Durban, South Africa,
11 July 2000

Outstanding issues in the international response to HIV/AIDS: The WHO Perspective
XIII International AIDS Conference

We now have the opportunity for a much more effective response to the HIV epidemic. The world is listening.

We know how to prevent the spread of HIV and provide care for those infected. The tools are complex and imperfect. But we know that when used correctly, these tools can help slow the epidemic, relieve suffering and enable millions of people to have additional years of quality life.

With opportunity comes responsibility and challenge. There are no more excuses. The millions who are infected and the hundreds of millions who are at risk will not forgive us if the world does not take advantage of the opportunities for action that exist today.

No one constituency can act alone to change the face of this epidemic, whether we are from national governments or international agencies, associations of people living with HIV, NGOs, the private sector, academic institutions, community organisations or public interest groups. Wherever there is inequity, conflict or lack of mutual respect, the virus feeds on our divisiveness. More than ever, we need to unite and exert our leadership in responding to the destruction to society that has been wrought by HIV.

So today, I talk about this leadership. Leadership is needed to act early, effectively and boldly. It is needed to set tough priorities. To seek - and then provide - the resources required to reverse the spread of HIV; to make sure that these resources are well used.

What is, then, the essence of this leadership: I sum it up in four words:

• Clarity.
• Certainty.
• Confidence.
• Creativity.

Let me begin with Clarity.

Clarity about what is happening now and what is at stake.

50 million people –1% of the world’s population – have become infected with HIV. Young girls are most affected. In a study of eleven African countries, the rate of infection in teenage girls was over five times higher than in boys of the same age. Each day more than 15,000 people become infected. 1,600 of them are children, infected during or shortly after birth.

Infection rates in the Caribbean are also high. There is an epidemic in Asia with more than 6 million people infected, and the potential for millions more.

We can be clear about the consequences. HIV affects more people than it infects. It makes families poor as they try to meet the costs of health care and funerals: they become poorer as they cope with the loss of income following the death of a breadwinner. HIV disease leaves behind orphans with an uncertain future. It is undermining many recent development gains: life expectancy and child survival rates have plummeted in several countries in Africa.

The spread of HIV through our societies is fuelled, mostly, by people experiencing high levels of sexually transmitted infection and having unprotected sex with multiple partners. This is more likely in circumstances where men purchase sexual activity through a commercial transaction or where women and girls are forced, by men, to have sex against their will.

We must never forget that almost half of those actually infected with HIV are women in monogamous relationships, dis-empowered, fearful, and often stigmatised. If they are infected, and pregnant, there is a significant possibility of the virus being transmitted to the newborn child.

In some parts of the world, and increasingly in developing countries, the recreational use of drugs, mostly by injection, is a significant cause of HIV spread. And, shockingly, HIV continues to be transmitted through un-screened blood and blood products, even though effective technologies exist to prevent this.

HIV infection thrives on poverty and marginalisation. The epidemic is sustained by social disruption, by historical inequities of wealth, gender and race, and by migrant labour practices.

We can be clear about what is possible. The major impact of the epidemic is yet to come. But we have found interventions that work. They can reduce HIV incidence by up to 80%.

We can be clear about the opportunities. During 1996, in Vancouver, we learned that a combination of medicines and services, properly applied, prolongs and improves the lives of those living with HIV. Later that year, in Abidjan, the voices of the millions of people suffering with HIV in Africa rose loudly, requesting access to care.

Yet, we can also be clear about the reality. Commitments on prevention for all, and care for those who need it, have yet to be fulfilled.

Now we are all looking for ways to increase access to care at a price which governments and their people can afford. The World Health Assembly, called for WHO and other UNAIDS partners to pursue dialogue with the pharmaceutical industry and with member states and associations of people living with HIV and AIDS, and to co-operate with governments on possible options under international agreements, as well as the TRIPS agreements, to improve access to HIV-related drugs. As you know, WHO generally recommends the promotion of essential drugs, and the use of quality generic drugs whenever possible.

