Changing the global health architecture
Dr Margaret Chan
Director-General of the World Health Organization
Honourable ministers, distinguished delegates, ladies and gentlemen,
The world has been struggling against this devastating epidemic for more than three decades. That is a heartbreakingly long time.
Along the way, we have become more and more determined, smarter and smarter in our approaches, more strategic, focused, effective, and cost-effective.
Now, finally, we have gained the upper hand. We are in a position to outsmart HIV, turn the epidemic around, and celebrate its end.
The modern world has never known a virus quite like this one, with its long incubation period, its ability to destroy the body’s defense system, its defiance of monumental efforts to develop a vaccine or definitive cure, and the multiple factors that make it so stubbornly persistent.
The fight has been not just against a virus, but also against stigma and discrimination. Against the mysteries of modern science, but also against policies that increase risky behaviours.
And now we are at a turning point. The dynamics have changed. The epidemic has stopped expanding and is now being pushed back. A shrinking epidemic is easier to manage. It is easier, but we must have no illusions.
As new opportunities open up, new challenges become apparent, including those with ethical and human rights dimensions.
How did the prospects for a disease that was once considered a death sentence change so dramatically? There are many reasons.
Wise investments in effective preventive strategies, like condoms and behaviour change.
The relentless, sometimes strident, protests of activists, against stigma and discrimination, against high drug prices, against unfair denial of access.
Money, including from new financing mechanisms, like the Global Fund and UNITAID, but also from domestic sources.
The high-level commitment of governments, to take care of their own citizens in many cases, or to tackle the epidemic abroad in others, with PEPFAR being a star example.
Strategies that got the price of antiretrovirals down by nearly 99% in less than a decade.
A constant refinement of operational strategies and approaches, with streamlining, simplification, and efficiency the overarching aim.
Year by year, services kept getting better, and easier and more affordable to provide, even in the world’s most remote settings.
Patients and programmes benefitted from a constant improvement and simplification of treatment regimens, with the recommended first-line therapy now available as a single pill, once a day, greatly increasing prospects for patient adherence and reducing the risk of resistance.
Research delivered vastly simplified tests for diagnosis and monitoring, including point-of-care tests that can be performed by health workers in communities and homes, further normalizing this disease.
These and other advances made it possible for more than 8 million people, in low- and middle-income countries, to receive antiretroviral therapy by the end of 2011. This is a 27-fold increase since 2002. This is the fastest scale up of a life-saving intervention in history.
And there are more recent advances, like last year’s treatment 2.0 framework, introduced by WHO and UNAIDS as the next generation of treatment recommendations. This is a five-pronged programmatic approach to make antiretroviral therapy more accessible, safe, effective, simple, efficient, and affordable.
Another recent advance is a new global plan, supported by world leaders and backed by WHO technical advice, not just to reduce mother-to-child transmission of HIV, but to eliminate it altogether by 2015.
But above all, opportunities to get ahead of this disease have been opened by scientific breakthroughs, which are now coming with rewarding speed.
Without question, the most transformational of these breakthroughs in the past few years is evidence that antiretroviral drugs deliver a two-punch blow to the epidemic. They not only keep people healthy and save lives. They also prevent new infections.
Studies show that the 2010 WHO recommendations on earlier initiation of therapy significantly reduce morbidity and mortality and also have significant benefits in preventing HIV infection.
But here is the critical question. Could we be saving more lives and stopping more infections by starting treatment even earlier?
As another advantage, antiretroviral therapy reduces the risk of tuberculosis, one of the biggest killers of people living with HIV, by as much as 65%.
The evidence base is now strong. Strong evidence supports strong policies.
Ladies and gentlemen,
The task now is to bring HIV prevention and treatment together. This symposium has the word “strategic” in its title.
The internationally agreed goal is universal access. We are striving to reach this goal at a time of unprecedented opportunities, tempered by the demands of sustainability, in a climate of financial austerity nearly everywhere. It is imperative that expanded coverage be strategic.
The epidemiological argument that supports our optimism is straightforward. When fewer people acquire infection and more people receive treatment, the epidemic will eventually be stopped dead in its tracks.
When is the optimal time to start treatment, and how high would coverage have to be in order to interrupt transmission in a given population? We simply do not know right now, but more than 50 studies are under way or planned that will help answer these questions.
In the meantime, we must use these medicines, for prevention and treatment, in the most strategic and efficient ways possible. We must combine them with other proven prevention strategies to amplify the overall impact on prevention.
We must stretch financial resources, whether from domestic or external sources, as far as possible. We must do the same for human resources.
Evidence and experience tell us that targeting interventions to those at highest risk in areas where transmission is greatest has a high impact and results in the lowest costs per infection averted.
In countries with generalized epidemics, one large and well-defined pool of people at high risk comes from uninfected partners in couples where the other partner is infected. As you will be hearing, this opportunity has been explored and sharpened through WHO technical consultations.
WHO supports the testing and counseling of couples, with mutual disclosure of results, and has issued the guidance that enables countries to pursue this option. It is a logical way to use these medicines strategically and with a major impact on prevention.
Another area you will be hearing about concerns options for preventing mother-to-child transmission of HIV.
In making recommendations, WHO considers what is operationally and programmatically feasible, what is best for patients, and what has the best chance of turning the epidemic around. WHO and the many experts who advise us also consider whether the recommendation is cost-effective in the short-term and cost-saving in the long term.
I am personally pleased to see that consideration of all these factors allows us to give more weight to treatment regimens that offer the very best for the health of pregnant women, and not just the minimum treatment needed to prevent infection of their infants.
Ladies and gentlemen,
We are only now beginning to tap into the potential benefits of antiretrovirals, bringing prevention and treatment together.
The times ahead are extremely exciting and promising.
We can accelerate the current momentum, and the current blows we are dealing to this epidemic, if we make the right strategic choices.