The Global Fight Against AIDS
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JEFFREY BROWN: As the world AIDS community met in Bangkok last week, the United Nations released grim new numbers: 2.9 million deaths from AIDS in 2003, and a record number of new infections, 4.8 million. The conference focused on the spread of the disease in Asia, and the continuing problem of access to drugs in developing countries. But the week was also marked by a bitter debate over funding available to fight AIDS, and whether the U.S. in particular is doing enough.
I’m joined by three prominent leaders in the field, just back from Bangkok. Dr. Anthony Fauci, of the National Institutes of Health, was a key member of the U.S. Government delegation. Dr. Helene Gayle is director of the HIV, TB, and Reproductive Health Program at the Bill and Melinda Gates Foundation. And Stephen Lewis is the United Nations envoy on HIV and AIDS for Africa. Welcome to all of you. I’d like to start with the question of the increasing spread in Asia.
Dr. Fauci, what’s behind that, what’s going on?
DR. ANTHONY FAUCI: Well, the numbers themselves are already quite concerning. But the issue regarding Asia is the enormous potential for an explosion, because of the population itself. The virus gets introduced into any given population by a number of means; it could be first injection drug use, it could be commercial sex workers, it could be gay men.
But sooner or later what’s happened in Africa, almost certainly is going to happen in some of the major Asian countries, namely spread into the general population through heterosexual contact, it’s a very interesting pattern as that occurs. We’ve seen it in other countries and we’re seeing it now. The issue with Asia is that we have the conference there. And it was in some respects fortuitous that we had it there, because right now is the time we need to do some major steps to contain the epidemic, not only with prevention, but also getting access of drugs to the people who are infected in Asia as well as, obviously, in sub-Saharan Africa.
JEFFREY BROWN: Dr. Gayle, some of the data that I’ve seen suggest that some of what’s going on in Asia right now is different somehow from what’s happening in Africa. Is that true?
DR. HELENE GAYLE: Well, I think it’s hard to compare one continent to another, particularly continents that are as heterogeneous as Africa and Asia, so I think you have to look at the picture country by country, and even in some countries state by state.
For instance, India that now has the highest number of HIV infections in Asia and second highest in the world, it’s difficult to get the picture of what’s going on in India if you look at the average HIV prevalence. For instance, less than one percent of people are infected overall in India, leading to five million people, given the large population size. But there are pockets in states and in districts in India where rates of HIV are much higher and increasing.
So I think it’s important to remember that it’s hard to just look at any continent or any country without looking at it for the different patterns that you see throughout the country, and throughout the continent.
JEFFREY BROWN: Dr. Gayle, do you see countries taking actions in response, in Asia?
DR. HELENE GAYLE: Well, I think that one of the hallmarks of this epidemic is that no country has acted fast enough. And probably it’s fair to say that no government has done enough soon enough. But I do think there are encouraging signs. While we were there in Bangkok for the conference, the premiere of China made a very encouraging statement about increasing commitment and increasing resources to fight HIV in China.
The Indian government over the last few years, particularly in the last year, has made greater commitment than it has in the past. So I think we are starting to see encouraging signs, the closing speech by Mrs. Gandhi, for instance I think was a very encouraging sign about the commitment to the new government in India to fight HIV there. So we’re starting to see those signs, but I think there’s always more that can be done, both in terms of more resources, more accountability about how the resources are spent, and more overall political commitment.
JEFFREY BROWN: And, Stephen Lewis, how do you see what’s happening in Asia, particularly how it could be prevented from becoming what you’ve seen so long in Africa?
STEPHEN LEWIS: I think Dr. Fauci’s point was the valid point, that the pattern of explosion which occurs at a moment in time is now what confronts Asia, that whatever happened in Africa must not happen there. And that means the most intense series of preventive interventions. I was fascinated by the language of the conference which reverted to what we know of yore, injecting drug users, men having sex with men, commercial sex workers — all the high risk groups, as they’re called, that triggered so much of the pandemic in other parts of the world, now coming together in Asia and requiring the toughest preventive response.
