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Combating HIV/AIDS Globally: A Five-Year Plan

Speakers: John Lange, deputy coordinator, Office of the Global HIV/AIDS Coordinator, U.S. Department of State, and Richard C. Holbrooke, president & CEO, Global Business Coalition on HIV/AIDS; former U.S. ambassador and permanent representative to the United Nations
Moderator: Princeton N. Lyman, senior fellow, Council on Foreign Relations
March 31, 2004
Council on Foreign Relations

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Council on Foreign Relations
Washington, D.C.
Wednesday, March 31, 2004

PRINCETON LYMAN: Thank you, Nancy. Nancy Roman is the new head of our Washington office here. And we are absolutely delighted, Nancy, that you're here. Thank you all for being here this morning for a really very important session here at the Council on Foreign Relations. There's no real easy way to describe the seriousness of the HIV/AIDS pandemic. It has already taken the lives of more than 20 million people, and it cuts down people in their most productive time of life. It destroys families. It creates enormous social and political tensions and raises extraordinarily challenging issues for the international community not only in terms of health, but in terms of policy, in terms of finance, in terms of shared responsibility in addressing this issue. And so it is an issue that cuts across almost every area of concern in international relations, as well as in public health.

This morning we are on-the-record in this meeting. We are normally off the record at the Council, but this is an on-the-record meeting. We're going to begin with a conversation among us up here for about 20, 25 minutes, and then open it up. And I will introduce our speakers in a moment. I do ask that you turn off your cell phones so we get them out of the way. And please don't leave early, unless it's an emergency, until we finish. The meeting will end promptly at 9:15. The Council's very good at being prompt on ending meetings.

Nancy did mention the report that will come out, a Council special report, and that is a joint report with the Milbank Memorial Fund. Dan Fox is here, president of that fund. And you all got a small sheet on that. And everyone who is signed up for this meeting, we will make sure you get notice of the report when it comes out. Let me introduce our two guests today. As you may have heard, Ambassador Randy Tobias, the president's coordinator on HIV/AIDS, is suffering from laryngitis. His doctor said "Don't speak for a while." But we're very fortunate because we have his deputy, Ambassador John Lange. Ambassador Lange was ambassador in Botswana, also the special representative to the entire Southern Africa Development Community. And as many of you know, Botswana, one of the really fine countries in the world, democratic and well-managed, but suffering from an extraordinary high prevalence rate of HIV/AIDS, and the center of one of the most dramatic international efforts to try and bring this under control. John has a great deal of direct experience there. He served in Tanzania; he was the chargé [d'affairs] there during that terrible bombing of our embassy. I've known John for a long time. We worked together on refugee affairs. John is a wonderful humanitarian as well as an outstanding diplomat. John, it's great to have you here.

Dick Holbrooke -- well, I think it's hard to -- anybody here who doesn't know Dick Holbrooke, a man of extraordinary contributions and talents, fashioning the Dayton peace process [to end the conflict in] the Balkans, a man who was assistant secretary for Asian affairs, a person who at the Security Council was one of the great American ambassadors to the United Nations. But I would just cite two things, Dick, about your being here today that I think are particularly relevant to our discussion. One is that while ambassador to the United Nations, Dick brought the issue of HIV/AIDS to the United Nations Security Council. It was the first time the Security Council had addressed a health issue, and they addressed it as a security problem. And that has made an enormous difference worldwide in the way people see this particular problem. And since then, Dick, as you know, the Security Council now every year reviews the HIV/AIDS situation. The second thing is that after Dick left government service, he became the CEO of a group called the Global Business Coalition on HIV/AIDS. I think when you started, Dick, it had about 20 companies, now has about --

RICHARD HOLBROOKE: Fifteen.

LYMAN: Fifteen. Now it has, I think, about 300 [companies].

HOLBROOKE: Hundred and forty, but you're close.

LYMAN: Huh? [Laughter.] Well, I was close. I was close.

HOLBROOKE: Three hundred next year. [Laughter.]

LYMAN: Three hundred next year. But it's grown extraordinarily. And it is -- and it's brought together businesses from around the world to look at how they can make contributions in the workplace, with their workers, with their families, but also in collaboration with governments in the countries in which they're operating. It has become another major force in the struggle against HIV/AIDS. So, Dick, it's a great pleasure to have you with us today.

We're going to have a conversation here this morning, not set speeches. And I'm going to start off, John, by asking you if the president's program, the President's Emergency Program for AIDS Relief, called PEPFAR, has gotten off to a very dramatic start, and not without a bit of controversy, as one might expect. But I think everybody is extremely impressed with the commitment of the United States to set forth a five-year program, a $15 billion effort. I think it's energized efforts around the world. The administration put forward a 103-page report to Congress on its strategy. I wondered, John, if you could bring us up to date in a few minutes on how you see the situation now with the president's initiative.

JOHN LANGE: Thank you very much, Princeton. And again, apologies on behalf of Ambassador Tobias, the U.S. global AIDS coordinator. He was not able to be with us today because of his laryngitis. He's at home, not speaking but sending e-mails. And he did ask me to express his regrets that he couldn't be with you here today.

