Editor's Note: The following keynote address was delivered April 15, 2002, at the 5th International Conference on Healthcare Resource Allocation for HIV/AIDS, which was sponsored by the International Association of Physicians in AIDS Care (IAPAC), in association with the Brazilian National STD/AIDS Program, European Commission, Pan American Health Organization (PAHO), and World Health Organization (WHO).
Honorable Minister, distinguished colleagues, ladies and gentlemen, it is a tremendous honor and privilege to be here to discuss how to translate the current momentum into concrete progress in the expansion of HIV/AIDS care in resource-limited settings.
Let me first of all express my deep felt gratitude to the organizers of this conference for inviting me to give the keynote address. This conference could not have been held in a better place. Brazil is one of the first few countries that dared to use its national budget to provide comprehensive care to those infected by the HIV virus. I am glad to be here and salute you, the people and government of Brazil, for your leadership.
Mr. Chairman, my presentation will focus on three broad areas: 1) the state of the epidemic and the response to date; 2) experiences and rationale for expanding comprehensive care; and end by 3) the road ahead, keeping up the momentum and moving towards achieving concrete progress.
During the first decade of this epidemic, with a few notable exceptions, both developing and developed countries failed to address the epidemic strategically. Few would speak openly about AIDS, and even fewer elevated it to a broader developmental issue. At about the same time, international support began to fade. In donor countries, stabilizing HIV incidence, promising new therapies, and disbelief of the worsening epidemiological projections blunted the sense of urgency that had motivated rapid action in the late 1980s. This persistent denial and lack of concrete successes in the hardest hit countries, mainly in Africa, also sowed seeds of doubt among donors that more money could, or would, be effective in blunting the epidemic.
The international response was also starved for funds. Annual global resources for AIDS had nearly quadrupled in the first years of the global strategy, from US$44 million in 1986 to US$165 million in 1990. Then growth in funding began to stagnate. By 1996, total global resources had leveled off at about US$300 million per year, two-thirds of which came from only three donor countries. This was, by any measure, insufficient.
By the mid-1990s there was a scientific breakthrough in the development of highly active anti-retroviral drugs. This brought hope to many and indeed for those who had access, AIDS became a treatable chronic condition. Despite rhetoric that it could not be done, countries such as Brazil, Thailand, and Costa Rica took bold steps to provide [antiretroviral drugs] to their people. The per capita income of these countries is about 10 times more than the per capita income of the poorest countries in the world and the HIV prevalence rate is also lower.
Despite the lack of good feasibility studies, however, access to care for resource limited settings was escalated to the highest level by activist groups and the international AIDS community. There are a number of issues that prevented the care agenda from moving ahead to reach millions. Let me mention the two that paralyzed the debate and prevented forward movement. The first one was the prohibitive cost of the drugs and the infrastructure required for proper administration of the drugs; the second one was lack of capacity and long-term sustainability.
Until very recently, the issue of access to care for resource-limited settings was not even considered by several bi- and multilateral donors, including the World Bank. While drug prices have come down substantially, the thinking behind access to drugs has not. The argument has been that for most developing countries the per capita health expenditure is US$12, and providing comprehensive care, which costs more than many countries could afford, was viewed as impossible and irresponsible. One has also to remember in many of these countries neither the basics of prevention such as condom distribution and cleaning the blood supply system nor basic care such as treating opportunistic infections and palliative care were implemented in large scale.
The HIV/AIDS epidemic also brought to the forefront the long neglected problem of health infrastructure in many of these countries. Many argued, even if the drug was available for free there is no way to ensure proper use, distribution and administration. These arguments made it look impossible for developing countries to benefit from this hope for life.
The issue of access to care emulates the history of capacity building and technical cooperation for the last fifty years of development. Let me quote a presentation by Evelyn Herfkens, the Dutch Minister for Development: "We can deliver our four-wheel drives, our procedures, and our policy documents. And we can deliver foreign experts but we have not really been transferring knowledge ... we should know the underlying causes when capacity constraints are being felt."