JEFFREY BROWN: On the question of another issue that was in Bangkok, a question of access, and especially access to the life saving anti-retroviral drugs. Stephen Lewis, starting with you, the World Health Organization said last week that the world has “failed miserably” in getting these drugs to millions afflicted with HIV. I wonder, do you agree with that, and if so, why? Mr. Lewis?
STEPHEN LEWIS: I’m sorry. You’re addressing that to me. My connection is moving in and out. I think that we’ve simply never been able to get the resources on the ground. And we haven’t been able to summon the supply lines of drugs in order to treat the millions of people we should now be treating, although the target of putting three million people into treatment by the end of 2005 is the most admirable target, and visionary commitment that’s been made within the U.N. family in some time. And I think that if we can do that, largely using generics drugs, these fixed dose combinations as they’re called, at very low prices, roughly $150 per person per year, then we can in fact reach the W HO target and have a sense of breakthrough in this dreadful pandemic.
JEFFREY BROWN: Dr. Fauci, how do you respond to this miserable failure language?
DR. ANTHONY FAUCI: Well, miserable failure is a bit confrontative, to particularly the number of nations that have been doing a considerable amount. When you say enough, you never have enough until you have solved the problem. Certainly we have a long way to go. I don’t think there’s any question about that. We do have a long way to go. But what we’ve seen now, at least over the past year, are some promising signs.
For example, there are a number of groups that global fund has now got money in the trenches, as we say, drugs are being bought, people are being treated. The president’s emergency plan for AIDS relief, what we call PEPFAR, now has the money appropriated from our Congress, it’s out in the field and people are getting access to the drug.
There’s a long way to go on the part of everyone, but one of the issues that I think cause us to at least feel there’s some hope there is that things are starting to move. But what we can’t, have and I think Steve and Helene had mentioned that, we can’t have a situation where people feel that this is not still an emergency situation.
This is really an emergency here, particularly in Asia, and as I mentioned, because of the potential for explosion there, as well as the situation that we already have a relative catastrophe in sub-Saharan Africa. So we’ve got to get the drugs not only to sub-Saharan Africa, but we’ve also got to get it in Asia and the Caribbean and other nations that need it. Prevention is an important part of it. You cannot — when you talk about access to all, I think you said it very well in the top of the show, is that access to all is very, very important. But we can’t forget prevention.
JEFFREY BROWN: Of course you ran, and the U.S., ran into criticism in Bangkok over this access question, correct, about the use of generic drugs, about the contributions to the global fund?
DR. ANTHONY FAUCI: Sure. I think there was a lot of misinformation, misunderstanding and a lot of rhetoric going back and forth on the part of activists and others in criticism — any group is subject to criticism of, when you’re dealing with a situation that is so drastically difficult as HIV/AIDS. But for example the understanding of what Ambassador Tobias was saying about generic drugs, we, this country and our program would like very much to get those copy drugs bought by the American dollars in the PEPFAR program.
What we need to do, and as the ambassador mentioned, we need to have some sort of assurances that these are safe and effective. So we have had now an FDA process where the FDA has promised to expedite the review of the material that they have so that we can get the money to buy those materials. That was, he wasn’t even given a chance to articulate that well in Bangkok, because of the criticism. I mean you saw the TV shots of him trying to articulate that with signs saying he’s lying. That was unfortunate. I think if there had been more of a reasonable dialogue back and forth, we would be closer to what the common goal is that all of us want. The United States, other countries, the activists — there should have been more reasonable dialogue instead of confrontation.
JEFFREY BROWN: Let’s just stay -
DR. HELENE GAYLE: I just wanted to add -
JEFFREY BROWN: Yes. Go ahead, Dr. Gayle.
DR. HELENE GAYLE: I just wanted to add on the issue of access, I think it’s important to remember that when we’re talking about access for all, it’s access to all the things that are necessary. That means prevention as well as care and treatment. Yes, we have not made our goals in treatment yet. But I think one of the things that was encouraging about the conference is that there were more practical experiences about how people were getting individuals who needed it on anti-retrovirals.
