systems, the 34,000 trained, skilled health workers in Ethiopia that we saw that they want to quadruple over the next, I think, year or two years. That kind of scale is going to get a whole range of services out to mostly women and children. And that will have a great effect and a great face but that does not in any way mean that we can afford to neglect the populations that won't make a poster.

QUESTIONER: Thanks. I'm Asia Russell. I work with Health GAP, and I want to pick up on a point that Bob Orr was making about stigma, and a point that Seth was making actually about Uganda, because 10 years ago, a key issue brought to the heart of the UNGASS declaration was the link between providing access to quality treatments and creating a flood of people who wanted to get tested, to know their status and to stop taking risks or to get themselves out of risky situations -- a really intimate link between being motivated to seek prevention, to find out one's status and then to extend one's life.

And at the heart of that is actually stigma, because treatment access has a tremendous effect in reducing stigma at the level of a community. And I think a terrifying moment happened in Uganda last year when treatment interruptions were a reality in some of the most well-served, well-penetrated communities in Kampala and a kind of a precipice that implementers and people with HIV were looking out over in the entire country. And this is a country where 46 percent of new infections are between serial discordant cohabiting couples and where incidence is rising tremendously; 2007 -- (word inaudible) -- data show 120,000 new infections every year.

So what are we -- what are we doing? And I think the reality is, 10 years after the UNGASS declaration, the value proposition about treatment has changed. And I think it's really important for the U.S. and the U.N. family to fully embrace this reality. UNAIDS just released data in the -- (inaudible) -- that's showing that if you scale up universal access, you avert 7 million new -- 7 million deaths and 12 million new infections.

And now we have data showing us that if people have access to treatment and safe sex, they're 96 percent less likely to transmit -- including those 46 percent of new infections in Uganda that are between serial discordant couples. And those data are lost in translation, whether we're in D.C., in the other Washington or, you know, across the street at the U.N.

And I think I want to hear from our panelists what you all plan to do between now and the FY '12 budget -- which Laurie (sp) is reminding us is going to be -- is going to be a scary one -- and not just over the week as we negotiate every single word. We're in an environment right now which we should be extremely enthusiastic to find ourselves in. But unfortunately, it seems like we're prepared to divorce ourselves from what the data are showing us. So please share a little bit about how the administration will be making the case on the Hill to fight for those -- not just maintenance, but the increases that are needed to reach 15 million people by 2015, and then what will the U.N. be doing to make the investment case? Thanks.

BERKLEY: Anybody want to take a crack at that?

MR. : (Inaudible) -- I'll be -- I'll be brief. You know, you've made some excellent points. And I think that certainly the tipping point to truly reach zero new infections, the vision that UNAIDS with partners has put before the world, will only happen if we go beyond what we've been doing now as far as with prevention, interventions. Risk behaviors can only be reduced to a level that's, while significant, is not going to be absolute. And I think the data shows that treatment does have a profound impact on transmission. We also have to go beyond that; the use of antiretroviral drugs in specific populations who are uninfected to protect themselves also needs to be entertained in some situations. The data's solid. And whether data is what sways political thinking and ministers of finance, always, I think, is open to debate. But I don't think we've ever had really for any disease, particularly a sexually transmitted disease, this strong of proof that use of antiretrovirals, particularly in infected people, has an incredible prevention benefit that goes beyond saving that person's life.

BERKLEY: Can I -- can I just challenge you a little bit on some of the data? Because we know that, you know, the PrEP studies in women did not show an effect. And the particular finding that we were talking about, the 96 percent, was between stable, discordant couples. But the population attributable fraction of transmissions of that is quite low. Most of the transmission occurs very early in infection when people have high viral titers, and therefore one would have to have a different strategy. So how does that all play out in terms of what we're doing?

MR. : Well, I think what that points to is certainly we need more information, but it means we have to be very careful about targeting the use of treatment as prevention, to make sure that we do get the benefits and that we don't do any harm. And we still need the studies that show that earlier and earlier treatment, while it sure looks like it saves peoples' live, doesn't cause any long-term adverse effects. So I think we just need more data. And ultimately we're going to have to target these programs. They aren't going to be massive general population type of intervention, particular for PrEP.

BERKLEY: So we're out of time. I was hoping to do a lightning round to ask questions on, you know, whether you believe that we have the tools in hand. Certainly, as many know in this audience, I believe we need better technologies for prevention. And that's something that we have to do particularly for women as a priority going forward.

But I want to thank all of the presenters. (Applause.) And I know that they'll be happy to answer questions in the reception outside.

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