International AIDS Society Meeting
Cape Town, South Africa
July 20, 2009
Well thank you. It’s a real honor to follow both Tony [Fauci] and Michel [Kazatchkine] in speaking to you today. I would like to say that it’s an honor to have the opportunity to speak to you in general, and I cherish this opportunity.
I’ve only been acting as U.S. Coordinator for a little over three weeks now, and it is a change in focus. The extraordinary number of tasks that are presented to fill your day have been somewhat overwhelming. And it’s going to take a concerted effort to remain focused on those issues that make a difference and at the same time promote an awareness of the work that you do, have completed and have continued to be engaged in to those who make appropriation decisions in Congress.
I had not realized the degree to which the programs that you are performing now on a daily basis in all the countries that you are involved in are being monitored closely by our colleagues on the Hill – on both Senate and House sides – to the level that the data collection burden that I know we are all burdened by is largely driven by the Hill. So, I think that a big part of my focus will be on trying to put an element of reason in what we ask you to generate in way of numbers.
I really want to thank you for your continued, concentrated efforts, your passion and your dedication to these works. You have permanently changed the landscape of global health. There is no doubt about that. And what you have done has impacted so many lives. And their lives have impacted their families and their communities – whole regions and countries have been affected.
Before I begin a discussion on some of the clinical and technical challenges facing PEPFAR, as well as the global AIDS community, I want to give broad overview of what President Obama and his Administration have focused on in defining, or continue to define, their global health agenda.
The fight against global AIDS is a central piece of the foreign policy and global health agenda outlined by President Obama, as Tony just alluded to. Secretary of State Hillary Rodham Clinton has made this a top priority, and continues to have a daily understanding of where we are in both our ability to continue programs, but also to begin to put a frame around the vision of an expansion of programs into impacting those diseases that are easily accessed from the PEPFAR platforms that have already been established.
The Administration’s Global Health Initiative will continue our country’s leadership on global health priorities like HIV, TB and malaria. But the idea is to expand the focus on integrating current programs with those that address maternal and child health, expand again into family planning and neglected tropical diseases.
Investing in global health, as well as broader development efforts, is considered a smart thing to do. Better health leads to improved safety, security and prosperity for countries. At the State Department, and throughout the Administration, there is a solid understanding of the importance that health and development programs play in achieving our foreign objectives.
We will increase the likelihood that our accomplishments in PEPFAR are more durable by conveying a desire to aggressively try to lay on top of the health activity a development activity that allows that progress to be sustained and more durable.
In remarks last week on the American foreign policy, Secretary Clinton really emphasized the need to update and create vehicles for cooperation with our partners and to elevate development as a core pillar, as she put it, of American foreign policy. Secretary Clinton, I believe that increasing partner country ownership and ensuring the sustainability of our efforts will be key to maximizing our development efforts, and expanding opportunity and prosperity to more people in more places around the world.
In order for our shared goals to be realized, we must commit to intensifying and invigorating our existing partnerships – and to cultivate new ones. From an HIV/AIDS perspective, I believe we can and must scale-up our efforts to foster alliances that promote government buy-in and ownership in a more intense way than we have done to date, as well as those of other diseases.
Partner country programs, partner country plans for prevention and treatment must be the central vision that we now embrace. To make this happen, we must collectively support country-led efforts to plan and manage programs, deliver services, and eventually finance health care delivery.
This will, of course, necessitate maximum coordination among all stakeholders, especially ministries of health, their regional and local facilities – realizing that the decentralized nature of health care has to be incorporated into our health care delivery strategies – and the other inputs in the health care delivery system, including civil society. This will not be easy, this will happen slower than an NGO-dominated implementation strategy, but it is a key component to the durability of these issues.
To begin with, we need to support partner countries, from governments to communities, in their national efforts to fight this epidemic. Strong national government commitment is central because each government ultimately holds the responsibility for promoting the health of its population.
Each nation’s epidemic poses its own set of unique challenges and obstacles, so interventions must be integrated into each country’s overall health planning and grounded in local capacity – both human resources as well as bricks and mortar. Through an inclusive process that includes communities within each nation, governments have the responsibility to identify unmet HIV need, craft national strategies to respond, prioritize the unmet needs, and convene partners to support their response to these unmet needs.
As international partners, our role is to support country leadership in establishing and managing their own programs ultimately. The end goal is for each country to be in a position to control its responses to HIV/AIDS – both strategically and eventually financially.
We understand, and we really do understand, that the majority of countries hardest hit by the epidemic, especially during this economic downturn, are not able to assume every aspect of this role right now – particularly with respect to financing – nor will they be able to in the near future. But that does not mean that we can’t work aggressively with governments as supportive partners as they build their capacity to respond in responsible ways that meet the needs of individuals affected and infected, or who are at risk for HIV.
