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Interview With Ambassador Stephen H. Lewis

United Nations Special Envoy on HIV/AIDS in Africa

Winter 2003/2004

Stephen H. Lewis

P4P: We're speaking with Ambassador Stephen Lewis, the UN Special Envoy on HIV and AIDS in Africa. Ambassador Lewis, I attended your presentation yesterday and you had six rather profound areas that you thought were really critical in terms of addressing the HIV pandemic. I would like to run through those one at time here. The first one you talked about was the money that's needed. Please tell us more about that.

AMB Lewis: Around financing and resources, UNAIDS, which is the UN body that does most of the statistical work, has indicated that we'll need $10.5 billion to address all of the aspects of battling the pandemic internationally by the year 2005, and we'll need $15.5 billion by the year 2007. Last year, we had about half of what we'll need, a third of what we'll need come 2007. Where the additional money is coming from is not yet clear even with the initiative of the President of the United States. So there is a tremendous shortfall at this moment in time of several billion dollars, which reflects itself in the work of the Global Fund on AIDS, Tuberculosis, and Malaria, which is the central financial institution to do the most intelligent coordinating throughout the world. So the basic and profoundly anxious truth is that the donor countries, the wealthy G7, the big Western countries, have simply been utterly delinquent, criminally negligent over the years in refusing to supply the developing world with the dollars that are needed. That pattern is improving, it's not as bad as it was, but we're nowhere near what we need.

P4P: Some of the other things that you talked about, generic drug combinations ... I'm guessing there was a specific generic combination that you had in mind ...

AMB Lewis: I raised the generic combination in the context of the World Health Organization's (WHO) new credo, new determination, to put 3 million people into treatment by the year 2005. One of the things that should make that possible is a fixed drug combination, a triple-therapy, which is available from generic drug manufacturers, not available from brand name pharmaceuticals. But available from generic drug manufacturers, which requires only 2 pills a day, morning and evening, and that seemed to everyone to be the best possible combination. I'm not familiar with the precise drug combinations, but it is the only triple-therapy combination of its kind, based on 1 pill in the morning and 1 pill in the evening, and it's cost is significantly below anything else on the market. So it seemed to me that that drug, which is being used in the clinics that do prevention of mother-to-child transmission and then treat the mother and the family, that is being used by big NGOs who have treatment capacity on the ground, like Medecins Sans Frontieres (Doctor's Without Borders), and which is being used in some countries by governments that are starting to do treatment, that that is the way it should be done. It has been pre-qualified and approved by the WHO, the pre-eminent body to approve drugs internationally. The worry is that some countries, possibly like the United States, may decide to pay more to buy the drugs independently and individually from the major pharmaceuticals, and that would be a pity. Not because the drugs aren't of good quality, but because the regimens are more complicated on the one hand, and the cost is greater on the other.

P4P: In your presentation yesterday you stressed community involvement. Talk a little bit about that. What kinds of community involvement versus government involvement?

AMB Lewis: That's actually a good distinction between community and government, because a government tends to be more dogmatic, more authoritarian, more prescriptive, not very collegial, so we've learned over time. I don't know why that should be, but that tends to be the way it works. You can't do the treatment unless it's at community level. We're not going to have an apparatus of high-flying doctors and high-flying bureaucrats to make it real, particularly in the rural areas. You've got to get it down to the community. When I talk about community what I really mean personally, and I think a lot of people share this, is the involvement of groups of people living with AIDS. The most lamentable part of the organization of the battle against AIDS on the ground is the way in which people living with AIDS are excluded. And the way in which their voices are not taken seriously. And the way in which they are not invited to take part in decisions. But people living with AIDS know more about the reality of the problem than anybody. They are the experts. So if you involve the community, meaning fundamentally the groups of people living with AIDS in communities at the grassroots, along with the other parts of community organization of course -- the municipal structures, the local community activists, the schools, the health district -- but the people living with AIDS are absolutely the key. And if you get them involved with the local medical facility in a kind of partnership, when they're working at distributing or dispensing antiretrovirals, you'll always have a better program. And that's one of the toughest battles, because people living with AIDS are uniformly excluded in country after country as the government engages in a kind of stigma, while pretending that it cares about discrimination.

P4P: Going a little bit further with community. ... There certainly needs to be some capacity building in community, because you're bringing together two very divergent groups, in terms of backgrounds and education. How does that play into capacity building for community? Where do you see that?

