The Age of Aids [home page]

interview: richard feachem

[photo of Richard Feachem]

Since July 2002, Dr. Richard Feachem has been the executive director of the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The Global Fund coordinates a global effort between the public and private sectors to combat these three preventable diseases, which caused more than 6 million deaths in 2004 alone. Here he explains how the fund works and addresses criticisms that it has been to slow to move; that there is frustration and confusion on the ground in some countries where the Global Fund distributes generic drugs while President Bush's Emergency Plan For AIDS Relief (PEPFAR) distributes brand-name drugs; that the Global Fund lacks a strong moral component; and that there is too much potential for corruption in the in-country distribution mechanisms. Feachem argues the world needs to understand the long-term promises it's making through the Global Fund: "We've now engaged in programs to finance very poor countries to do something that otherwise they would be quite unable to do financially, which is to put ... several millions of people on drug therapy for life in a situation where, if that drug therapy were to be interrupted because the money wasn't there, the individuals would die rather quickly. We have never before between the rich nations and the poor nations entered into a long-term morally binding commitment of that kind." This is the edited transcript of an interview conducted on April 21, 2005. In March 2006, Feachem announced his plans to step down when his current term ends in July.

What is the Global Fund [To Fight AIDS, Tuberculosis and Malaria]? Are you part of the United Nations?

No, we're not part of the United Nations. We're an independent financing mechanism set up in 2002 for the purpose of providing large amounts of additional finance for the fight against HIV/AIDS and TB and malaria. We were very deliberately created independent and not [as] a part of the United Nations.

Why?

Because those who founded us realized that this organization had to be very nimble, had to move very quickly, had to pioneer new ways of getting large amounts of money to people on the front line, and it was felt that the very established U.N. systems would not be the best way to launch this new vehicle.

Why?

Well, you'll have to talk to many others to get a full flavor of that. I wasn't part of those original design decisions, but certainly what I can tell you, having run the Global Fund for its first three years, is that the decision of our founding fathers and mothers to create us as a completely independent foundation was a very wise one. It's enabled us to have a speed and independence of action, a degree of innovation that would have been very difficult within the government structures of the U.N. It's also enabled us to take very tough decisions on purely technical grounds.

It's really insulated the Global Fund from the political dynamic, which inevitably and appropriately permeates the U.N. We are a very apolitical organization, and we've had some rough, tough discussions with a number of countries, and we've been able to take principled and technical decisions which haven't always been popular because we're not subject to the political influences that would come to bear in the U.N. ...

There's a lot of criticism that, particularly in the beginning, it was slow. Where does that criticism come from?

Well, it depends what you mean [by] "in the beginning it was slow." In the beginning, January 2002, there was no Global Fund. There were no people in no offices and no money in any bank account and no applications, so there has to be some degree of realism about getting [started] from scratch, literally from nothing. This is not attached to some existing financing agency which was then asked to do another job. This is de novo, from scratch. We were making our first grants within 12 months, and we now have a very large volume of funds flowing to 130 countries. As I say, I'm restless and impatient and I'm not complacent, but we have come a long way in a short period of time.

You mentioned 130 countries. Why have you taken such a large, all-encompassing approach to this?

One of the early decisions that had to be made about the Global Fund was the eligibility criteria: Which countries are eligible to seek funds from the Global Fund? The decision was all low-income countries by World Bank definitions, and all lower-middle-income countries by World Bank definitions. That's about 140 countries. We're already in 130 of them.

We're making a huge moral long-term commitment, and I think the world is only just waking up to that

Why is that a good idea? Because the HIV/AIDS epidemic is not an African epidemic; it is a global epidemic. India is the epicenter of that epidemic today and increasingly will be in the future. Russia, China -- everywhere you go in the poorer parts of the world, you find rapidly growing HIV/AIDS epidemics. Unless you tackle that comprehensively, you're not going to turn around the pandemic, which is the way we describe the global epidemic.