Honoring our collective commitment to be honest about where the science tells us to go and, as Tony said, to honor that, and to try to integrate what the science tells us to do in all of our works. But at the same time wanting to work with governments to find, without giving up excellence, or quality or quantity, the ability to roll out prevention and treatment programs.
We have already begun to set the course for increased country ownership. Through the PEPFAR activity, the United States Government is now engaging in Partnership Frameworks, which are five-year joint strategic frameworks that are designed to put a process in place, increase the dialogue with partner countries in such a way that technical assistance needs are more explicitly identified to transition program management, budget creation, budget used as a planning tool, and continue what has already started: medical technical assistance to maintain the clinical care at the highest possible levels.
We provide an essential opportunity to hold countries and partners – and especially ourselves – accountable for the contributions and the results. But these Partnership Frameworks are just one step in the right direction. More can, and needs to, be done – particularly around HIV interventions to strengthen the large health care systems in a more strategic manner.
A critical goal of the Global Health Initiative – and a longstanding focus of PEPFAR – is the support for health systems strengthening. Continued and intensified investment in this area, including the health workforce, will be crucial to scaling up proven interventions and adding to the sustainability of PEPFAR and other health and development programs.
By using HIV treatment as a platform, PEPFAR support has strengthened and extended health systems in many areas including human resources, infrastructure, informatics, commodities logistics, and laboratory services.
We need to take advantage of PEPFAR programs and data collection to rapidly define implementation strategies that work, or sometimes don’t work, to maximize positive outcomes. Building health systems to adequately respond to HIV/AIDS means systems that can better respond to other health issues as well. Those opportunities need to be indentified and engaged.
As physicians, as health care providers, you know this well. These systems can become a focal point for the convergence of other health and development activities, including those involving women and children, economic stability, gender equity and education. Not to do all things, but to use that as a basis on which to engage the community, through the patients that are interfaced with the delivery system already on a multiplicity of levels that further stabilize their health, their families and their communities.
As we seek to better integrate our global health programs and strengthen our development efforts, we must also ensure that we are building on our success to date.
We know, for example, that we must place a special emphasis on women and girls to address gender inequities. We also must also develop that target men, find men, bring them into care. Strategies that go out into the work setting, where men often are, and engage them in discussions that are peer-led around their role and their relationships with women, and the issues around gender inequities. But not in a talk down, or in a condensing fashion, really more to explore the feelings and the issues that are many hundreds and thousands of years old, and giving perhaps a new frame on which men can begin to think about themselves, begin to question and evolve in their own self perception and increase the quality in which they engage in their partnerships with women.
As we engage in HIV/AIDS work, we cannot ignore the gender realities – gender inequities, economic dependency, gender-based violence, the lack of educational opportunity and inability to access broader health care in women. PEPFAR is committed to finding ways to focus on these issues and find ways to mainstream these issues into the program areas.
Globally, sexual transmission remains the primary driver of the epidemic. We must improve our ability to work collectively to determine how to identify and disseminate effective behavioral, structural and biomedical interventions that converge on a given population over time. These prevention interventions need to be aggressive, continuous, and multifaceted, in order to succeed. MSMs, commercial sex workers, transgenders, injection drug users present different challenges in different cultures that require the development of special strategies that identify access points and retention strategies for these populations. This has to be an integral component of our care. For to forget to focus on those who do not easily reveal themselves to medical delivery systems creates an opportunity lost, but also a vulnerability for the continued transmission of HIV throughout the community.
Continued efforts to leverage our existing care and treatment platforms are essential to ensure that prevention is well integrated into the care for all HIV-positive individuals. As of September of last year, PEPFAR supported more than two million people on antiretroviral treatment. By targeting this existing treatment base – the HIV positive communities – we can reach an even larger number of people living with HIV/AIDS, their partners, and families with prevention interventions. Again, this needs to be an integral, standard component of our effort. And allow us to also look at the difference in these communities and tailor the prevention interventions accordingly.
In generalized, high-prevalence epidemics, many HIV-positive individuals are in discordant relationships. Recent data from Kenya shows that approximately 45 percent of people living with HIV/AIDS have an HIV-negative spouse or a cohabitating partner. Of these, approximately 80 percent who tested positive were not previously aware of their status.
In order to best reach those at risk, we need to scale-up counseling and testing efforts that target better, that try to meet the patient where they are at the moment when they are accessible and open to getting tested with a test that will not take two weeks or be associated with a long post-test counseling discussion, but actually engage the individual in introducing strategies that allow them to decrease risks of behavior. For those who are linked into – for HIV-positives that are found – into a continuum of care and prevention services; for prevention with individuals who are HIV-negative and at high risk, we must utilize more intensive case management strategies that links them into a continuum of care from the beginning, and does not allow that individual to be lost to the system.
We know persons who engage in high-risk behaviors, including sex workers, injection drug users, and men who have sex with men are disproportionately at higher risk for HIV. Globally, an estimated five to ten percent of HIV infections can be attributed to injection drug use alone. In low HIV prevalence settings, the rate of HIV infection among men who have sex with men is 58 to 60 times higher than those of the general adult population, while in high-prevalence settings infection rates were nine to ten times higher than the adult population. These data must continue to inform our outreach and retention strategies.
