After leaving office in 2001, the former president started the Clinton Foundation, whose HIV/AIDS Initiative has helped reduce the cost of antiretroviral drugs and improve prevention and treatment efforts in many countries. Here he talks about fighting the epidemic at home and abroad during his presidency, including why his administration didn't pursue needle-exchange programs to help reduce the spread of HIV among injection drug users. "A lot of people wanted needle exchange ... but the opposition to it was simply overwhelming." Clinton also discusses his efforts to change attitudes toward the disease in India and China, two of the so-called "next-wave" countries, and the moral imperative of rich nations in leading the fight against the pandemic worldwide. One of the biggest challenges remaining, he says, is to get medicine to the people who need it. "One of my big arguments about putting medicine out everywhere is that it's necessary for the prevention to work. Because if young people believe that going in and getting tested is just going to tell them they've got a death sentence ... they're highly unlikely to get tested. But if they know if they get tested it means they've got a chance to live a normal life because medicine will be there." This is an edited transcript of an interview conducted on April 26, 2005.
- Some highlights from this interview
- The debate over needle exchange
- Why AIDS is a security issue
- His thoughts on abstinence
- Why he embraced a young HIV-positive Chinese man on national television
How did you first encounter AIDS? What was your first personal experience with it?
My first personal experience was that a man who was a very close friend of mine, a gay man in Arkansas, got AIDS and died in the 1980s. I visited him in the hospital, before there were any antiretrovirals. He had huge black welts all over his body, his face. ... I also learned a lot about the pathology of AIDS fairly early in the '80s, because when the Democrats went to San Francisco for the Democratic Convention, it was still basically the epicenter of the epidemic in the whole world there. The host of my state delegation was a doctor who had treated a lot of people with HIV and AIDS, so I spent hours talking to him about it. ...
What do you think the impact has been that the epidemic hit homosexuals first?
I think the fact that the epidemic hit homosexuals first may have made America a little slow to deal with it.
But we owe a lot to Dr. [C. Everett] Koop, who was President Reagan's surgeon general, because he basically brought the AIDS issue out into the daylight and told people that we had to talk about it and do whatever was necessary to prevent it. ...
[Magic Johnson announced that he was HIV positive right before your 1992 presidential campaign. What did you think about that?]
... I think he had a big impact on making the American people see AIDS as something that could hit anyone, and that it didn't have to be a death sentence. He serves as a continual reminder ... that we can't give up on people with HIV and AIDS, ... because who knows how many Magic Johnsons there are out there, or Albert Einsteins for that matter, who are just being permitted to die because there's a mismatch between the availability of medicine and medical care in the places where people have the disease?
... What is the responsibility of the developed world for the developing world?
I think the responsibility of the rich countries to the poor countries ... is to do what I've tried to do with my foundation: to train medical personnel and help countries get the people out there to do education and prevention and care and then get the medicine in there. The idea that the prohibitive costs we pay here -- $10,000 or more -- should be permitted by neglect to keep other people from getting medicine is ridiculous.
Our foundation has negotiated ... drastic price reductions, so for $200, now you can have both the medicine and the tests. We're all doing it too late, but it's beginning to move now. I would imagine that within a couple of years, you would probably have 4 million people getting the medicine at present levels of effort. But over 6 million need it, and there's no excuse not to give it to all 6 million.
There was a report circulated by the CIA in 1991 that pretty accurately predicted that 45 million people would be infected by 2000. Did you see it?
I honestly don't remember, but I was well aware that the number was growing.
When I became president, I had met with a lot of AIDS activists in the 1992 campaign. And I was very much focused on the United States, because we had the biggest problem in the world. ... By my second term, we already had a terrible problem overseas, and I did everything I could to get more money for it. We tripled assistance, but it was a pathetically small percent, about $600 million a year. There was just no more sentiment in the Congress for [more]. Then after I left office, the Christian evangelical community essentially embraced the cause of fighting AIDS, and it changed the votes of the Republicans in Congress. They joined with the Democrats, who were already in favor of doing more. ...