We can also be clear that there will be no simple solution to the problems posed by HIV. Even when an effective HIV vaccine eventually emerges, experience have shown that it will take years to make it available to all who need it. Primary prevention effects will still have to be sustained. The expectation of a vaccine in the future is no excuse for inaction now.

As good leaders we know when it is right to be certain about key issues. Our actions are based on clear values, and are informed by scientific analysis of available information, and past experience. They are not just based on belief, anecdote or ideology. The evidence may cause us to change positions: we know how to decide the right time to make changes, and implement them.

We know what works – and what does not work – in reducing HIV transmission.

Efforts to prevent HIV infection must prioritise the groups most vulnerable to infection:

• Girls and boys, who are at their highest risk of infection just as they begin to explore life;
• The infant who may have been infected before she entered this world;
• and other people who are at high risk.

In the process of creating expanded multisectoral responses to the epidemic, the focus on the most vulnerable groups has slipped in many countries.

We know through both pilot projects and national-scale programmes that reducing the transmission of HIV among groups with high-risk behaviour is an effective way of limiting the spread of infection.

Ensuring regular condom use by a person who has 1000 different sex partners each year is much more efficient at reducing HIV transmission than ensuring condom use by 1000 people who have one new partner a year. This is true in countries with very high spread of infection, as well as in those with a low infection rate.

Yet, we still have not seen any systematic, nation-wide action to reduce high-risk behaviours. This will have to change. It will often mean accepting unhappy realities about the societies we live in.

We are certain that HIV testing is critical. In a population where HIV infection rates are high, it is crucial for individuals to know their own status – and that of their partners.

Voluntary counselling and testing is the entry point to both prevention and care. It is the key to responding to the major obstacle to prevention efforts - that the majority of people living with HIV/AIDS do not know they are infected.

We are certain that condoms work, particularly among those who change partners often. Experience suggests that it is easier to make sexual contacts safer rather than stop the contacts occurring at all.

Amazingly, although condoms have been recognized as the main safeguard against transmission of HIV and other sexually transmitted infections for more than 15 years, efforts to promote their availability and use are far from universal.

Men’s reluctance to use them should not be used by governments and NGOs as an excuse for not promoting them. It is simple. Every man and woman should have access to - and know the importance of – condoms.

We are certain that effective treatment for sexually transmitted infections reduces HIV incidence. Yet, as leaders, we are not doing enough. The global burden of curable sexually transmitted infections is enormous. STI are one of the leading causes of loss of healthy years of life even in the absence of HIV infection.

STI detection and treatment must be an essential component of HIV prevention programmes.

We are certain of the importance of working with adolescents - in ways that have meaning to them. Around 11.2 million or one third of the world’s HIV infected population are boys and girls between the ages of 10 to 24. Every day, 7,000 of them acquire HIV. That means 2.6 million new infections among them every year, 2 million are in Africa.

The evidence has never been clearer – programmes that target and involve young people work. In Brazil, Senegal, Thailand, Uganda and parts of Tanzania, HIV infection rates among young women have been cut by over 40% as a result of effective prevention programs.

Moving on - good leaders know the importance of being confident.

Good leaders themselves have gone through the cycle of denial, apathy and desperation. But they have quickly emerged, putting in place effective actions to counter the epidemic.

Being confident means taking bold decisions based on incomplete information. We will never know enough. We can never be 100% sure about success. But once we stand on solid scientific and moral ground, we must act and act confidently.

There are no dress rehearsals. Every day of hesitation results in thousands more infections.

Considerable progress has been achieved. We now have better evidence of the potential for antiretrovirals, administered in pregnancy, to reduce HIV infection rates in infants.

The challenge now is to make safe antiretrovirals available to all who need them. Preliminary results indicate that Nevirapine administration reduces Mother to Child transmission, but more work will be necessary to confirm safety and efficacy. There shall be no delay in this effort.

New studies confirm what we long have suspected. Breast feeding by mothers living with HIV puts the infant at risk of infection – often negating drug therapies that saved the infant from infection during delivery.

This raises extremely difficult issues on the recommendations for breast-feeding. How do we ensure that the lack of breast-feeding does not jeopardise further the growth and development of the child? How do we make sure that mothers that do not live with HIV or are unaware of the HIV status continue breast-feeding?