While we have scientifically sound interventions for these populations, we must expand access to ensure that we reach those less likely to have access to services due to fear of revealing themselves, the stigmatization that is associated, or the criminalization that they may incur.
At the same time that we intensify outreach and retention, these strategies must also be sensitive to the individuals participating in high-risk behaviors and must not increase discrimination or place them at higher risk for violence or incarceration. No matter how effective the intervention, it is imperative that human rights context be the frame in which we engage.
We must remember and have our actions guided by the intention to first do no harm. Along with more targeted prevention interventions, another key component of prevention is biomedical prevention. We know that there is an increasing need to expand the prevention interventions and to factor them into programming as appropriate. I think Tony gave a nice review of what the horizon shows. We are excited about the pre-exposure, post-exposure, but especially the pre-exposure prophylaxis. The idea of the test-to-treat strategy needs to be looked at – a very promising idea of putting a public health moment and engaging in that opportunity makes a lot of sense if the data so shows.
For instance, the medical male circumcision has proven effective in reducing men’s risk of acquiring HIV at least 60 percent. Having and incorporating where acceptable in communities the ability to voluntarily opt-in to a male circumcision strategy should be available – easily available – in medical settings as part of a comprehensive program. We are also exploring additional strategies to further reduce HIV incidence for male circumcision of children at birth.
We must continue to explore new biomedical prevention tools as well. And I think that NIH, CDC, PEPFAR, the Global Fund are all involved in projects and studies that are attempting to get the data to show that these indeed are interventions that are worthy of support.
We need to prove that it is possible to achieve the very high coverage and adherence rates to saturate populations and lower individual viral loads, and to impact the transmission. There are a number of clinical trials as was alluded to that look at the patients being treated with antiretroviral drugs, looking at the different combinations that may make more sense, the laboratory burden, etc. All of which are promising and have great potential to impact large numbers and should, with data, be incorporated into our armamentarium.
But we must consider the long-term impact of such strategies. Having treated patients living with HIV for, I guess almost 25 to 30 years now, it’s clear to me that we get into an area that is difficult when we put a public health strategy in the tool box or in the black bag of the provider/physician. The physician must always maintain a relationship, that doctor/patient relationship, that provider/patient relationship that communicates to the patients so that the patient knows and believes that the physician/provider –the provider – every time will do what is in their best interest. When we start confounding a public health intervention in a clinical setting, we run the risk of having a public health intervention as realized through that doctor/patient relationship confound or confuse that element of trust, that pact of trust. We want to be careful about how we interpret the data so as not to challenge that, in that the longer term side effects may not be in what is in the patients best interest – for a patient with diabetes, or coronary artery disease – to start them on antiretrovirals, adding five or ten years to their duration on these drugs may indeed not be in their best interests. And those things, those questions, need to be answered.
As we work to strengthen our partnerships and elevate the importance and impact of global health and other development efforts, we recognize that the solutions to the challenges of sustainability, country ownership, HIV prevention, and ensuring effective programming can only be made possible through concerted, collective efforts.
Secretary Clinton noted last week, and she was quite eloquent about it, that no one nation can meet the world’s challenges alone. And after many years in the global fight against HIV/AIDS, everyone in this room knows that’s true. We must work together to defeat this disease.
I recall, and I’ve heard both Tony and Michael reflect through the years the advances that have occurred with HIV. In the 1980s, we got very good at diagnosing and treating opportunistic infections. In the late 1980s, antiretrovirals with AZT, DDI, DDC, D4T, then 3TC started to come in. It wasn’t until 1994 that we really had antiretroviral therapy that effectively impacted longevity more than a couple years. That actually looked like initially we thought that to treat hard, treat early, was the mantra that came out. In 1994 through 1996 that we really thought that these drugs really perhaps were on the verge of really showing a cure. It was Tony’s data, with others, that showed that this cure was not really there, and that really the virus was harbored. The ability to juggle multiple antiretrovirals and keep individuals, even with persistent viral loads, slowed in their progression of disease in themselves really became the state of work. Many of our patients now are on five, six drugs, sometimes seven drugs, to maintain them at a high functional level – many able to continue to go to work and interact in a normal way, but requiring monitoring and a close relationship with their providers, so that this is done safely and allowed to make the best decisions at the right time.
I think that we are also humbled by remembering the IAS meetings. I can remember the first meeting in Washington, DC – and I know Tony as well – where we gathered, what was it around 1984 or 1985 – around what we could do with this new disease. And the meetings that went on for Geneva, then Barcelona, then Durban where it moved from a north-north to then a north-south, and I think that, and would hope, that we are on the verge of now creating the foundation on which a south-south support and vision can now dominate.
I thank you very much for this opportunity, and look forward to questions.
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