In the State of the Union Address in January of last year, President Bush announced his Emergency Plan for AIDS Relief. In May of last year, the Congress passed the authorizing legislation. In July the president announced his intent to nominate Randall Tobias for the position of U.S. global AIDS coordinator. And Ambassador Tobias was confirmed on the 3rd of October [2003] and sworn in on the 6th of October. Two days later, he and I left for southern Africa. And four days after he was sworn in, he was in the office of President [Festus] Mogae of Botswana, which has close to the highest infection rate in the world, talking about HIV/AIDS, talking about testing and various measures that are being taken by that country to deal with this pandemic. And since then he's had the experience and traveled in several of the African countries, both in southern Africa and in east Africa. But this is a global pandemic and the focus countries in this plan, as you may know, are 14 in number -- 12 of them in sub-Saharan Africa, two in the Caribbean, and a 15th country has not yet been named. That will be named soon, and it will be somewhere other than the Caribbean and Africa, at the request of Congress.

Congress appropriated the legislation -- the budget for this office -- on the 22nd of January. And where we stand now is that we're rapidly getting money to the service providers -- in fact, about $350 million worth committed to those service providers in the first month, within one month after the appropriation was passed. I've been in the Foreign Service of the State Department for 23 years, and barring an earthquake or a refugee outflow, which you used to deal with, this is just about record time. It's really a very high-speed effort because this is an emergency. And our plan is to basically provide about $100 million a month over the eight and a half months of the fiscal year that we'll have from the time that the appropriation was passed to the service providers to deal with prevention, care, and treatment. This money goes to the Global Fund to Fight AIDS, TB [tuberculosis], and Malaria. It goes to continuing programs that are part of what the U.S. government has been doing for several years in about 100 countries -- and money also particularly for the focus countries. The total this year in our budget is $2.4 billion; the president has requested $2.8 billion for fiscal year 2005. The plan all along, from the time this was announced, was to ramp up expenditures as we were able to build up infrastructure so that the total over five years will be $15 billion.

LYMAN: John, one of the themes in the president's program is that it's an emergency program. And I understand very well that the sense of emergency -- because there are people out there who will die if treatment isn't made available, and there are people who need care, et cetera. But one of the things in our report that we discussed at great length was, as we look ahead several years -- five years of this emergency program but beyond -- can you really build that kind of a system without a broader development of a public health system in the developing countries that can sustain it? Or let me put it in different terms. Even if we succeed as part of an emergency effort -- international effort -- to create a very effective way to reach the 30 -- let's say 30 percent of people who are suffering from this disease, is that sustainable politically or financially in countries where the other 70 percent are suffering from other general health problems? Don't we need to think about how we, over time, start to build this broader public health system in the country?

LANGE: Certainly we recognize that this program has to match in with other efforts that are going to build health infrastructure and health systems. We also recognize that there are crying needs for human resources, and that's a continuing theme of many discussions, in terms of the limitations, especially at the middle levels of trained personnel. And so we're working in various ways on that. There are twinning proposals between, for example, U.S. hospitals and hospitals in the focus countries. We want to use volunteer efforts from the U.S. to be able to help out in terms of some of these training needs, and this will all be complimentary to existing health programs. But when you look at the broad scheme of things, HIV/AIDS is extremely complex, and actually the impact isn't just on the health sector or the need for health infrastructure. It has broader ramifications, and you have to deal with food issues and water and sanitation and the social and legal structures, and it really has this huge impact. We have a niche in a sense, but we -- in a way that we want to work very complimentary to all the other efforts that are being undertaken.

LYMAN: Yeah, we need to come back to how that relates. But, Dick, let me ask you, you've been around the world many, many times. You've dealt on this with the private sector, the public sector. Where are we internationally in awareness and commitment to this problem? How do you see it from your perspective?

HOLBROOKE: Awareness is very high. Commitment is very low. But I wonder if I could make a generic comment about this discussion --

LYMAN: Sure, absolutely.

HOLBROOKE: --and about Randy Tobias before we get into the details. And I say this because, as some of you may have heard, there's a presidential election in this country later this year. [Laughter.] And so I want to put this in a political context, because John and I -- I have great respect for John. I visited him in Gaborone when he was ambassador [to Botswana]. And we -- inevitably as we discuss things, there are going to be certain disagreements. I need to put this in perspective. Of all the -- this is not, in my mind, any more a political issue, and I cannot stress that too highly. I see Henry Owen in the front row here, one of my colleagues in the Carter administration, who's working very closely with the Bush White House. Ten days ago I co-chaired an event with two members of the president's Cabinet, [Secretary of Commerce] Don Evans and [Secretary of Health and Human Services] Tommy Thompson, plus Randy Tobias. I think what President Bush did in his State of the Union last year was of historic importance. And like the funding issue at the United Nations which you mentioned earlier, in which [Senator] Jesse Helms [R-N.C.] and I became truly the odd couple -- [laughter]--and worked together to pay the arrears [U.S. dues owed the U.N.]. And we took the U.N. out of partisan politics, at least for the 2000 campaign -- unfortunately it's been reintroduced -- this issue can only be addressed if it is removed from presidential and domestic politics.

So we're going to disagree. John and I may disagree on generics later on in this discussion. We may disagree on the amount of money that's gone to the Global Fund. And we may disagree on what the 15th country that John just alluded to should be. I think it should be India. The State Department is taking a long and inexplicably tedious time making the only possible decision. [Laughter.] But these are technical disagreements. And I'm sorry Randy isn't here, but having talked to him a few days ago when he could barely talk -- he's all set to cancel congressional testimony -- this afternoon he sent me a long e- mail. I know that he wanted to be here, and I think he's a terrific choice, and I'm delighted to work with him.

