Stephen Lewis is the UN Secretary-General's Special Envoy for HIV/AIDS in Africa. In an interview with PlusNews recently, Lewis said that gender inequality, ineffective leadership and lack of resources were key issues facing the world in the battle against HIV/AIDS in Africa.
In Part One of this interview, he said that although there was much greater awareness of HIV/AIDS throughout the continent he still felt "extremely angry" at the inertia in the response to the disease. But Lewis expressed optimism that the tide of the pandemic could be turned if the necessary commitment could be found to reproduce successful individual projects in many African countries on a larger scale. He also discussed the role of the Global Fund to fight HIV/AIDS, and the issue of generic and brand name drugs.
QUESTION: What do you see as your greatest challenges?
ANSWER: In a pretty fundamental way the biggest challenge is gender. It is to get the entire continent to understand that women are truly the most vulnerable in this pandemic, that until there is a much greater degree of gender equality women will always constitute the greatest number of new infections and there is such a degree of cultural oppression that has to be overcome before we really manage to deal with the pandemic. You simply cannot have millions of women effectively sexually subjugated, forced into sex which is risky without condoms, without the capacity to say no, without the right to negotiate sexual relationships. It's just an impossible situation for women and there has rarely been a disease which is so rooted in the inequality between the sexes. Therefore, gender is at the heart of the pandemic and until governments and the world understand that it will be very difficult to overcome it. To me this is one of the challenges that is at the heart of the solution.
Second, there is still not a sufficiently effective leadership in the countries. There is a much greater awareness in Africa than there ever was before and there is some evidence of behaviour change in some countries. In Uganda and Senegal there is evidence that you can lower the rate of infection and begin to stall the pandemic. But the leadership that is growing at the president level must somehow infiltrate leadership at every level of society: political, bureaucratic, professional, community, NGOs etc and that has not yet happened.
Third, I am absolutely persuaded as I travel that there are so many good things happening in many countries that if we were able to take them to scale we would be able to turn the tide of the pandemic. I don't feel despair. I am tortured by the numbers as everyone is but not paralysed by the tremendous challenge that is involved because we know how to turn the pandemic around. We know how to decrease dramatically mother-to-child transmission, we know how to do testing and counselling, we know how to undertake prevention of many kinds through the schools and targeted at vulnerable groups. We know how to do antiretroviral therapy - initially limited of course but available to us. We know what it means to find a way of integrating orphans back into the community when their parents have died. We have all over the continent individual projects and programmes that are successful and the frustration lies in our inability to take them to scale. That's not simply a matter of improving the socio-economic environment, the health infrastructure and so on.
What it really needs is the fourth challenge. It needs dollars. It is the single most inhibiting factor. It's not just drug prices, you can lower drug prices as low as they will go and countries will still not be able to afford them so you've got to have the resources. And that's where the Global Fund comes in and that's where we are struggling. No question.
Q: Why is the Global Fund to fight AIDS, tuberculosis and malaria so grossly under funded? Why have donors not been forthcoming?
A: I'm not sure they haven't. I have a quite different take on this. What has happened here is that through the good offices of the [UN] Secretary-General we have unleashed the concept of a global fund. Countries have started to contribute to it. The amounts are not yet sufficient but once you've got some global funds going it will build in momentum. You won't be able to turn it back. The one-and-a-half billion [dollars] which I think will move pretty quickly to two billion has got to start being distributed, it's got to reach communities, it has to start making a difference in the lives people lead, it has to give money for care, money for treatment, money for prevention and then there will be so much recognition of its value that the donors will start giving more money. Nobody said the fund was going to reach 7 to 10 billion dollars in the first year. Everyone said it was going to try to reach it over a four to five year period and I for one think we’ll get there.
Do you think the terrorist attacks of 11 September have been a setback to the fight against HIV/AIDS?
Yes I do. There's no question that 11 September set us all on our heels, set the donors back, the preoccupation with terrorism, the war in Afghanistan, the building of the international coalition, finding [Osama] bin Laden. All of this haunts the nights of every individual government that has the money to contribute. So the agenda has shifted dramatically since 11 September and there was tremendous momentum beforehand. We had Durban, the Africa Development Forum in Addis, we had Abuja, we had the UN Special Session, we had donors excited, African presidents coming on board, the Security Council taking positions for the first time ever, drug companies lowering their prices, the Secretary-General of the United Nations saying "This is my personal priority". You had the voices of people living with AIDS finally influencing the debate and nobody is more expert than them. It is enormously sad but understandable that the world got preoccupied after 11 September but one senses now that people are starting to get engaged again. And I think that this World AIDS Day will re-galvinise the effort.