To find the right answers, we must put aside old conventions, old solutions. We must think creatively and we must act together: health authorities, the private sector and the NGOs.

They no longer talk about "what we do" and instead focus on "what people get". They have stopped using terms like "could and should" and instead use "will and can". When solutions to new problems are proposed, and make sense, they say "lets give it a try." Above all, they believe in bringing people together, in concerted action.

This means that leaders engage their constituencies in setting targets and prioritising. They mobilise the human and financial resources, medicines and commodities, needed to scale up action. They explore the potential for mass marketing of preventive action, franchising of services, means to subsidise poor peoples’ access to services, and independent mechanisms for monitoring progress. They don’t give up.

Courage to act. Courage to confront our societies in their full complexity. Courage to talk openly about sexuality, about violence against girls and women, about drug use and about poverty. Courage to focus on those who are most vulnerable to HIV. Courage to break the silence.

Despite strong statements and heartfelt promises, people with HIV still experience discrimination and stigmatisation. We need the courage to end such attitudes once and for all.

Only six months ago, the potential for better access to care seemed non-existent. Then in May, as you now, five leading pharmaceutical companies agreed with UNAIDS and its UN partners to begin a dialogue on how to drastically improve access to care and reduction in prices of drugs. That dialogue also needs to comprise companies in the generic sector.

It is good news that the companies are now working with several countries to improve access to care for people with HIV. The Ministers of Health in these countries have shown great courage in starting to work in this way given the difficulties they might have – short term, at least, in meeting their people’s expectations.

The UNAIDS secretariat and cosponsors have set up a structure to facilitate discussions for wider access to care can be discussed between the companies and interested countries. We are making real progress, more than we could have expected only a few months ago.

But care for those infected with HIV, those living with HIV disease and those dying from it involves much more than distribution and administration of drugs. I would like to pay a heartfelt tribute to the courage and commitment of millions of care providers in families, communities and hospitals all over the world.

Courage is needed to prevent HIV spread. The focus is on changing some of the behaviours that contribute to HIV infection. Violence against women is an important contributor to HIV’s spread. It is a significant public health and social problem. Real courage is needed to start addressing gender-based violence within the context of preventing HIV infection. Along with incest and child abuse, rape and violence against women remains a taboo.

In 1980, 20 per cent of the adults infected with HIV were women. Ten years later, that figure has more than doubled. At the end of the century, 46 per cent of HIV positive adults were women. In some parts of Africa infection rates of adolescent girls now run 3 - 6 times higher than boys of the same age, a glaring result of gender inequality and the exploitation of girls.

We will not achieve progress against HIV until women gain control of their sexuality. Women’s courage is unbeatable. I am confident that – over time – we will succeed. The first step is to speak out against all forms of violence against women: domestic violence, rape and sexual abuse. But it goes further. Women must know and feel that society supports them when they say no to unwanted or unprotected sex.

Women must get the means to protect themselves against HIV infection. We have seen recent setbacks in trials with microbicides, but such setbacks only doubles our determination to find a solution that proves effective and safe. WHO is also studying the safety and efficacy of the female condom.

Governments need courage, as they decide how best to help their people to live with HIV. This calls for effective stewardship of resources, in ways that respond to people's real interests.

Let us focus on the challenge facing those with the cash – the foundations, development agencies and Banks.

We are hopeful that the G8 meeting in Okinawa in two weeks will drastically scale up the effort against the diseases of poverty; malaria, TB and AIDS.

Comprehensive services to prevent HIV and sexually transmitted infection will probably cost up to $3 billion per year. As leaders become confident about the specific interventions needed, will those with funds have the courage to back them? I appeal to governments, international agencies and foundations to unite and respond, with their joint forces and financial resources, to the unprecedented challenge created by the HIV epidemic to the fight against poverty and to human development.

Leadership means making choices. Making choices with a reasonably degree of certainty. Confidently. Creatively, so that results can be demonstrated, and sustained. The choices will be difficult. But to shrink away from them will mean failure.

We can make that difference. Let us work together and let it happen.

Thank you.