I can't underscore enough the political importance of having removed this issue from the political and cultural wars that plagued it from 1984 on, and which were most exemplified in movies. And that is what the president did. And when you have allies like Jesse Helms and Reverend Franklin Graham [president of the Billy Graham Evangelical Association], I can live with a little bit of cognitive dissonance on such issues as whether condoms or abstinence are a better way to fight AIDS, when the self-evident answer is you need them both. So let the purists fight. And I want to stress that, because any disagreements we have going forward are, on this issue, nonpolitical. And I know that [Democratic presidential candidate] Senator [John] Kerry [D-Mass.], who is one of the original sponsors of this and who spoke along with Secretary [of State Colin] Powell and Senator [Bill] Frist [R-Tenn.] at our fundraiser last year in Washington, which many of you were at, shares that view. And I'm also glad that Congressman Jim Kolbe [R-Ariz.] is here, because the appropriations process will go through him. And I'm very concerned about some of the events that appear to have happened the last few days on [Capitol] Hill, and I hope that Congressman Kolbe will be able to illuminate us on whether it's a pickup or a serious setback, what happened recently. So that would be my opening statement. Now back to your question, Princeton.

My narrow focus is the business community, which is conservatively doing -- well, no, generously doing 5 percent of what it should do. It's true we've built, in two years, from 15 companies to 140, with headquarters in 19 countries, with millions of employees, but that's a fraction of what happens. We've opened an office in Paris. We're going to open an office in Johannesburg. And we may be the only NGO [non-governmental organization] you've ever met that's not going to ask anyone in this room for any money, because we've got a business model in which the companies pay for themselves. We don't think foundations or handouts are necessary. Business should do this in its own interests.

But President Bush's leadership was indispensable in triggering the leadership of other countries, and it underscores the need for American leadership in every sense of the word. But denial -- as the old song goes -- denial isn't just the name of a river in Egypt. And the Indians, in particular, are in fantastic denial. And I cannot stress highly enough to the people in this room that if India does not change its attitudes now, when the infection rate is hovering around 1 percent, and past 1 percent in three of its states already, India, which already has the second-largest number of AIDS victims in the world after your old stamping grounds in South Africa, will -- you can do the math -- become the leading carrier of AIDS. Because if India goes to only 4 percent, compared to 31 percent in Botswana last time I looked, and even higher in Swaziland and slightly lower in South Africa, 4 percent of India is more AIDS victims than Africa now has, which is, of course, why I think that we have to show our concern for India -- notwithstanding the fact that our aid will be only a drop in the bucket -- because we have to wake the Indians up.

When I was in Delhi a few months ago, I went to see the president of India, their famous nuclear scientist, Dr. [A.P.J.] Abdul Kalam. He was sitting in his desk with all these papers about a vaccine. And he told my wife [Kati Marton, chair of the International Women's Health Coalition] and me that, "Oh, they'll find a vaccine." And I was stupefied. I said, "Yes, maybe, but it's seven to 10 years away." And he just brushed it away. And the Indians don't want to talk about this, they really don't. They don't want anyone to think that what happened in Africa might happen to Indians. If you discern a subliminal race consciousness there, you might not be wrong. And when we had the AIDS session at the Security Council that you mentioned earlier, the Indian ambassador, a very fine man, came to me on instructions and said, "Please don't mention India, this is about Africa." Now, those are small vignettes on the road to disaster. We did a war game in India, with [consulting firm] Booz Allen Hamilton doing a brilliant job, and tried to wake some of the Indian health officials up to the fact that they could still lower the rate of increase.

But throughout the world, we're facing these problems. We don't -- we have 140 members, but we don't have one Japanese company yet. It's unbelievable. Not one Japanese company has joined. Trevor Neilson, who's here with us today, our executive director, has just been in Tokyo. And he was not supposed to come back without a Japanese member. But here he is. [Laughter.] Get back on the plane, Trevor. So we have an unbelievable amount of work to do. And it is American leadership that will trigger the rest of the world.

LYMAN: Thank you, Dick. Well, let's jump into a little bit of the controversy, if I can. John, you -- and Dick alluded to this. One of the areas that has people concerned is now that there is a commitment to treatment -- and we'll come back to the implications of that -- but now that there is a commitment to trying to reach people with treatment, there is quite a controversy going on over what is the drug regimen that ought to be the standard or approved, or what should be the means. And the argument between the fixed-dose combinations, which the WHO [World Health Organization] has endorsed -- which maybe many of you know is putting three pills together into one, and it's only taken twice a day, but has to be, so far, generically produced -- versus other drugs. And PEPFAR is right in the middle of this, because the United States has said so far that we have not yet accepted the WHO certification on that particular approach.

And there are two issues here. One is what's this dispute all about, and how much will it impact on the ability to find the safest, lowest-cost drugs, which is in your strategy statement. But second, what people are worried about is that we will have different countries reaching for different drug regimens, going on different paths without perhaps proper monitoring and evaluation. And that the epidemiologists worry about a great deal, because it could produce drug-resistant strains, et cetera. So it would seem to me that rules of the road here are going to be very important. Maybe you can speak to this, John.