In addition, of course, we have TB and malaria. TB is a global disease. You have to fight it everywhere. And malaria affects nearly all countries within the tropics. So 130 countries is a lot of countries to handle; it's demanding on the Global Fund systems, but I think it's the right approach -- to be comprehensive, to be global and to be large. We weren't set up to be small; it wouldn't make an impact.

Let's just talk about India. You mentioned that it was the epicenter of the epidemic. That's surprising. The popular conception is it's in the developing world, mostly centered in Africa. Why do you talk about India, Russia, China?

If we look at the epidemic today and think about the future of the epidemic, or the global epidemic, which we call the pandemic, clearly it is worse, much worse, in Africa today than anywhere else. In Southern Africa we have prevalence rates of 30 percent to 40 percent in the adult populations. That's devastatingly high, and it can go higher -- in eastern Africa also high rates; in western Africa, steadily developing and increasing rates of HIV. So Africa is the most affected continent.

But this is a global disease, and what we've seen in the last decade is major epidemics growing very rapidly in the large countries of Asia and Eastern Europe, and outstanding among those is Russia, China and India.

Now, of those three big epidemics, sometimes called the new-wave epidemics -- Russia, China, India -- India is the biggest one. On conservative estimates, 5.1 million people [are] already infected -- actual number probably a good deal higher than that, growing rapidly in a population of 1 billion people. So if you project out those infection rates and that rate of growth in such a large population, and if you bear in mind that the Indian response today -- despite coming out of denial and despite recognizing the gravity of the situation -- the Indian response today in prevention, in testing and treatment falling well short of the level, the magnitude, the seriousness that would be required to make a big difference, you see an epidemic that is going to reach very high levels before it turns around. So the statement that India is becoming the epicenter of the global pandemic I think is being borne out month by month. I wish it weren't true.

When you say the Indian response, you're talking about primarily the Indian government?

No. When I talk about an Indian response or a South African response or a Chinese response, we're talking about all sectors of society. HIV/AIDS is not a problem that governments alone can solve. It's a problem that requires very strong government leadership. It requires major investments of national resources. It requires expansion of programs in the public health infrastructure. But it also requires major responses by communities, by NGOs [non-governmental organizations], by corporations, by the great faiths -- including the great faiths of India. Without that multisectoral mobilization, HIV/AIDS is not turned around and cannot be turned around. It's a broad response that is necessary, and there aren't many places in the world today where we see a sufficient and broad response. It's coming.

[When] the Global Fund works in a particular country, you work through something called a Country Coordinating Mechanism [CCM]. What is that, and why was the decision made to follow this route, which some have criticized for being too government-centric?

The Global Fund took a very early decision that, because of the need for a multisectoral response to HIV/AIDS and because of the statement I made a moment ago that governments alone can't solve this problem, we needed to create a mechanism to talk to all sectors and to have a relationship not just with governments but with the churches, with other faiths, with NGOs, with the private sector, well beyond government.

Now, we could have taken the view that anybody can apply, and we'll directly fund anyone who applies. The problem with that is that you completely lose any sense of national cohesion. We could be funding things by accident that were actually cutting across other programs and where the national oversight was somehow lost. So the decision was taken to create a multisectoral committee called the Country Coordinating Mechanism, which would be able to maintain a degree of cohesion: What is India as a whole doing? What is Malawi as a whole doing? What is Guatemala as a whole doing? But around the table would be the churches, the NGOs, the private sector, etc., and the government.

Now, this CCM idea is a new idea, and it evolves through time. I think the glass is very much half full. Some of the CCMs have been spectacularly successful; others have been slower to develop the realization of that real ideology of multisectoral participation. But encouragingly, when I visit countries, as I do frequently, and meet with CCMs, as I always do, I see the direction is the right direction. I know of no CCMs that are going backwards. They are moving forwards in terms of more stakeholder participation, stronger voice for faith-based organizations, stronger voice for NGOs. ...