Sustainability and cost effectiveness concerns have paralyzed access for many years. While it is easy to dismiss these questions as hard-hearted, that does not make them any less real. A dollar spent on one thing cannot be spent on something else. Until recently, these therapies were so expensive, and resources for AIDS were so scarce, that countries faced heartbreaking choices between treating a fortunate few or giving far cheaper life-saving services (such as vaccines or tuberculosis treatment) to many others.
Today, however, the calculus is rapidly changing, for four reasons:
First, the cost of these drugs is plummeting. Activism and competition have worked together to make these therapies 70, 80, 90 percent more affordable. While countries must still face hard choices, what is affordable grows with each passing day. Moreover, the more these drugs are used, the more these prices will eventually drop as more suppliers join the market. So what we do today will affect how much we can do tomorrow. And what we learn by starting today will help us be more effective tomorrow.
Second, the amount of resources for AIDS is growing rapidly. Donors have realized that if countries hit by AIDS deplete their other development investments to respond to AIDS, it will be like trying to fill a leaky bucket. HIV preys on under-development, on lack of education, on inequality. If we lay down our gloves in those fights today, we will be hit back by HIV even harder tomorrow. What we need is more resources for both AIDS and development, and that is what donors committed to in Mexico last month.
Third, the benefits of preventing AIDS deaths are becoming quantifiable. Brazil, again, serves as a good example. Some of the impacts of comprehensive care are reduced mortality, reduced morbidity, reduced hospitalization, and tremendous cost saving. And these are only the savings to the health system. To [perform] a proper cost-effectiveness calculation, one needs also to add in the value of the extra productive years of those affected, the reduced years of orphanhood for their children, the averted strain on families and communities, and the preservation of educated manpower for the public and private sector alike.
Finally, there will be a great indirect benefit to expanding care -- the strengthening of health systems around the world. Let us be blunt. Far too many developing countries have neglected their health systems over the past generation, for reasons you know better than I. AIDS is a wake-up call, and it will not be the last. The fact that so few health systems now have the foundation in place to administer widespread therapy gives these countries the strongest possible motivation for giving these systems the attention they deserve. If we do not seize this chance to show what we can do, it may take another generation and another pandemic before another opportunity arises.
First and most important, governments of both developed and developing countries are increasingly showing the necessary leadership. Inadequate political commitment had long been the missing link in many of the responses.
Second, this rejuvenated international response is more strategic, comprehensive, and collaborative than were its predecessors. Governments, agencies, and other entities now share a broad consensus that the global response must:
In designing their programs, nearly all donors and agencies are now working through national authorities in prevention, care, and treatment and coordinating with one another in a cluster of common efforts, including UNAIDS, the Global Alliance for Vaccines and Immunization, the International AIDS Vaccine Initiative, and the Global Fund.
Third, the new commitment is being matched by new funding. For example, between September 2000 and February 2002 the World Bank launched the Multi-Country HIV/AIDS Program (MAP) for Africa and the Caribbean, which set aside US$1 billion and US$155 million, respectively, in concessional funds to support national programs. Unlike previous programs these funds will be used for the full spectrum of prevention, care, and treatment. Within a year, 16 African and six Caribbean governments had reached agreements. Nearly US$570 million of the money has been committed. That represents more than four times as much as total external support for AIDS in Africa in 1998. Under the Highly Indebted Poor Countries initiative, donor and recipient governments have agreed to channel savings from debt relief to fund HIV/AIDS programs.
Fourth, efforts of the past two years have been driven by a far broader understanding of the pandemic, both in the professional AIDS community and in the general public. In the professional sphere, experience has proven the effectiveness of many replicable means of preventing HIV and caring for those living with AIDS.
Perhaps even more important has been the growth in public awareness. Over the past three years, AIDS has commanded ever-widening public attention in Africa, Europe, and the Americas.
First, governments of these countries, their people, and the international community must ensure that they have the capacity to carry out and sustain their own response. In the past, too little capacity was built, sustained, or retained. Capacity means more than trained personnel. It means strong systems supporting health, education, nutrition, social welfare, and community development, among other things. HIV has preyed on weaknesses in these core systems and on the poverty, inequality, and social exclusion. If these contributory causes are not addressed, many of the developing countries will remain ever vulnerable to HIV as well as to [a] panoply of long standing endemic ills. If they are addressed, the effort against AIDS could also produce beneficial spin-offs in a wide range of related areas.