LANGE: Thank you. There's a technical meeting going on in Gaborone, Botswana, in fact, as we speak -- it's ending today -- on the subject. And of this concern that you alluded to of epidemiologists who are concerned about building up resistance, if we were to purchase at the large scale that is part of this plan anti-retroviral drugs that did not meet quality, safety, and efficacy standards, we could actually build up resistance and do far more harm than good in the long run, as resistance would build up on the African continent and elsewhere. As you saw from the strategy document that was released on the 23rd of February, there's a commitment to buy the lowest-cost drugs, at the same time ensuring that they are -- have quality, safety, and efficacy. And the whole purpose of this meeting in Botswana, which some people haven't fully understood, is to develop international principles for determining that quality, safety, and efficacy, particularly of the fixed-dose combinations. Normally, one looks to a stringent regulatory authority to determine this -- that's a term of art, "stringent regulatory authority." The World Health Organization is not a regulatory body, per se. They do have their pre-qualification program. But what we're looking to is not to avoid buying generics, but to ensure the quality, safety, and efficacy of them. And that's why this meeting, which is really at the technical level -- and the discussions have been very technical over the last three days -- is going on to determine international principles for this. My understanding is that we are close to coming to an agreement on a draft of this which will be finalized in the coming months.

LYMAN: So can this be resolved fairly quickly? Because people are out there buying drugs.

LANGE: I would expect that it will be resolved quickly.

HOLBROOKE: And how's it going to be resolved?

LANGE: Through the international principles that -- there were 23 countries represented in Botswana, and they need to go back to their capitals and come to an agreement on these established principles. The World Health Organization was part of this, the Department of Health and Human Services was one of the co-conveners of this, as well as the Joint Program on HIV/AIDS.

HOLBROOKE: But I don't understand, John. I mean, I understood -- I'm just reading a letter here that [Representative] Henry Waxman [D-Calif.] sent the president four days ago on this subject, and he said in it that leading drug regulatory authorities in the EU [European Union], the European Agency for the Evaluation of Medicinal Products, are not sending experts to Botswana. And he goes on to really blast the administration on this issue and question their motives. So what I'm not clear on is, since people cannot take six pills twice a day and keep with the regimen -- it's hard enough in the U.S., it would be impossible to administer in Africa, particularly rural Africa -- are we going to end up, after a delay for solving this, with generics? Because everyone except the U.S. seems to think they work already. And if we have a reason not to think they work, that's legitimate. But I'm just not clear from your answer where we're headed here. What is your goal?

LANGE: The goal is to ensure that the drugs that we buy are safe, are of quality, and are effective. And we don't know that now because we haven't seen the data.

HOLBROOKE: And how long will it take to ensure that?

LANGE: We're going in as fast a pace as we can. There was a meeting a few months ago on this subject. This is, in a sense, a definitive meeting going on in Botswana. And then, within a month or so, we expect the draft principles to be agreed upon. And at that point, we will proceed with analyzing the data.

HOLBROOKE: But I don't understand. If the FDA [Food and Drug Administration] is going to do -- is the FDA doing its own testing of generics now?

LANGE: That's undecided at this point. But these are --

HOLBROOKE: So there's been no testing of the single --

LANGE: The FDA is concerned about drugs coming into this country, these are not --

HOLBROOKE: Yeah, I understand that. But we're not -- but we're not agreeing to the generics because we're not sure they work. How are we going to determine whether they work or not? It's a legitimate issue. You don't want to distribute a drug, for instance, that increases the resistance to the disease. But how are you going to determine that? Everyone else is distributing it already, based on whatever. Maybe they tested, maybe you're right, and the WHO doesn't do testing, although Waxman's letter suggests otherwise. How are you going to determine this? This is a big issue, and it could undermine all the good work we're doing in other areas because it's going to become -- the failure now, it will become a symbol of a feeling that the United States is protecting the big pharmas [pharmaceutical companies]. So I'm just trying to get a sense -- we're getting hammered on this at the Global Business Coalition.

LANGE: We expect that this process is going to move quickly, and that we will have the information we need to purchase any, quote unquote, generic medications that meet the necessary standards that I mentioned to you, by the fall of this year.

LYMAN: By the fall. So what happens to the programs that are under way internationally already?

LANGE: Well, our programs are still in the beginning stages. As I said, we didn't receive the appropriation until --

LYMAN: So we won't be buying drugs until the fall?

HOLBROOKE: But the Global Fund -- we aren't blocking the Global Fund from doing it.

LANGE: No, we're not blocking others from --

HOLBROOKE: And is the American portion of the Global Fund being withheld from this program, but other money is allowed to be used? Is that how it works?

LANGE: We're not -- this is for the program under the direct control of the coordinator. It's not for contributions to the Global Fund.

HOLBROOKE: So the Global Fund -- we're not objecting to the fact that the Global Fund is going ahead with this, including using some money which comes from us?

LANGE: That's true.

HOLBROOKE: OK.

LYMAN: I want to open it up in a minute, and I just -- you know, put something on the table and we'll come back to it later. I mentioned that we've crossed a line here, which I think is a very important line, in the last year or so, and that is a commitment, an international commitment, that people who are infected and who reach the point where they need this kind of treatment should have access to that treatment whether they live in the poorest countries of the world or elsewhere. This is an extraordinary commitment. It's one that's not been made for any other chronic disease, and it's an extraordinary one and for good reason. But over time we're talking about 30 to 40 million people who will need this treatment for life, and that is an enormous international commitment. And I don't think we've looked out ahead to who is going to carry this responsibility, because the developing countries themselves will not be able to carry it. And when the strategy talks about graduation plans in our projects, and I'm thinking, wow, this is not going to end in five years. So maybe we'll come back to these long-term implications.

But I'd like to open it up. I'd like to call first on Congressman Kolbe if I might -- it's great to have you here -- and get your thoughts on this and also to Dick's question about the current state of appropriations. Let me just say that we -- normally as we open it up to questions, we ask the person to stand, give their name and affiliation, and then ask the question. This is Congressman Kolbe -- [laughs]--and his affiliation is called the U.S. Congress. [Laughs.]