On the other hand, I've talked to a lot of people in India and Ethiopia, Russia, China, who are on the CCM and are just so incredibly frustrated by the role of government. ... They see the CCM as calcified. I hear it time and time again. People don't say it on the record because they're afraid to, but this is what I hear.

We're not short of information about what's going on in the CCMs, so it's not that we hear only what people want us to hear. We have many sources of information. We also have independent evaluations and audits of CCMs. We know what's going on. And we have CCMs that work well and we're very proud of and pleased with, others that have a journey to travel. ...

... When the Bush administration was putting together its plan in secret, were you aware of what they were up to?

I was aware that there was strong interest in Washington in developing a major HIV/AIDS program indeed. Of course, prior to the launch of PEPFAR [the President's Emergency Plan for AIDS Relief], which I think you're referring to, the U.S. was one of the founding fathers of the Global Fund, a very significant founding father. President Bush's speech in the Rose Garden in the summer of 2001, alongside President [Olusegun] Obasanjo [of Nigeria] and [U.N. Secretary-General] Kofi Annan was one of the points of birth of the Global Fund. The U.S. was our first major donor, the first country even before the existence of the Global Fund to say, "This is a good idea; this is the kind of mechanism we need, and here's a large amount of money on the table to help it get up and running."

Then later on, PEPFAR was announced and launched, and Ambassador [and Global AIDS Coordinator Randall] Tobias came on board. He's now a member of our board as well, representing the United States. So the PEPFAR program developed, working very much hand in hand with the Global Fund, [with] PEPFAR focusing on 15 countries, but also working beyond those countries, [and the] Global Fund in 130 countries -- and interestingly, the Global Fund being the major vehicle for U.S. investments in HIV/AIDS outside the PEPFAR 15. If you look at U.S. investments against HIV/AIDS in India, for example, the Global Fund is the largest vehicle, and in Russia and in China.

Were you disappointed when the U.S. announced what [economist] Jeffrey Sachs has called a unilateral approach to this, rather than to contribute the $3 billion a year directly to the Global Fund?

Well, it's no different from what all our major donors do. Something of a spotlight of controversy has shone on those decisions in Washington, but I have to say that all our major donors -- take Germany, take France, take the U.K., take the United States, take Japan -- maintain very active bilateral programs. None of them say, "Let's take all our HIV money and route it through the Global Fund." They all say, "The Global Fund is an important new financing mechanism and is the largest financial engine in the fight against the three diseases -- not only HIV -- but we have a variety of reasons to maintain our bilateral programs." ...

So Jeffrey Sachs is wrong when he says that it was a big mistake to basically go it alone on the part of the Bush administration?

Well, I wouldn't characterize the Bush administration as going it alone. I would characterize the Bush administration as greatly expanding their bilateral program, and the $15 billion commitment in the State of the Union was historic. It's much, much more money than any country has ever put on the table for any single development challenge, and within that commitment comes a commitment to fund the Global Fund -- if you like, the multilateral arm of PEPFAR -- and a commitment to fund the bilateral thrust of PEPFAR, which is to make a big impact quickly in the 15 countries. Were there other ways to do it? Of course. But is this an unusual way or out of step with what other countries have chosen to do? No, I don't think so. It's just more visible and larger.

So when some people say that the Bush administration effectively crippled the Global Fund by not contributing that $3 billion a year directly to the Global Fund, do you think they're off base?

No, the idea that the Bush administration has crippled the Global Fund is rubbish. The Bush administration is the largest donor to the Global Fund -- the first to make a big first contribution, the first to make a second contribution, the first to make a third contribution. The Bush administration is contributing a third of the total income of the Global Fund, and there are many in Congress who are fighting hard to maintain that contribution to the Global Fund at one-third of our rapidly expanding year-by-year income.