[There was a lot of hope during your presidency that there would be federal funding for needle-exchange programs. Can you tell us what happened?]
A lot of people wanted needle exchange because of the role of dirty needles in [infecting] drug users, but the opposition to it was simply overwhelming. It was overwhelming in Congress, and it was overwhelming within the Drug Control Office of the administration, and it simply would have been reversed in Congress if I'd done it. Politically the country wasn't ready for it.
So I decided we should do what we could do, and it worked. The death rate went down by more than 70 percent. However, today, there are still disturbing trends in certain discrete populations where the [HIV] infection rate is going up again, and a lot of it I think is related to drug use. So we've got to keep working on that. There's just no way we could have done it. It wasn't going to become law [at that time].
Would you do things differently if you had them to do over again?
I think I did about as much as I could, given the Congress that I had to work with. The Republicans were simply unwilling to do more on AIDS until the conservative Christian community decided that this was a moral cause. [Lead singer for the Irish band U2] Bono helped to change [Sen.] Jesse Helms [R-N.C.] after we'd all worked together on global debt relief.
What was the connection between the work on global debt relief and AIDS?
Bono established a relationship with Jesse Helms when all of us were working on the so-called Millennium Debt Relief Initiative in 2000, which we did pass and which made 33 of the poorest countries in the world eligible to have their debt forgiven if they put the money into economic development, education or health care. And a lot of the countries that got the debt relief put it into health care. [Bono] helped us, along with the American Christian community, in trying to convert Jesse Helms and other conservatives to the cause of the international fight against AIDS. Certainly more than any other non-American, he deserves a lot of credit for the response that the Congress has had and the response that the Bush administration has had, and I'm very grateful to him.
[How do you think that changes and improvements countries make to respond to AIDS can ripple out into other areas?]
AIDS is not just a health issue. AIDS is an economic issue, an education issue, a law enforcement issue; it's a security issue. I said when I was president it was a national security issue, and a lot of people looked at me sort of askance, but clearly it is. You have African countries where they're more vulnerable to civil war, more vulnerable to violence, more vulnerable to corruption; where there aren't enough teachers, there aren't enough health care workers, there aren't enough police officers because of AIDS. When you get the AIDS rate down, you get economic growth up, you get social cohesion up, and healthy societies come forward. ...
[Can you tell us about going to see the AIDS Memorial Quilt?]
I remember when Hillary and I walked on the Mall [in Washington, D.C.] to see the AIDS Quilt. We walked back and forth to see all the squares, and we were looking for people that we knew. We had several people that we'd known and cared about who had had HIV, and it had grown into AIDS, and they had not survived it, including someone that Hillary worked with very closely in Legal Services back in the '70s. It was a personally emotional thing, seeing the love and devotion that those sections of the quilt represented for all those people who died prematurely, and knowing that now, with medicine, they didn't have to die anymore, if we did the right things. It was a very emotional day.
Why do you think people don't care?
Oh, I think people do care. I think there's more caring than ever before. Look at what's happened here, where you've got a Republican Congress that wouldn't have given 50 cents to this effort a few years ago. That's not literally true -- I did milk $600 million out of it -- but now they're going to give somewhere between $2 billion and $3 billion a year. The president cares about it.
Now, there are counterpressures. I still believe that we should use this money in concert with the Global Fund [To Fight AIDS, Tuberculosis and Malaria]. I think we ought to buy more generic medicine. I think we ought to serve more people with the money we have. We still have fights and arguments about it, but I think people do care.
The public at large doesn't see people dying every day of AIDS the way they saw people dying in the tsunami [in Southeast Asia in December 2004]. But if they did, I think we would get more done. And if they knew 8,000 people died every day, I think that we would have even more grassroots donor support for getting this medicine to these poor countries, for getting the health care systems up so people can receive the medicine. ...