QUESTIONER: Thank you. And more specifically, as chairman of the Foreign Operations Subcommittee [of the House Appropriations Committee] which, as --

LYMAN: Right.

QUESTIONER: --Dick suggested, has a little bit of interest in this issue here today and how the funding takes place. First of all, thank you very much for this excellent panel here and this discussion. I think it has been enlightening conversation even thus far, and we're only just getting started. Let me just make a couple of comments about the budget issues which Dick raised. And I assume when he was talking about the disturbing events of the last couple of days, he was talking about the budget resolution. I want to urge you all not to get too exercised about budget resolutions. They're very broad and they really provide little guidance to appropriations committees. Now the Budget Committee would not be happy to hear that coming from an appropriator, but the fact of the matter is -- [laughter]--the fact of the matter is the really decisive and the only really critical figure that the Budget Committee has is that top figure, that 302a [total amount allocated for government programs]. That is the big number, and we cannot, in all of our appropriation bills, exceed that number. But what they set forth as functional numbers underneath that have no bearing whatever on the allocations that are given to the particular subcommittees. So I think that you have to continue to just observe this and watch this. There's no doubt that the debate that took place in the House [of Representatives], and I think the debate that's taking place -- has taken place in the Senate, as well, and will take place when we get to a conference on the budget resolution -- reflects a legitimate and a real concern that a lot of Americans have, and a lot of members of Congress have, over the growing size of the deficit and what we are going to do to try to hold the line and control that. I happen to think that the 17 percent of all federal spending that comes from discretionary, non-defense, non-homeland security is not the place where you're going to solve all the budget problems, which some people think that perhaps you can. I mean, I believe we have to look at entitlements. But that's a subject for another day -- [laughter]--another debate that we won't get into today.

Having said that, I do think that there is a strong commitment, and I want to reiterate this, a very strong commitment on the part -- bipartisan commitment, as Dick suggested earlier -- a bipartisan commitment on the part of Congress to follow through with the president's initiative and to make sure that it is funded, that it is fully funded. There will be disagreements, I think, and I don't know how they will end up being resolved -- about how the proportionality between those funds, as to whether, where we go to -- what part of it goes to the Global Fund, what part of it goes to the president's funds initiative, even though the AIDS coordinator will have some say in that, ultimately, as to how they get allocated. Congress also is going to have some say. But I think that the message that I wanted to leave with you today here is that I think there is, A, strong commitment on the part of Congress to make sure that this is followed through, and I certainly have made that commitment; but, B, I think there is a need that we all have to look very carefully at the funding levels and to make sure that the money is getting spent wisely. I think one of the dangers that we have in this is that we pour money in, and in a few years people begin to -- there are scandals, people begin to see -- become frustrated, they lose hope, they lose interest. And suddenly our commitment to the initiative is lost.

So I think we have assembled under Dick Holbrooke there a very powerful coalition of the business community -- of private sector and business community. I think it can be an enormous -- make an enormous contribution to this whole debate and to making sure that we are meeting the requirements of fighting this epidemic. But I -- and so I urge us to get more involved -- the private sector continue to get them more involved. You've done a great job so far. We just need to renew that effort. There are going to be limits on what governments are going to be able to do, and it is going to require a complete commitment on the part of the private sector as well as government to do this. But I can assure you that Congress, I believe, is committed to -- is following through on the initiative.

HOLBROOKE: Can I just add on your last point, Jim, that the role of the private sector -- the Global Fund is about to approve its first grants to the private sector. This will be a huge breakthrough. And Trevor Neilson and I have been working very closely with [Global Fund Executive Director] Richard Feachem on this. There are companies -- DaimlerChrysler, Coca-Cola -- which others, Trevor? Is Unilever one of them? Anglo- American, Lafarge, Tata in India. These are all companies that have applied either in west Africa, South Africa, or India for Global Fund money. The reason this is important is that if we can -- if we get -- if you think about it, the way to get to people is through their employees -- through their employers. It's much easier than political organizations, which are all messed up because of politics -- South Africa and India being two classic examples -- or religious groups, which are conflicted by all sorts of dogma and theory and theology. People respond to their employers. And so if these programs that -- follow on your point -- get the Global Fund money, we're going to try to publicize them to get more companies involved.

QUESTIONER: Let me just add, if I might, one or two other thoughts. One, I just came back from Africa a couple weeks ago and the -- I was extraordinarily impressed with what we saw there, in terms of the U.S. commitment and moving it as rapidly as -- this is just a month after the bill -- the appropriations bill had been signed -- and how much money was actually moving already. I mean, it really, as Ambassador Lange has said, is really quite extraordinary, quite unusual for government programs to move as quickly as this has done now. Granted, they are filling the pipeline of programs that are already in place, and now we have to look at where we go from here, what are the new things that we're going to be doing. But nonetheless, I think it is important that we were able to do that.

The second point that I would make is that we do have some concern -- we have expressed this to the administration -- we have concern about the non-focus countries. At the moment, you look at it, I think there's -- if there's reason to be concerned, it's that right now we have kind of frozen everybody that's not one of these 14 or the great 15th country, whatever that's going to be here -- we've frozen the non-focus countries. And I think there's some concern. This is not something that respects political boundaries. This is an epidemic that moves, and that moves -- can move with astonishing rapidity. We have to be aware of that, and so we can't just say these are the 14 focus countries, and we're not going to be paying attention to what is happening in the rest of the world. And so, that is one of the concerns that we have about the non-focus countries, and we've expressed this to the administration in the appropriations process. And I know this is going to come up again as we get into the markup of our bill. Thank you.