Now, if the U.S. is able to keep to that as our overall income grows from $1.5 billion in 2004 to $3.5 billion in 2006, if the U.S. is able to keep up with that, as some in Congress would dearly like to do and are fighting hard to achieve, to stay at 33 percent of our income, that will be quite remarkable in a number of ways. One, it will be a very large amount of money. Secondly, it is a far larger share than is conventional for the U.S. to contribute to multilateral efforts. Typically the U.S. fair share of multilateral initiatives is in the 20 percent to 25 percent range, and early on the U.S. Congress said, "Thirty-three percent for the Global Fund is our ceiling," and then many in Congress went further and said, "Not just our ceiling, but where we should be."

And up to now that's where the U.S. is, and if they can hang in there and keep their contribution growing as the total pie grows, it will be remarkable, and the response of the world should be that is more than a fair share for the U.S. in financing this multilateral, multi-stakeholder initiative, which everybody else has got to come to the table. It's not for the U.S. alone to pick up the bill.

With all this money on the table from these two funds and others, there is -- I'm sure you encounter this -- a high expectation in much of the developing world to get particularly the treatment quickly. I was in a hospital in Addis [Ababa, Ethiopia], a PEPFAR focus country and a huge recipient from the Global Fund, where the chief doctor in the central hospital was saying: "This is all great, but where are the drugs? My patients are dying now. Where are the drugs?"

... What we have found in the early years of our experience of trying to finance this is that the mechanical act of procurement -- having the money from the Global Fund, but then going out into the international marketplace for antiretroviral drugs; tendering, buying, getting the deliveries to come to the port; getting them out of the port and getting them distributed around the country -- that mechanical process has proved to be very slow, and in some cases sclerotic.

We are now working very actively to find ways to break through that and, for example, to aggregate the demand, because at the moment we pass money to each of the countries that we're financing, and then they go through their local tendering and procurement systems and buy whatever they want to buy on the international marketplaces, that turns out to be very slow, and there are more efficient ways to do this. For example, if countries ask us to withhold the money, pool the demand, and, if you like, bulk-purchase on their behalf and ship or get procurement agents to do those things … this is clearly going to speed things up, and [is] beginning to speed things up. So we're pushing strongly in that direction, and we hope that within six to nine months these long procurement lead times will have been greatly shortened. Also, of course, once the drug supply is established, then you're refilling behind the earlier supplies, so these big initial delays should be a thing of the past.

I've been in some storerooms in hospitals, this one particularly in Ethiopia, where you see the drugs that are there. On one shelf you have the PEPFAR drugs, brand name; another shelf next to it you have generic Global Fund. Isn't that confusing, to have these two big programs running side by side?

It's absolutely confusing. It's something that Randy Tobias and I have been talking about since his appointment, and we're working on together. ... We're both funding treatment, and at the moment, in too many countries, the Global Fund money is purchasing generics and the PEPFAR money is purchasing the same drugs, but the branded version from the North American and European manufacturers.

There are two problems with that. One is that it's very confusing in terms of training the doctors, establishing standard clinical protocols, making the supply chains work. I went to one hospital in Nigeria where I was told that there was something called PEPFAR patients and then ordinary patients. I said, "What's a PEPFAR patient?," and I was told a PEPFAR patient is a patient who has a clinical file with this color and gets these drugs, and then the other patients have a file of a different color, and they get the generics, and that's funded by Nigerian domestic resources and the Global Fund.

Nobody wants this. Nobody thinks this is sensible or helpful, and Randy Tobias and I are working on it in two ways. Firstly, FDA [Food and Drug Administration] has opened up this window which is now beginning to operate, whereby generic producers can apply for this special registration which would allow their products, although illegal in the United States and in Europe, to be bought by PEPFAR and used in developing countries where the IP [intellectual property] regime permits it. Now, we already have Aspen [Pharmacare], the South African company, having got through that FDA process. There are a number of Indian generic products that are in the pipeline in the system. We hope they get approved quickly. That will create convergence in what the Global Fund is able to purchase and what PEPFAR is able to purchase. So that's approach number one. It's taking a few months to get there, but we hope it will get there pretty fast.

