Video Remarks as Delivered for the International Association of Physicians in AIDS Care Meeting Jonathan Mann Memorial Lecture


December 1, 2009

New Orleans, Louisiana
December 1, 2009

Good morning. Thank you for allowing me to join you today, even though I cannot be there in person. It is a privilege to join you in remembering Jonathan Mann, a friend of mine.

Jonathan was a pioneer in the field of HIV/AIDS and a true champion of human rights. He was among the first to realize that this disease challenged medical delivery systems in new ways, and to call for us to adapt our systems to meet this challenge. Through his efforts at the World Health Organization (WHO), as well as his research in the field, he helped to chart the course for how we treat and prevent this disease. I know we all remain grateful for his work.

Jonathan was also among the first to place health within a human rights framework. He reminded us that health is key to enabling people to reach their full potential. And he reminded us that everyone deserves the chance at a healthy life free of this disease - a chance that a growing number of people around the world are now receiving.

Today, on World AIDS Day, we cannot forget his message. Through the President's Emergency Plan for AIDS Relief, the U.S. Government is committed to supporting efforts to ensure that individuals can live full and healthy lives.

President Barack Obama and Secretary of State Hillary Rodham Clinton are committed to continuing and building on PEPFAR's critical work. PEPFAR is a cornerstone of the Global Health Initiative outlined by the President and Secretary Clinton. Both are committed to promoting sustainable HIV/AIDS responses in the countries where we work. And they will also want to take advantage of our opportunity to leverage PEPFAR as a platform to expand the accessibility of health care services such as maternal and child health, family planning and neglected tropical diseases through our HIV/AIDS programs. Given the growth in programs, resources and donors, now is the opportunity to focus on strategic integration and coordination of these services with our HIV efforts.

As Jonathan knew long ago, and we all know now, better health leads to improved safety, security and prosperity for countries. But to maximize our development efforts and expand opportunity and prosperity to more people in more places around the globe, we must support partner countries in increasing their leadership and ownership of the response to HIV/AIDS.

To demonstrate the impact that these efforts can have on a nation, I want to share with you a short video produced by the Bill and Melinda Gates Foundation as part of their Living Proof Project. This video captures the story of a father and a son from Cote d'Ivoire who benefitted from a PEPFAR-supported antiretroviral treatment program.

[http://www.gatesfoundation.org/livingproofproject/Pages/video-gallery.aspx]

The U.S. Government is proud to support bold local leadership from individuals like Kevin and his father. Through PEPFAR, we will continue to support partner country leadership at all levels, from communities to national governments, in their national efforts to stop HIV/AIDS.

At the same time, we also recognize that the path to sustainable HIV/AIDS responses involves government leadership. A government ultimately holds the responsibility for promoting the health of its population. PEPFAR will look to our partner governments to define their countries' unique challenges. 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, we will support governments as they 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 countries in developing the leadership and capacity to orchestrate a response to these unmet needs. We are all obligated to support countries in assuming control of their HIV/AIDS responses - in terms of strategy, management, and eventually financing.

Of course, most countries hit hardest by the AIDS epidemic, especially during this economic downturn, are not able to assume every aspect of this role in the near future - particularly with respect to financing. That's why it's so important that the President and Secretary have indicated that the U.S. Government will maintain its strong support for PEPFAR, even as budgets tighten here in the United States.

PEPFAR will continue to work with governments to build their capacity to meet the needs of individuals at risk for HIV, those infected with it, and all affected by the epidemic. We have begun to set the course through PEPFAR Partnership Frameworks - five-year roadmaps, established between the U.S. and partner governments, to increase country commitment and capacity. This will begin a new dialogue that will increasingly feature the partner governments as the program implementers.

But Partnership Frameworks are just one step in the right direction. More can, and needs to, be done - particularly to strengthen the larger national health care systems in a more strategic manner.

Health systems strengthening is a critical goal of PEPFAR and the Global Health Initiative. And it will play a pivotal role in achieving sustainability of national HIV/AIDS responses. Currently, 50 percent of all hospital admissions are related to HIV/AIDS in the hardest-hit regions, presenting a problem that this stretches beyond HIV and into every area of health care. Through the implementation of successful HIV programs, PEPFAR can help to reduce hospital admissions for HIV/AIDS and drastically decrease overall hospital utilization. This in turn helps to ease the burden on clinicians throughout the system and free up additional time for them to spend with patients with other diseases.

Building upon our successes to date through intensified investment in the health workforce and infrastructure, we will use PEPFAR as a platform to strengthen and extend health systems. This is crucial to the sustainability of PEPFAR and other health and development programs.

As we address HIV/AIDS, we are confronting the gender realities that drive the pandemic - gender inequities, economic dependency, gender-based violence, women's lack of educational opportunity and inability to access health care. We are also developing strategies that target men, bring them into care and engage them in peer-led discussions around their relationships with women. PEPFAR is committed to 'mainstreaming' gender considerations into HIV/AIDS programs.

Globally, sexual transmission remains the primary driver of the epidemic. We will improve our ability to support countries in behavioral, structural and biomedical interventions. We cannot treat ourselves out of this disease, but we can leverage our existing care and treatment platforms to ensure that prevention is well integrated into care for all HIV-positive individuals as an integral, standard component of our effort.

The data showing persons who engage in high-risk behaviors face a disproportionate risk for HIV infection inform our outreach strategies. We know populations such as sex workers, injection drug users and men who have sex with men, are at disproportionately higher risk for HIV infection. For example, an estimated five to ten percent of HIV infections can be attributed to injection drug use worldwide. If we are to succeed in reaching these populations at elevated risk with HIV/AIDS services, we must rededicate ourselves to aggressive, continuous, and multifaceted prevention interventions.

At the same time, these efforts present different challenges in each culture, requiring the development of special strategies that identify access points and retention strategies for these populations. While this is challenging work, we must make targeted outreach an integral component of our care. If we neglect to focus on those who do not easily reveal themselves to medical delivery systems, we lose an opportunity to reach an individual at risk, and we permit a vulnerability for the continued transmission of HIV throughout the community.

But as we intensify outreach and retention, we must ensure that the strategies we use are sensitive to the individuals participating in high-risk behaviors, and that they do 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 also are working to scale up targeted HIV counseling and testing efforts, especially in clinical settings, to meet patients where they are and at the moment that they are open to getting tested. For those who are found to be HIV-positive, we seek to link them into a continuum of care and prevention services, and for those found HIV-negative, we seek to provide support so they can remain HIV-free.

Biomedical approaches are another key component of prevention. In two trials, medical male circumcision proved effective in reducing men's risk of acquiring HIV by at least 60 percent. We are thus working with partner nations to make circumcision widely available in medical settings as part of comprehensive prevention program.

Another critical biomedical intervention is prevention of mother-to-child transmission. There's no mystery about this. The success of Botswana, which has reduced infant infections to levels similar to those in the U.S., shows that these programs work and the need is to scale up rapidly. PEPFAR has done a lot, but in most partner countries the unmet need remains great. So PMTCT is something we're now focused on supporting countries to scale up much more aggressively.

We recognize that the solutions to the challenges depend on concerted, collective efforts. On this World AIDS Day, let's rededicate ourselves to working together in the fight. Let's recall Jonathan's message that health is a human right - a right all of us must protect and nurture, especially as health care providers. You each have a role to play in making decisions that are always in the best interest of your patients, so that they may pursue and achieve their highest potential.

I look forward to continuing to work with all of you, and the global community, to win this fight.

Thank you very much.

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