LYMAN: Thank you, Congressman. Again, I want to second what Dick said about the extraordinary leadership in the Congress -- and bipartisan leadership in Congress -- on this. And Representative Kolbe is just one great example on this. Start here with Ms. Levine.

QUESTIONER: Thank you. I'm Susan Levine. I think my relevant affiliation today is that I'm on the board of the International Center for Research on Women, which has been focusing on the role of gender in the whole crisis. And Dick, you wrote a very compelling piece in The New York Times a month or so ago about the importance of testing. And I wanted to ask if you could, you know, talk a little bit about what you think the sequencing of such testing should be, because there's lots of evidence that while people may get tested, for example, there was a clinic in India where the women all were told when they went to the clinic, they should get tested. They all got tested. It took an hour for the test results to come out. They all left, because they didn't want to know the results of the tests. So I'm wondering what you're thinking about in terms of when does testing -- when it should be implemented and what other things need to be in place.

HOLBROOKE: It is my conviction now, based on having worked on this problem for five years, that testing is the weak link in the chain to defeat HIV/AIDS. And it is a weak link for -- because, not to put too fine a point on it, the United States, in an extreme example of ethnocentrism -- exported to the rest of the world a battle that was waged in the streets of San Francisco in the mid-1980s. It was the "Angels in America" [a play about HIV/AIDS victims] period. And the Reagan administration -- and not just the Reagan administration, but President Reagan himself and members of his administration and people in public life at that time said very publicly -- and you all remember this -- that the disease was God's punishment for people of a certain sexual orientation. And the result was that the gay community in San Francisco and New York went into the streets and went ballistic. And they won the war. And one of the things they -- because they were right. I mean, the issue -- it wasn't a gay disease. It was obviously a disease that can attack anyone. As a result of that bizarre cultural event in American life, testing was going to henceforth always be confidential and, in most cases, voluntary, with certain important exceptions. If you work for the U.S. government, you have to have an AIDS test. If you're in the military and you're shipped overseas, you have to have an AIDS test. Insurance companies may require it. But it is voluntary. Fine. That worked in the U.S.

But when we exported it to Africa, and the WHO and the U.N. and UNAIDS adopted our standard and enshrined something called voluntary counseling and testing, VCT, they made a historic mistake without realizing what they were doing. The word "voluntary" -- people don't volunteer for things, in most cases. They certainly don't volunteer a lot for a test to find out whether you have a disease. And if you have that disease, you're going to be doubly victimized. Before you die, you'll be ostracized. You'll lose your job, you'll be thrown out of your family, and so on and so forth. And as we all know, the available treatment wasn't there. So a terrible vicious cycle occurred, where -- and this is why we're spending so much money on anti-retrovirals rather than a fraction of the money on testing.

Now, you've all heard thousands of statistics about AIDS. The single most important statistic is that 95 percent of the people in the world who are HIV positive don't know it. Ninety-five percent. And then it incubates for seven to 10 years without any visible signs, although you can find out now with the new tests, which don't take an hour, as Susan's story tells you, but take a few minutes. I'm sure you -- I hope most of you saw in The New York Times and The Washington Post the other day that the OraSure saliva test, the swab test, has now been FDA approved. And that takes just a few minutes and can be self-administered.

But testing has been voluntary, which means it's almost never done. On the trip that I made with Tommy Thompson and Randy Tobias in December [2003] to -- to Zambia, Rwanda, Kenya, and Uganda, even in Uganda, the gold standard on this issue -- we'd go to the clinics, we'd be briefed on voluntary counseling and testing, but then if you went back after the briefing was over and you said privately to the nurses and the doctors, "Have you been tested?" No one had been tested. The people administering the testing hadn't tested themselves. And, in fact, they weren't administering the testing. And you'll notice that one statistic you never hear is how many people have been tested. Why do you never hear that? Because it would be in the single digits.

Now, we are never going to break the cycle until people know whether they are carrying the disease or not. It is axiomatic that if you test people and they test positive, you have to make ARVs [anti-retroviral drugs] available as an incentive. So I'm not disconnecting testing from what the administration is trying to do. It's also axiomatic that you can't mandate testing. You cannot have mandatory testing in the current political environment. But at a minimum there ought to be required testing at certain moments in a person's life, at a minimum when they get married -- because they will infect their partner.

And this is extraordinarily complicated. The "B" in [Ugandan President Yoweri] Museveni's ABC [AIDS prevention program] is to "be faithful." And all of you in this room, unless you've gone out and looked at Uganda, will think, "Well, that's good, a monogamous marriage means no spreading of AIDS." It ain't true. In the CDC [Centers for Disease Control] testing in Tororo, on the eastern edge of Uganda, where I spent a harrowing day visiting people, 35 percent of the people the CDC tested had HIV-discordant marriages. One of the partners was HIV positive, one wasn't. So in a monogamous marriage, untested, the infected partner would be infecting his or her spouse and the child, if there is a child. And I'm not making this up. I visited, quite by chance, when we broke down into small groups, I went by random to a rural -- to a hut in the middle of a jungle clearing, and the woman was HIV positive, her husband was HIV negative, but the CDC had tested them, and she was taking the drugs. And they weren't going to have children. But that was very, very rare. This is critically important. And I have urged that ABC -- Museveni's Abstinence, Be faithful, Condoms [program]--be [renamed] ABCT, Testing. And Randy Tobias and I have talked a lot about this. We should drop the V for voluntary and make it recommended testing. And I think Randall Tobias is very favorably inclined towards this. And I want to say in the presence of the WHO representative in Washington that the WHO has been a real stumbling block here. The U.N. system is dragging its feet and fighting this issue tooth and nail while pretending not to, while claiming that they're reviewing the policy. We have to start encouraging testing.