The second approach is to do sensible deals country by country. For example, in Tanzania there is a deal between the Global Fund, PEPFAR and the Tanzanian national AIDS authorities. The Global Fund finance buys first-line antiretroviral generics, particularly the triple dose, the three drugs in the one pill that come only from the generic companies, and that's the recommended first-line treatment in Tanzania. So our money pays for that, and PEPFAR money pays for the second- and third-line drugs and for the pediatric formulations, which are more expensive and where the main source is the North American and European companies rather than the generic companies in India and elsewhere. So that's the kind of sensible division of roles that has been locally negotiated and I think makes life easier for the Tanzanians in terms of juggling these funding streams.

But you can understand the frustration right now at the local level?

Oh, absolutely. The frustration is immense. I mentioned my experience in Nigeria. I meet it every time I go to a PEPFAR country, and so does Ambassador Tobias. This doesn't make sense in the longer term. We have a joint commitment to provide treatment to as many people as we can with the next dollar, so lowest prices are an important consideration.

Assured quality is also an important consideration. Neither the Global Fund nor PEPFAR wants to be in a position of buying substandard drugs, so we want those lowest prices. We want the drugs to have either the WHO [World Health Organization] prequalification or the FDA approval so that we are assured and the patients receiving those drugs are assured that they are fully effective and up to the highest pharmaceutical standards. Those mechanisms are increasingly beginning to work. ...

What's your take on what some call the ideological bent of the president's fund, the emphasis on abstinence and some of the new regulations coming out regarding sex workers and IDUs [injection drug use] and needle exchanges? What's your take on that?

... Firstly, I would point out that when the U.S. money flows through the Global Fund, it loses some of the conditionality that may be applied to it when it flows through bilateral channels. One of the interesting things about the Global Fund is that it is a pooling of international funds, which are then applied according to the policies of the Global Fund, set by the Global Fund board, not the policies of one capital city or another capital city. ...

The second point is that there is no doubt that A and B and C and a lot of other things need to change before transmission will go down and HIV/AIDS rates will decline. So the view that we might have had 10 years ago, of "Use condoms, but otherwise keep doing exactly what you were doing," it isn't true. That is not a solution to the HIV/AIDS epidemic. We've got to shine a light on actual sexual behavior. When do teenage girls in this country have their first sexual experience? What kind of a sexual experience is that likely to be, and what happens after that? Is this violent sex? Is this involuntary sex? Is this rape? Is this sex forced on the girl by economic necessity, by poverty and by desperation? "Unless I have that sugar daddy, unless I have that relationship with that older man who's probably HIV positive, I won't get through school, or I have no future. I'm desperate." Those are the realities, and saying, "Use condoms" -- condoms don't do much for a raped 13-year-old girl. Condoms don't do much for a faithful young wife of a very promiscuous husband who comes back and demands whatever he demands after his travels. We've got to bear down on the reality of sexual behavior country by country and community by community. We've got to understand it; we've got to talk about it. ...

That's the hard thing about HIV/AIDS. It isn't easy. Most people don't want to talk about it. Most societies don't want to come to terms with the reality of sexual behavior rather than the mythology of how we would like to behave. These are the tough issues that we're all facing around the world.

When we interviewed [Samaritan's Purse President] Franklin Graham -- he probably would agree with a lot of what you just said, but he also said that the Global Fund and generally [the] U.N. approach to HIV/AIDS is too secular and lacking a strong moral component and that that will mean that ultimately you won't succeed in what your goals are.

Well, next time I talk to Franklin, we should talk about those things. I don't want to talk for the U.N. at all; we're not part of the U.N. But for the Global Fund, that is absolutely not true. If you speak to the board of the Global Fund, those who set our broad policies, and if you speak to my staff of 150 really dedicated men and women from all around the world, you will hear no shortage of moral commitment and passion. They are Christians; they are Buddhists; they are Muslims. They come from all around the world. Some of them are more secular; some of them are more spiritual. We have all kinds of men and women working for the Global Fund, but they share a great moral passion about this disease, and they have it because they go and see things, things that Franklin Graham may not have seen, but things that we see every time we go to visit the projects that we're financing, horrendous things. And the moral passion is there.