However, fixing the problems mentioned above takes time. The way forward will be finding short cuts to reach those who need help now while working to solve the long-term concerns. These two must go hand in hand. For example, the [World] Bank programs for Sub-Saharan Africa and the Caribbean can be used to cover 60 to 80 percent of the needs within the spectrum of comprehensive care. As most of us know, antiretroviral therapy is only at the end of this spectrum. Additional resources from the Global Fund can supplement these resources and be used to buy antiretroviral drugs. These resources could be used to quickly build capacity for the short term and at the same time lay the foundation for sustainable capacity.
There are several examples of these short cuts worth mentioning. AIDS Empowerment and Treatment International (AIDSETI), an organization of people living with HIV/AIDS, has managed to reach thousands with left over drugs from rich countries in only a very short time. This organization has established a system where each patient's data is computerized, and they know where each pill has gone and how many people live with a better quality of life.
Second, the global response must remain vigilant to keep the current momentum. Same countries that are unlikely to reach the millennium development goals (MDGs) are also the ones that are hit hardest by the HIV/AIDS epidemic. It looks very similar to the health goals as well. These are the kinds of evidence we should use ... upon those who are in charge of the development agenda to show that without dealing with the HIV/AIDS epidemic effectively, it will be difficult to reach any of the MDGs.
The struggle against HIV/AIDS will likely be long. Setbacks are inevitable. The virus may take turns for the worse, as may whole societies in the countries most affected. It is vital for the developing world and its global partners to prepare themselves and their constituents for a protracted effort. A retreat to denial or complacency would amount to a reprise of the retreat of the 1990s, with catastrophic consequences.
Third, we need to address comprehensive care in terms of "how" and "when" not "if" and "perhaps." While the global community needs to make clear that no magic bullet is likely for years, if ever, people in resource-limited settings should no longer be denied from benefiting from these therapies. While it is true that universal treatment is not yet within reach, we cannot bring it in reach without starting wherever we can. Indeed, the sooner we begin trying, the sooner prices will fall and the sooner we will learn the "locally specific" knowledge that will help make treatment feasible and accessible for millions.
We have been working in prevention for more than two decades now. We know that prevention works. We also know that prevention has never been given a chance. Many countries hit hardest by the epidemic never had the means to scale up prevention to cover whole nations. Prevention remains important and cheaper than treatment. However, with over 40 million people living with the virus, we need to realize that to care for those already infected is to give prevention a huge incentive. Knowing one's sero-status becomes meaningful only if there is hope for treatment. Care should never be seen as taking away resources from prevention; at this stage of the epidemic we cannot do prevention without care.
Let me go back and use the rationale by the Dutch Minister of Development. Let us provide menus of care with several choices and empower the governments and the people living in resource-limited settings so that they can choose what is feasible and what works for them. Remember they also observe the miracles that have happened and are happening in people living with HIV/AIDS in the North who can afford these drugs and lead a better quality of life.
Let us pledge to ourselves today that when we leave Rio [de Janeiro] we will not waste any time despairing of the obstacles we need to overcome to expand care to people in resource-poor settings. Instead, let us pledge to accelerate action to overcome obstacles. [Let us]:
Finally, Honorable Minister and distinguished colleagues, there are 40 million people living with HIV, who given proper care and treatment could lead normal lives, otherwise they are sentenced to premature death. Let us imagine that these 40 million people are citizens of one country. Let me compare this nation of people living with HIV to countries with populations of similar size: Colombia (41.5 million), Myanmar (45 million), and South Africa (42.1 million). Who among us is prepared to write off the future of Colombia, Myanmar, and South Africa? We need to remember that, "everyone has the right to be cared for and to die with dignity."
It is in our hands to leverage this time of great momentum and promise. If we use it appropriately and effectively we will indeed make sure that millions and not hundreds are cared for.
Let us liberate ourselves; change our mindset from it cannot be done to each of us pledging "I will contribute to make it happen!" AIDS, which has been a global tragedy for so long could yet become a testament to global solidarity.
Charge forward we must! We dare not fail!
Debrework Zewdie is the Coordinator of the Global AIDS Campaign at the World Bank in Washington, DC.
Back to the August 2002 issue of IAPAC Monthly.