It's easy to forget about because of the grinding nature of the epidemic. We've got about 16,000 more people [infected] every day; we've got about 8,000 people dying a day. You've got massive, massive death tolls. And we're all in a race to try to set up the education, the prevention and the care to get ahead of this thing.
It's a challenging endeavor because of the way the AIDS virus in effect invades the cell, reconfigures the DNA. I don't know if there will be a cure in my lifetime, but I think there will be an effective vaccine. I think that's not too far over the horizon. But it's also maddening because it's 100 percent preventable, and we lose sensitivity to the dimensions of the epidemic. We also let the prevention slide, which is a big mistake.
Prevention is hard, right?
Well, it's hard for people who insist on taking drugs. It's hard in places where they still don't have the sophisticated equipment we do to make sure that needles are sterilized and to test blood content for the HIV infection. I have a friend whose mother died ... [because] she had a surgery and she got infected blood, but that doesn't happen here anymore. And so when it happens overseas, that's tough. But really in a lot of countries -- Senegal and Ghana, Cambodia, some parts of Thailand -- where they've been really aggressive on prevention and basically told people that having unprotected sex was like giving a death sentence, they have succeeded in lowering the infection rate.
But it's hard when people don't take it seriously, and young people sometimes think they're going to live forever. Or in some places where circumstances are desperate, they think they're not going to live very long anyway, so what difference does it make? It's hard when people don't get tested. A lot of people would practice safer sexual conduct if they knew they were infected.
One of my big arguments about putting medicine out everywhere is that it's necessary for the prevention to work, because if young people believe that going in and getting tested is just going to tell them they've got a death sentence or [eventually] they would otherwise found it, they're highly unlikely to get tested. But if they know if they get tested it means they've got a chance to live a normal life because medicine will be there, then you have them in a positive frame of mind, and they're more likely not to give the disease to other people.
[You've had conversations with Nelson Mandela about HIV. What did he say?]
I think he felt when he got out of the presidency, that he had brought genuine multiracial democracy and freedom to South Africa, he'd given it a modern political state, and that everything he had done was now threatened by the enormity of the AIDS problem -- 5 million people with AIDS or HIV in the country.
I think he wanted to personally do something about it for the rest of his life. ... He's even written personal checks to support people with HIV. Of course we know he lost his son to the epidemic, so for him it's immediate; it's personal. It's a source of great grief and I think a source of profound regret that after struggling so long to make South Africa free that it is not free of this epidemic.
What do you think was going on during his presidency?
I think that in a lot of these places, there was just a lot of denial. And then ... the epidemic grew in a hurry. It was amazing to me that when I became president, America had the biggest problem in the world, and within four years we were going way down, and Africa had exploded. By the time I left office, two-thirds of all the cases in the world were in Africa. I think that a lot of times political leaders and their administrations and their bureaucracies have, I hesitate to say blinders, but we all are like that. We say, "OK, I got elected to do this, and this is what I'm going to do." And all of a sudden, the job gets redefined by something else. So I think all countries were a little slow to turn around.
But he certainly has done everything he could. Even when he was president, he was never particularly in denial about it; there just wasn't much he thought he could do about it. Then ... as a free citizen, he focused all his attention on it, whereas when you're in office you have to think about a lot of different things.
AIDS is tricky, because it's often fraught with politics, isn't it?
It is some places, but I think it's changing quickly. AIDS is a hot political issue in a lot of places where people are uncomfortable talking about how it's communicated. They either don't want to admit they've got a drug problem, or they think it violates their culture to talk about the sexual communication, or it's embarrassing that blood transfusion equipment is contaminated and blood can't be tested. ... So a lot of people say, "Well, we're not going to do this." But denial only makes it worse everywhere. Sooner or later people break out of it. Once the Chinese decided to openly embrace the fact that they had a problem -- that real people were affected, good people who deserved to live -- and they didn't want an epidemic, and the only way they could avoid it was to get organized, they turned on a dime.