AMB Lewis: Well it's just extremely difficult, because of course what has to be realized is when you're talking about a continent like Africa a lot of people have died, and a lot of people are very ill. So a lot of capacity has been lost. Lost forever. It's going to take time to rebuild that capacity. You frequently have to rely on the people who are treated. That's the wonderful thing, as you get treatment in place, people regain their strength and their involvement, and they return to work and you have a much larger group to call upon. But you'll have to do the training, and the training will come from outside organizations who give some help; it will come from community health workers, counselors who are associated with a hospital or with a district health clinic. The training will start at the top with doctors and nurses and pharmacists, and gradually it will move out to counselors and community health workers, and get down to the community. Countries have to very carefully sort out how they fill these gaps, how they get people trained in the community, because so much of the capacity is lost. It's heartbreaking to visit some of these communities and realize how many of the key community activists have died.

P4P: One of the things that really struck me yesterday was your emphasis on opening the doors to women and the impact of this disease on women. It seems that too often women are the forgotten part of this epidemic, and I was really pleased to hear you speak so clearly on this. Could you talk about what it means to open those doors?

AMB Lewis: The area that I feel most strongly about in terms of the entire pandemic is the ferocious assault on women. Women are more vulnerable; they are disproportionately affected and infected in huge numbers. Of the 25 to 30 million people living with the virus between the ages of 15 and 49 in sub-Saharan Africa, 58 percent are women; and in the younger age groups, which are crucial, 60 to 70 percent are women and girls. They are tremendously vulnerable to predatory male sexual behavior. All of the laws, all of the realities discriminate against women. They lose their property rights, they lose their inheritance rights. There's a tremendous amount of sexual violence, which transmits the virus. There is an absence of gender equality so palpable, so frontal, that women are struggling with enormous difficulty in the face of the pandemic. And what is even more important, of course, is that the men tend to get infected first, often in the urban centers, they come home, they pass the virus to their wife or to their partner, and the partner gets ill. While she's ill, she not only looks after herself, but she looks after others who are ill in the community, she looks after the orphans, she does the farming. Women carry the entire burden of care and sustaining the entire society. Therefore, when one is dealing with the pandemic, one must do things that empower women; one must make sure that women have particular access to medication and to care. And in fact we have to stop the endless nonsensical run of meetings and reports, and just zero in on the inappropriate male behavior and put them in jail for long periods when they engage in rape and sexual violence, and change the laws that give them the free run of the land. There just has to be very firm dealing with the men who are making such a dreadful hash of gender equality.

P4P: I'm so happy to hear you say those things. ... Last item, and it certainly plays into the impact on women, as well as the impact on orphans. When you have a child who has no parents, no schooling, no job, no hope, how do you see that playing into the potential for terrorist recruitment? What about the terrorist who comes to a young person in this situation and says, "Here's 15 pounds of ...; strap this on yourself and walk into an embassy."

AMB Lewis: That's a particularly American fear. There has been some real discussion about the question of security in these countries. I think it's probably fair to say -- I want to phrase this carefully -- that if you have large numbers of orphans who are rootless and homeless and foodless, and bewildered by their position, and feeling pretty angry and anti-social about what has happened to them, they are a lot of gangs in many of the urban centers in some of the African countries -- Nairobi, Johannesburg, Lagos -- you have a possibility of real instability. I won't go further than that. Poverty can be the basis for the attraction of extremist groups, as much as disease can be, and poverty and disease are inevitably linked. But what HIV/AIDS has done is introduced the possibility of instability down the road, because these young kids who, as you say, have had no nurturing, no love, no affection may become ominous if they are angry and in gangs and distressed. So, there's a possibility of instability and the important thing, therefore, is to start moving now to do the best we possibly can to respond to the orphan crisis, which is in the millions. We expect there will be over 20 million orphans under the age of 15 by the year 2010; roaming the landscape of Africa, looked after by grandmothers, living in child-headed households, desperately absorbed by communities that are already impoverished, unable to go to school because they can't afford the school fees. The world really needs to concentrate on what's happening to these orphan children who have inherited a sad finale to a process they had no part in. And that's the toughest challenge of all.

P4P: Ambassador Lewis, thank you so much for your time.

Back to the Winter 2003/2004 issue of Positives for Positives.

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This article was provided by Wyoming: Positives for Positives. It is a part of the publication Positives for Positives.
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