Q: The World Trade Organisation's Doha Declaration appears to clear the way for developing countries to use generic drugs in times of health crises, overriding the patents held by the pharmaceutical companies. How do you see that victory being effectively exploited by poor countries to tackle HIV/AIDS?
A: Again you will have to forgive me for not completely embracing the official position. There is no question that Doha introduced an element of strength for developing countries to manufacture generics, to do parallel pricing for imports etc, but there is an element of delusion in all that. And that is that even the generics are too expensive for most countries to afford. Even internal manufacture if that is achieved – and there is a real question mark about that - is very, very difficult to afford so we come back to the question of resources. I was on a panel recently with Family Health International. They have a project in Ghana where they have lowered the cost of generic drugs down to $350 to $600 per person per year. They went to the cadre of several thousand people who would receive the drugs and asked how much they could contribute and they said roughly $3 per month if pressed. So even if you appear to have a victory in Doha the truth of the matter is that you are still way behind in terms of your resources. There have to be enough resources available internationally to be able to subsidise these prices either by the countries themselves or with external aid that will make the drugs acceptable. Otherwise we will extend the antiretroviral treatment but it will be far too marginal in terms of the need. So you can cheer about Doha but don't be seduced by it as there is much more at stake than the appearance of progress.
Q: The Fund is supposed to tackle HIV/AIDS, malaria and tuberculosis. Are these going to be separate or integrated programmes? Is there a danger that HIV/AIDS action will be diluted in preference for efforts against the other more preventable diseases?
A: I rather think not because I think that the whole world is so focused on HIV/AIDS that it will not be eclipsed by the others. But I think it is also true and important that the Global Fund pay real attention to tuberculosis and malaria. After all tuberculosis is the key opportunistic infection in conjunction with HIV/AIDS. We have to be able to treat it and deal with it. Malaria is taking a horrendous toll of life in some countries. So in a way I think people who were at first a little begrudging about going beyond HIV/AIDS now realise that the link among HIV/AIDS, malaria and tuberculosis really does justify the way the Global Fund will apportion its money.
Q: In setting out his vision in April for the Global Fund, UN Secretary-General Kofi Annan was clear that both prevention and treatment went hand-in-hand. There is a perception now that treatment action is slipping off the political and funding agenda. How has this happened and how can we return to the original vision of the Fund?
A: I think the perception which I know the NGOs have that somehow treatment is being pushed off the table is a perception in error because I don't think anyone could get away with it. Treatment is part of Abuja, treatment is part of the declaration of commitment, treatment is part of the Secretary-General's speeches, treatment is part of [UNAIDS Executive Director] Peter Piot's speeches. I just don't think that you can create a Global Fund and minimise a component to which everyone has paid homage. It's just not possible nor does it make any sense. It doesn't make any sense to depreciate care or prevention either. It makes sense to do all three in concert.
Q: Will there be a role for NGOs and civil society in the Fund?
A: Definitely because if there isn't a role for NGOs and civil society then the Fund would be distorted. And the NGOs are going to have places on the board just as they have places at the table now. They'll have to choose pretty carefully who represents the broader civil society. Obviously that's tough. But the NGOs are indispensable because of their knowledge of what happens at the grass roots because of their contacts with community-based organisations and with NGOs in small communities. And somehow eventually the money has to get to the communities.
Q: Would the Fund ever buy or recommend generic antiretrovirals over brand name drugs?
A: I don't know whether it would be over brand name drugs. You are putting it in an unnecessarily combative fashion. I'm not sure it couldn't be done in conjunction with brand name drugs. I'm not sure that you couldn't have a range from which you pick based on price and availability and application – what has worked and what hasn't worked. You understand that you have me at your mercy because I am not privy to the discussions, but I would imagine that any sensible person would recognise that as all of us have talked about how generic drugs have been indispensable to bringing down drug prices of major manufacturers that they will be a part of this. They are already being used in countries. [Nigerian President] Obasanjo sent his Minister of Health to India and said go to [generic drug manufacturer] Cipra and negotiate the best price possible. And he went to India and he negotiated a price of $350 per person per year and the drugs have now arrived in Nigeria. So surely the Global Fund will respect what many of the countries are doing and generics will be a part of the package but they won't be the sole package.
* In Part Two of the interview, Lewis talks about the role of political leadership in Nigeria, Botswana and South Africa, and his prognosis for the future of the HIV/AIDS campaign.