One last point: if one-quarter of the population is HIV positive as they are in the two countries which my friends here were accredited to as American ambassadors, that's terrible. But it also means that three-quarters of the people are not infected.

LANGE: Exactly.

HOLBROOKE: And if you test and you find out you're not infected, isn't it self-evident that that will encourage safe-sex practices which will slow down the rate of increase? So this testing thing -- and by the way, you go and read the U.N. AIDS brochure, the WHO brochure, the ILO [International Labor Organization] brochure, or the U.S. government brochures until John and Randy -- [inaudible]--the barest mention of testing. It's all about prevention and treatment, and it is a colossal failure.

LYMAN: I'm going to ask John to comment briefly on this, and then because time is -- I'm going to take several comments and questions from people and then come back to the -- so we can get as many people commenting. Did you want to say something on this testing?

LANGE: I certainly want to reinforce the needs of testing, because the most elemental aspect of fighting this epidemic, whether it's prevention, care, or treatment, is for the individual to know his or her status. But what is, in many senses, revolutionary is the availability of antiretroviral treatment, which is a major aspect of President Bush's plan. And treatment clearly reinforces testing. When Ambassador Tobias and I were in Botswana in October of last year, we learned that they had doubled the number of people who had been tested at the testing centers there in the previous 15 months. Why are more people coming to be tested voluntarily? Because treatment is available. They see people getting better through what they call the Lazarus effect -- people who are on their death bed, take antiretroviral treatment, and are able to go back to work -- and that encourages others to be tested. So it's really an integrated plan of prevention, care, and treatment that we're talking about.

LYMAN: I'm going to take several comments. We'll start from the back right there on the end there.

QUESTIONER: Hi. My name is Jen Cohn. I'm with the National Association of Campus Newspapers. I just wanted to say that FDCs have been called -- excuse me, fixed-dose combinations -- have been called the backbone of any treatment scale-up plan. This, because they simplify regimens and also simplify procurement and distribution because they are so simple to take. And according to Thomas [inaudible], the U.S. has not even actually asked to review the WHO's dossier on prequalification generics, nor has it asked -- nor has the U.S. asked to review data from generic manufacturers. It would appear that the U.S. is actually thus concerned with issues other than those of safety and efficacy, and it is those other issues which are motivating the U.S.'s refusal to accept or even actually investigate the internationally supported WHO pre-qualification project.

LYMAN: Could we -- we need to move to a quick question --

QUESTIONER: OK, sorry.

LYMAN: --because we've got a lot of people with their hands up.

QUESTIONER: Sorry. The U.S. is actually asking for parallel structures of funding and procurement so that PEPFAR monies actually do not commingle with other monies, such as the Global Fund intended for generics. If you're really committed to generic FDCs being available, will you commit to basically allowing countries to have their money commingle, their PEPFAR monies commingle with monies that would be intended for generics from institutions like the Global Fund?

LYMAN: OK, Ter?

QUESTIONER: I'm Teresita Schaffer, director of the South Asia Program at CSIS [Center for Strategic and International Studies], and I'm also directing the India portions of CSIS's Task Force on HIV/AIDS. I wanted very briefly to amplify what Dick said about India. Dick, there has been a continuing change in political and social awareness of HIV -- I tracked this back over a number of years -- but even since you were there. There's still a lot to do. I would cite two data points, though. First, when you get outside of Delhi into the high-prevalence states, you have chief ministers -- and I'm thinking of [Chief Minister] Chandrababu Naidu of [the Indian state of] Andhra Pradesh -- who are not at all shy about communicating. There are posters and graffiti all over town in Hyderabad [state capital of Andhra Pradesh] about HIV/AIDS. He chose to make his speech to the Confederation of Indian Industry all about AIDS. The second data point is the Health Minister [Shushma Swaraj], who is something of a maverick, kind of hard to read, but who evidently decided about six months ago that it was good politics to have an active AIDS program in her district, and who set about commissioning a plan for an AIDS-free Bellary [district in southern India]. This suggests that you might eventually reach the point where democratic politics become a help.

The question I have, though, has to do with whether you agree that this is a strategic moment for dealing with AIDS? My experience is India, but I think the same logic holds in countries in Africa. If treatment is being introduced, as it is in India, supposedly next month, that raises the bar, it gives you an incentive, but it also gives you a challenge to make sure that the treatment is a spur to prevention and testing and not a reason for people to say, "Oh, well, it's not incurable anymore."

LYMAN: Right. We'll take one more. Henry Owen here. I'm sorry that we're -- because I need to get -- let our --

QUESTIONER: Dick mentioned India. Are Russia and China just as important and just as desperate? All three of these countries have a higher rate of increase than Africa. And therefore, everything that you said of India could be said equally to Russia and China, where the governments are criminally negligent and the problem is growing more rapidly than anywhere else in the world.

LYMAN: Let me allow our guests to have a final word here. And I apologize that we didn't get to more questions and answers. But, John, go ahead, and then Dick.

HOLBROOKE: Better answer the first one.