So I think we’ve made progress and we shouldn’t lose sight of that. But it’s also important to remember that even if we were to reach our target goals like three million people on anti-retrovirals by the year 2005, we’re not going to keep pace unless we are equally vigorous about our attempts to prevent people from getting infected. Almost five million new HIV infections occur every year. We will never keep pace with our treatment goals if we’re not equally vigilant about prevention and recognizing that they do go hand in hand. So access for all is really both about prevention as well as care and treatment.
JEFFREY BROWN: Well, Dr. Gayle, tell us more about the prevention side of it, bought because I know this has always been a running question with limited resources, how much goes to the treatment of those already sick, how much goes to prevention for those who are not yet sick. It sounded to me as though in Bangkok there was more emphasis on prevention.
DR. HELENE GAYLE: Well, I think that there was more emphasis on prevention partly because it was in Asia, and clearly for all the reasons that we’ve all mentioned, there needs to be a high priority on preventing the further spread of HIV in Asia, where the largest percentage of the population lives. So even small increases of HIV in countries like China and India and Indonesia will mean huge numbers of newly infected people with HIV, so prevention has to be a priority.
I think the fact that HIV is rapidly spreading and the increased toll that it’s taking on women was highlighted, the increased toll that it’s taking on youth. So I think it’s clear that the prevention goals have to go hand in hand with the treatment goals, and also that we need to continue to expand our options for prevention. We know that the strategies that we already have changing behaviors, treating sexually transmitted diseases, access to condoms, counseling and testing, abstinence, delaying sexuality, all these things we know work, but it’s also important that we expand the options. The quest for a safe and effective HIV vaccine has to be a priority. Developing a microbicide, a tool that women could use to protect themselves and put prevention in the hands of women, other tools and new technologies for prevention; this has to be a key priority as well.
JEFFREY BROWN: Okay. Stephen Lewis, come back to the political question that Dr. Fauci was talking about as well, because clearly that was a big event, a big deal in Bangkok. What did you hear what was going on with the criticism, particularly of the Bush administration on this issue?
STEPHEN LEWIS: Well, let me just put it in context. Seventy-five percent of the people in Africa between the ages of 15 and 24 who are infected, almost five million, are young women and girls. Treatment and prevention are inseparable in this dealing with this scourge. And therefore you have to get the treatment going. And with great respect, I can’t sort of sit here and accept the faintly disingenuous argument.
These drugs we’re talking about are drugs that have been pre-qualified by the World Health Organization, using scientists from Europe, Canada, Australia, every bit as scientifically capable as those from the United States. The fact of the matter is that PEPFAR as it now stands will purchase only brand name drugs. We can therefore treat only one-third or one-quarter of the numbers we could treat. And if we’re going to stop this carnage, then we have to use the most effective combination that has now been tested and indicated to be utterly safe and effective, as recently as an article as Dr. Fauci knows in the Lancet just a week or two ago. So I really think we should shift the ground towards the global fund and the generic drugs.
JEFFREY BROWN: Okay, let me give Dr. Fauci a response.
DR. ANTHONY FAUCI: There are multiple ways to do things. And I respect Steve’s opinion, but I think we need to put the facts on the table and look at the position that the United States is in. They want very much to get those copy drugs approved. Now, Steve mentioned that the WHO pre-qualified it.
Now, with all due respect to the WHO, it’s not one scientist against another scientist. That’s misleading. I’ve looked at the clinical data from the Medecins Sans Frontieres, which used the drug, and the clinical data actually looked pretty good. But the point that Ambassador Tobias made is that he is responsible for $15 billion of United States taxpayer money, and I can tell you for sure that if we use taxpayer money to get purchase of a drug that we would not allow to be used in the United States, we would be before 25 congressional committees explaining that, and anybody who knows how things work realizes that that’s the case. So it isn’t as clear-cut as Steve makes it out.
STEPHEN LEWIS: Dr. Fauci, that’s not the argument. The other part of the argument, Jeff, is that more money should be going to the global fund from the United States because that’s the multilateral instrument which is most effective. That’s why the secretary general of the United Nations Kofi Annan asked that a billion dollars go instead of $200 million annually. This is a vast global pandemic.
JEFFREY BROWN: All right, Mr. Lewis. Thank you very much. We heard much of the debate that was in Bangkok. Thank you all three.