I've seen it happen in African countries. I've seen it happen in the Caribbean, where we're working. In two years in the Bahamas, we've quadrupled the number of people getting medicine, cut the death rate in half. There were no mother-to-child transmissions last year with anybody who got the medicine. There was a lot of denial in India. I remember when I went there, and I talked to people about it, and they said, "Oh, but it's hard to talk about this in our culture." I made some rather pointed remarks about that. But I've got to give it to the Indians. They've also turned it around. ...
All of us in the rich countries have to understand that our impact is going to be very limited unless the countries in question are really committed to doing something about it. It is so much easier to go in and help when they are committed. If you look at the marvelous job done by Brazil, for example, ... where you had a commitment from government, from civil society, from the church, from everybody at the grassroots level to turn this around, and they did. That's what we have to have everywhere.
[What were your pointed remarks to the Indians?]
Just that given the history of their country, it seemed strange to me that people would be uncomfortable talking about the way AIDS is communicated. You had Mother Teresa's order of nuns ... very active in AIDS hospices in the United States, but I thought they should be doing it [in India]. They're all working now, but there's always this period of reserve, and then once people break through it, it's forgotten quickly, and they go to work, and that's what I see happening in India now. It's very encouraging.
[South African president Thabo] Mbeki came to the White House soon after ascending to the presidency. Did you speak about AIDS with him?
I offered to help the South African government and invited my foundation there to work with him on developing a plan, which we did. It included bringing in antiretroviral medicine. And when we went down to South Africa for President Mandela's 86th birthday [in 2004], ... President Mbeki said that he wanted our foundation to come in and ... provide the medicine if I could promise him that it would be of the same quality that [the National Institutes of Health] would approve in America. I said, "I give you my word I won't bring any bad medicine," so he said, "OK, we'll do that." ... Then they decided they wanted to do it all by themselves, and they didn't want us to help. So they are using our plan, and now we try to work with the state governments in South Africa. ... We're doing more work at the regional level now, but it's obvious that there are enormous internal tensions in that country still over what the proper course should be.
We interviewed [Executive Director of the Joint United Nations Programme on HIV/AIDS (UNAIDS)] Peter Piot, and he said in 2000 he had a conversation with some USAID [United States Agency for International Development] officials who said it was not feasible to provide treatment in the developing world because it set up unfair expectations. What do you think of that?
I think not only USAID officials thought that, but a lot of big American non-governmental organizations thought that. A lot of people spending time and money on health care and clinics thought that. But they were thinking about the amount of money we'd spent in America -- somewhere between $10,000 and $11,000 a year, per person. ... They weren't thinking about the availability of generic drugs. So they thought that we ought to spend our money on education and prevention and decent care.
But I think what they have all come to see is that if you don't provide treatment, you are not going to have an opportunity to really get ahead with education and prevention programs, because people won't come in and get tested. They don't want to find out they're dying and then be told by some patronizing person from a rich country that they can't have the medicine that we take for granted.
I think it's a crazy position, but there were people in [US]AID who thought it. But to be fair to them, the Congress at the time wouldn't give them any money, and we were trying to alleviate poverty in the developing world, too. ...
But ... there are problems. Once you start people on this medicine, you have to take it for a lifetime. [Countries and communities] have to have an infrastructure to show people how to take it and then check up on them. It's not that there was nothing to the arguments the other side was making, but practically and morally they just can't stand. You can't go around saying, "Well, we're going to take care of all of our people, and we're going to let you die because this medicine's expensive, and the rich countries are trying to keep you from getting the generics," or, "We can't serve everybody, so we're not going to serve anybody." That's insane.
When I started this two and a half years ago, there were only 300,000 people in poor countries getting this medicine out of over 6 million who needed it, and 170,000 of them were in Brazil. Our foundation alone has gotten another 110,000 on medicine. And then the money's beginning to flow through the Global Fund and elsewhere, and they are up to probably another 200,000 or 300,000 with that.
[What are your reactions to the restrictions that come with money from President Bush's Emergency Plan for AIDS Relief (PEPFAR)?]