Do we need more abstinence? Do we need more faithfulness? Do we need changed behavior between men and women and a huge reduction in involuntary and violent and nonconsensual sexual relations, particularly involving younger women and teenage girls? Yes, we do. And is that a moral course that we're engaged in? Yes, it is.

Talk about China. ... There seems to be on a certain level a very strong commitment at the national level to do something, but there's a problem often in the implementation. A concern we heard a lot [was] that the Global Fund money, even with the best will in the world from Beijing, could well be falling to a fairly endemic system of corruption, particularly at the provincial and local level when it gets filtered down. How are you going to deal with that?

You raised I think two very distinct points. The first is what is happening in China in relation to HIV/AIDS. I was there in December, and I think there's some very good news, and then there's a big challenge. The very good news, which I've commented on publicly, and so have many others, and you probably saw when you visited, is that in a matter of 18 months, Beijing has moved from denial to a very high level of engagement -- the vice premier, Madame Wu Yi; her senior officials; the party; the government apparatus; corporate leaders; NGOs who are now much more tolerated and are speaking out. In Beijing I found a real understanding of the magnitude of the problem and a real dedication to solve it, to take it seriously, to be transparent about it. I think the experience of SARS [Severe Acute Respiratory Syndrome] in China had some influence on that, and Beijing has moved a long way in a short period of time in terms of identifying the enemy and confronting it in an open way.

The challenge is that what Beijing says and thinks can be a long way from what is happening out in the provinces. And again, senior officials were very frank with me about this when they said to me, "The challenge now is to get what we believe implemented as routine policy and approaches out in the remote parts of China, in the provinces and the country, where the people are infected and dying." That is easier in China than in many countries because there is an apparatus for the party to work and for social control in China, so the messages can get out, and people can be held to account. But it hasn't happened yet. It's work ahead of them, and they know they have to do that. So that's a major challenge.

In terms of your second, different point, which is about corruption, the Global Fund is investing in 130 countries. They include the most corrupt countries in the world, so no one is naive about the possibility that someone today or tomorrow might attempt to steal or misuse Global Fund money. We have in place -- I won't bore you with all the details -- a series of safeguards which are in some cases rather innovative, and we believe that those safeguards are giving us a high measure of both protection and vigilance: protection in the sense of making it hard to steal our money, and vigilance in the sense that we would know about it quickly if it began to happen. We've had one dramatic case where we did know about it before it actually happened, cancelled all agreements, got all the money back into our bank account, and started again with that country.

Where was that?

Ukraine. And can we bring the risk of corruption to zero? No, of course we can't. I mean, World Bank money is stolen; USAID [United States Agency for International Development] money is stolen. Anyone in the business of development finance has their money stolen on some occasion in some places, so we cannot make this a zero-risk game, but we can set in place procedures that minimize that risk and procedures that maximize the chance that we'll know about it quickly and be able to take very strong action. ...

[To whom is the Global Fund accountable?]

... We're a financing agency; we're not a development agency. We don't implement programs; we provide the finance. I think we're responsible to the millions of men and women around the world who are suffering terribly from these preventable diseases, and our duty is to finance the programs that will bring help and support to them as rapidly as we possibly can.

So the implementation is at the national level, but who oversees the implementation then?

As I explained, we fund government programs. About half our money goes to government programs. About roughly the other half goes to NGO, faith-based, private-sector [and] other organizations in the developing countries that have the capacity to do more good work in prevention, in treatment, in testing, in care of orphans. We're major financers now of the support for orphans, which as you know is a huge problem in Africa and will soon be a huge problem in India and other countries.