LANGE: On the idea of commingling funds, this is something that Congressman Kolbe's very well aware of in terms of concerns that the United States government has to be accountable to taxpayers. So we really do not provide our funding in baskets, as they sometimes say, for commingling. At the same time, we're working very closely with other organizations, very closely with host governments. And as I said, the meeting that's been going on in Botswana to talk about the principles for safety, efficacy and quality of fixed-dose combinations is being cosponsored by the World Health Organization and U.N. AIDS. So it's not -- we're working very closely with them.

And on the other issue I wanted to mention, which is Russia, China, and India, this is a global problem. There was a meeting that the Irish presidency of the European Union hosted involving 55 countries in Europe and Central Asia at the end of February. They noted that there had been a 50-fold increase in HIV infections in Europe and Central Asia in the last 10 years. This is something that every country in the world needs to step up, show the leadership necessary, and deal with this with their citizenry.

LYMAN: Dick --

HOLBROOKE: On Henry's point, in amplification of what John just said, yes, of course it's a problem in China and Russia, and as well as Ukraine and the Transcaucasus. The reason I single out India rather than China is because in China this problem will or will not be solved solely by the government itself, which, if it wishes to, could solve it in less than a week because of its totalitarian control of the people. All of you in this room know that they have rules about how many children you can have, and they exercise the most brutal repression of people if they feel like it. And therefore, dealing with the Chinese issue is completely different than dealing with any other country. The SARS [severe acute respiratory syndrome] crisis was a fantastic wake-up call to China. The same people who are ignoring AIDS are the ones who covered up SARS. It brought down several high-ranking ministers, and it created a crisis.

We are going to try to do the same war game in China later this year that we did in India. And if we can pull that off -- we had Chinese come to the Indian seminar, and they were blown away, and they said they would try to sneak us into China. [Laughter.] I say "sneak" because we can't do it in Beijing; we'd have to do it in Shanghai.

QUESTIONER: How about Russia, then?

HOLBROOKE: Russia is the third country we're looking at. And Russia's also a problem. And as John Lange just said, it's a worldwide problem. But I singled out India because of the great complexity of the country and the fact that it could spread very fast there. If it started to spread to China, the Chinese would take methodologies we wouldn't approve of to deal with it, if it spread beyond limited areas. India's a different case. It's a democracy. It's chaotic.

I'm glad that Ambassador Schaffer mentioned the states and added -- and drilled down to a lower level of detail than I was able to get to. I should mention that CSIS and the Asia Society, which I am chairman of, and the Global Business Coalition collaborated on all these events in India, and using a Gates Foundation grant, we had a wonderful teleconference between New Delhi and New York, which Tessie participated in. And if you think that all these efforts, Tessie, are actually increasing awareness, I'm delighted to hear it. But there are a billion people in India, and the governor of one state does not mean it'll happen elsewhere. And -- but I think my conclusion about India -- I don't know if you'd agree -- is that we have to work with the state governments because the central government's too far away and too elitist.

And I would just end with one point about India which probably applies elsewhere but certainly applies in India. And I'm glad we're spending a lot of time on the non-African part of this today, because the most important thing you could take away from this session is to remember that it's not just an African disease. And what happened in Africa's not unique to Africa. There's a subliminal racism in the theory that what happened in Africa could only happen in Africa. And it ain't true. And Henry Owen and Tessie and John and the rest of you should all remember that.

But I want to end with one anecdote, if I might, Princeton, about India. And that was that at this conference, which Tessie attended by teleconference and Trevor and I attended in person, we were sitting in this great hotel in New Delhi, being told by all the Indians about the cultural taboos and the social mores of India, and how you couldn't talk about condoms, and you couldn't talk about faithfulness, and you couldn't about this, you couldn't talk about this. So at the end of the conference, Kati and I went and spent a day in the New Delhi slums. And we went out and talked to people, groups that were assembled for us, but not specially arranged groups, ordinary people from the area who came into centers to chat, young kids, men, women, wives, prostitutes. And we sat on the floor on the mats and talked to these women. And we tested these cultural taboos -- "Does your husband use a condom; is it hard to get him to use a condom?" -- thinking that they wouldn't be able to discuss it. And they started laughing and talking among themselves. And then they got very animated and they turned back to us, and through a translator they began answering all the questions. And you know what? There were no cultural taboos. They were having a great time. One woman said, yeah, she can't get her husband to use a condom. The next person said, "Oh, it's not a difficulty, here is how you do it." And so we went back to the hotel, where there was all the elite again -- [laughter]--telling us you can't have that kind of discussion in our country.

The people -- there's a tremendous gap between the -- parentheses, mostly male, end parentheses -- elites and the realities of the villages and slums of the great cities of Asia and Africa. You've both seen it because you're two of the best who worked on it. And the only way to deal with these elites is to hit them frontally, shame them into recognizing that it is their embarrassment -- and that's what it is, their embarrassment -- that prevents this, from the public information side of this effort, from reaching down and helping people prevent the spread of the disease.

LYMAN: Thank you. I'm going to, just for a future discussion, take a little bit of issue with you on China, because the experience with AIDS worldwide is you need community involvement, you need active civic society. And the thing that worries me most about China is exactly what you say, that that isn't very permissible. And we know from Botswana, a very democratic country, that without the community engagement, the program isn't working. We'll open that up for a future discussion. But I think what's been demonstrated today is that we've just opened the door on this enormously challenging issue. We've had a tremendous start with the United States, the initiative, a bipartisan initiative. We've got a long way to go. Thank you all for being with us. And I ask you to give a hand to our guests today. [Applause.]

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