Well, in terms of the abstinence part of it, I'm all for that, but I think we should do it the way the Africans did it. That is, in the Uganda campaign they promoted abstinence for young people, for single people, but they also promoted fidelity within marriage and said if you're going to have sex, it can't be unprotected. So it was not abstinence only; it was abstinence plus. That's where I want it, and that's the only thing that makes sense if our goal is to save lives.
The other thing that I'm concerned about is whether we'll have too many restrictions from the American money on the drugs that can be bought. ... Central America is getting the drugs for about $215 and then whatever the testing equipment costs. ... Even if the big pharmaceutical companies cut the price to $1,000 or $1,500 a year, ... you can't morally justify essentially giving up seven-eighths of the number of people you could treat to pay that kind of money when you know this other medicine works. ...
When I flew to the pope's funeral with the president [in 2005], he talked to me about this, and he was very interested in it. And he said, "The policy of my administration is not to prohibit our funding for generics, but to make sure that the generics have passed the quality test." We talked through it, and he made some notes, and he was genuinely interested in it. So I think there may be some real movement there. …
[The general criticism is that the President's Emergency Plan is ideologically based. What do you think?]
It's a very ideological administration, and maybe on this I have to hope that the human element will trump ideology. We have seen that there are a lot of the Christian evangelical communities around the world who genuinely want to keep people alive who are HIV positive or who have full-blown AIDS. We have seen that it is a problem that is helped by exposure to it. That is, the more you help at it, the more likely you are to have good, solid policies. ...
Are you sanguine about the future?
On balance I'm sanguine about the future, because we are treating a lot more people than we were a year ago. I think a year from now, we'll be up in the millions of people getting treatment. So on balance I'm sanguine, but the virus has the capacity to mutate, and mutations can be stronger or weaker. There is no sign that we can ever figure out what to do about a virus that reconfigures the DNA of a cell, although I think someday [we] will. But I'd feel better if I thought we were on the verge of a vaccine. There's just a lot of moving parts here. I'd feel better if I thought every single country with an HIV/AIDS problem was committed to coming up with a plan to deal with it and getting people to try to deal with it. But I can tell you it's drastically better than it was two years ago.
I just met with President [Viktor] Yushchenko, the new president of the Ukraine. He says: "Oh, we understated our AIDS problem. You've got to come in and help us. Will you help us deal with it?" When you have national leaders instead of being in denial saying, "I think we're understating this; I think we've been behind the eight ball; I think we've got to go to work," I think that's hopeful. When you have people across the political spectrum in America saying, "Let's spend more American money to save poor people's lives in Africa, in India, in China and the Caribbean, in the former Soviet Union," I think that's got to be positive. So for all the problems, I think on balance we're just light years ahead of where we were two years ago.
I was at Tsinghua University in Beijing, and I gave my speech on AIDS. There were three deputy ministers of the relevant government departments with me at the head table. After I answered a couple of predictable questions, this young man -- I later learned he was HIV positive and an activist by the name of Song [Pengfei] -- stood up. And you could have been in America: He had, like, a spiky hairdo, and he asked me a really sassy question, and so I said, "Come up here." Just on instinct I said, "Come up here," because I knew it was being televised nationally. He came up on the stage, and I put my arm around him and hugged him and shook his hand, and I took him over and introduced him to the vice ministers. And the Chinese showed the whole thing on television. They showed this man, a real person, shaking hands with these government ministers. None of them had ever shaken hands with anybody who was HIV positive before. Within 10 days, the prime minister had 10 AIDS activists in his office. Then before you knew it, President Hu [Jintao] was out visiting hospitals of people who were HIV positive. ... I knew that the picture could be powerful.
When I went to Nigeria and President [Olusegun] Obasanjo brought a woman up on stage who was HIV positive with her husband and embraced them both because of the struggle they had gone through to get the medicine to keep their daughter from being born HIV positive, when Nigeria saw the pictures of their president holding these two people with AIDS or who were HIV positive, it made a huge difference. So that's what happens.