So the implementers are a wide range of different organizations whose applications come through the CCM, the Country Coordinating Mechanism, to the Global Fund [and] are reviewed by an independent technical review body, because we have a firm commitment to the evidence base of what we're financing. We don't finance any crazy idea; we finance ideas that are vetted by an independent technical panel that assures us that this is consistent with the latest scientific evidence, that it's the right treatment and the right approach for which we have evidence. That is the approach taken.

In any given country, does the success depend on the political will? Even though the CCM may be reaching out to civil society, governments play a huge role in the success depending on the political will.

… We practice a very advanced form of performance-based funding. So we say, "We've approved your program; here's an initial disbursement to get you started, and then all subsequent flows of money are dependent on results that you obtain, report to us, and have independently validated, so you can't just make up numbers and we'll send you another check."

So the performance-based funding system, which I think we've taken to a level beyond that of most other development financing agencies, provides a huge incentive and a huge assurance that the money is flowing to programs that are delivering the goods. If the work goes faster the money flows faster; if the work goes slowly the money flows slowly. If the work isn't done at all, the money is cut off and given to others. So that's part of the design of the Global Fund, which I think maximizes the chance that the investments are made in a way that has the greatest impact.

Both of these programs, Global Fund and PEPFAR, are limited by a certain number of years. In putting people on treatment, what sort of commitment are you and others who are funding these treatment programs making to those new entries put on treatment?

We're making a huge moral long-term commitment, and I think the world is only just waking up to that. If you look at development finance -- building a road, building a bridge, treating a case of malaria, educating a girl in a classroom -- these are things where if the money were to be turned off in five years' time, it would be a pity, but it's not a life-or-death matter.

We've now engaged in programs to finance very poor countries to do something that otherwise they would be quite unable to do financially, which is to put hundreds of thousands and then millions and then several millions of people on drug therapy for life in a situation where if that drug therapy were to be interrupted because the money wasn't there, the individuals would die rather quickly. We have never before between the rich nations and the poor nations entered into a long-term, morally binding commitment of that kind.

Now, if you're talking about funding South Africa or India or China or Indonesia you can say: "We'll support [you] for five years, support [you] for 10 years, and then you're on your own. Your economies are growing. You're not poor; you have resources. It's a question of political choices. You can choose to finance these things yourself, and you should do, and so we will scale out, and you will scale up."

But if you take the Malawis or the Nepals or the Malis, that's not a realistic option. The international finance will be necessary for decades to support and expand these programs, so we are making a very special moral commitment, and the wealthy countries I think are just beginning to come to terms with the true magnitude and long term-ness of that commitment. ...

Are you optimistic?

I'm very optimistic, because I think we have now, for the first time, very recently, we have now the ingredients that we need which we didn't have before. We have the political leadership -- not enough of it -- but in many countries leaders speaking out about the problem, and that's a precondition. You've got to have that. You cannot mount effective programs where you don't have that leadership.

Secondly, you need lots and lots of cash. This is really expensive. We don't have enough money, but we've got far more today than we had three years ago, and in three years' time we'll have far more. The graph of investment is rising rapidly.

The third ingredient that we didn't have but we now do is the practical and affordable technologies. ... Four or five years ago, treatment of a late-stage HIV-positive person would cost about $25,000 a year and might involve taking 30 pills per day. Today, with the prices negotiated by the Clinton Foundation and the generic companies, in agreement with the Global Fund, it's $140 per patient per year -- not $25,000, but $140 per patient per year -- and it involves taking two pills a day, one in the morning and one in the evening. They're the same pill, and in each pill are three different drugs. …

And, in fact, the research machine is incentivized by the existence of the Global Fund. If we invest in research and development, there is a big purchasing power out there to buy what we bring to the marketplace, and it's called the Global Fund. So we're beginning to drive the R&D engine, the research and development engine, so we will see better drugs, better diagnostics. And one day -- we have no idea when -- we'll see a vaccine. That won't be a magic bullet. It will not make HIV go away, but it will be an important additional weapon, and we pray for that day to come as soon as possible.

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posted may 30, 2006

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