Interview with Stephen Lewis, UN Special Envoy (Part 2)

The following is the final instalment of a two-part interview with Stephen Lewis, the UN Secretary-General's Special Envoy for HIV/AIDS in Africa. In the PlusNews interview, Lewis highlights the importance of political leadership - represented by Botswana - in the fight against the epidemic. He also describes the failure of the international community to act timeously and effectively against HIV/AIDS in Africa as "one of the most astonishing moral lapses in post-war history". QUESTION: Nigeria took a bold step earlier this year with a programme to provide generic antiretrovirals to 15,000 people living with HIV/AIDS. Was this a demonstration of positive African leadership, and what do you make of the delays to the implementation of the programme? ANSWER: Every delay is desperately painful as human life is hanging in the balance but this was actually a valuable delay. Initially, Nigeria was thinking of a two drug combination. They brought a UNAIDS team into Nigeria to take a hard look at how they wanted to handle the antiretrovirals and what the regimen should be. They came to the conclusion that they needed three drugs and not two. So the delay was in part changing the regimen which they had intended to purchase and making sure Cipra had the required combination of drugs. And now I gather they have arrived. So instead of being two years this delay was two months and I think the programme is about to begin. It is supposed to start on December 10th and I am literally going there in person on the 16th to view the project as it is launched. (President Festus) Mogae's in Botswana seems to me to be the most dramatic (programme) of all. It hopes to have well over 100,000 people in treatment starting dramatically in the year 2002 and building in numbers. And they've really laid the groundwork. It's just truly impressive. I sense that the preparation they're doing means that there will probably be success and Botswana will be seen as the country against which antiretroviral treatment is measured because they will have the largest numbers. They obviously have an advantage as they have money. But the actual use of antiretroviral drugs and the way they restore life, the way people start eating and look better and their hair doesn't fall out and they return to work and it's like a miracle transformation in a very short period of time. All of that will be happening in Botswana and it will have an impact. According to the UNAIDS report there are now 10 countries in East and Southern Africa which are introducing antiretroviral drugs to a greater or lesser degree. Q: In South Africa, the government has come in for criticism over its HIV/AIDS policies, which have been marked by an alleged lack of political commitment. What can be done when national governments appear hesitant to tackle the epidemic head-on? A: I am not going to comment on things like the court case because that it something distinctly internal to South Africa and it involves a legal interpretation of the South African constitution. The arguments have been made and it would be presumptuous to comment on a high profile court case. But I would say that the policy of UNAIDS and WHO and therefore the UN system is absolutely clear. It is that nevirapine should be available in mother-to-child transmission clinics, that it is an effective drug, that any side effects or difficulties are far, far outweighed by the positive impact of the drug itself because kids emerge HIV negative and huge numbers of children's lives are saved. And it is the view of the UN family that the drugs should be widely available right across the board in countries. That is the UN position which came out of a conference of experts in the year 2000 which WHO convened. And now with I think the blessing of everyone associated a group of foundations, headed by Rockefeller, are introducing something called [prevention of mother-to-child-transmission] PMTC-plus. And the plus is antiretroviral treatment for the mothers because until now, of course, you had the very difficult human situation where you saved the life of the child and the mother looks at you and says with a kind of poignant terror: 'What about me?' And now there will be a significant effort made first on a pilot basis to introduce antiretroviral treatment for the mother and this is being launched in a few days time. And I think people in the UN family are glad to see this initiative taking place. You can see in many countries in Africa the presidents and the political and health authorities even though they are desperately impoverished, more impoverished than South Africa, are introducing antiretroviral treatment. I guess these things are a matter of time and of recognising that the international agreements which most governments in the world signed on to in the Declaration of Commitment at the (UN) Special Session and in Abuja are the agreements which govern what the world thinks should be done and the world thinks treatment is a legitimate component. How do you get governments to change their minds? We struggle with that on all fronts all the time. Mostly these things happen when a concerned citizenry within the country makes its positions known. Q: Given that the Fund is going to be directed through national governments, where does this leave cross-border migrant populations such as seasonal workers, or mine labourers in South Africa - populations that are highly vulnerable to HIV/AIDS? A: They are often lost and there is just no question that conflict and refugees and internally displaced, migrant populations are often the source of the spread of the pandemic. In conflict situations it is particularly horrific because if rape is a weapon of war as is always the case, the virus is spread through sexual violence. If you visit Rwanda today and visit the Polyclinique d’Espoir – the polyclinic of hope - in Kigali you will meet the women who were raped in the genocide and who are now dying of AIDS. This is just one of those human tragedies that is constant. In Southern Africa there is a tremendous advantage in having SADC (Southern African Development Community) and having sub-regional policies. So you have a group of governments sitting down and saying through their health ministers: 'We've got to deal with this regionally and collectively.' They are trying to set up protocols to deal exactly with this phenomenon of migrant workers and shifting populations. It is not yet foolproof and it is not yet fully in place but at least there is a basis to address it. Q: What is your prognosis for the future? Do you believe that HIV/AIDS will eventually be brought under control? A: For 20 years we watched this plague grow exponentially and ruthlessly. HIV/AIDS is the most apocalyptic thing that has happened in the history of disease. For 20 years African leadership was largely silent, in denial, frightened, traumatised, paralysed. For 20 years the Western world, which had the resources, was developing the drugs and knew how to deal with the pandemic. The Western world contributed a negligible quantity of money to Africa. It only started to turn around in the year 2000. In the process 17 million lives were lost and 25 million people were already infected. It is one of the most astonishing moral lapses in post-war history. I really feel frustrated and extremely angry at the inertia in response to the epidemic and where is really drives me nuts is when you travel around Africa and you meet these extraordinary people who are living with AIDS and you know they are running out of time and you know their lives could be gone in a two or three year span and you just stand there and you feel yourself wondering: 'How did this happen? How did anyone allow it?' You see orphaned kids by the tens of thousands as you wander through the continent and you know they didn't have to lose their mothers so early. You know the mothers' lives could have been extended for many years. And behind this incredible obsession with abstractions and statistics there are these individual human predicaments and it's as if the world and its negotiations just can't focus on the human reality. And that's what has to change in the next year or two because we're losing millions of people who need not be lost at least not so quickly. And who in the world has the right to deny these people a life that they might otherwise have. And what makes it even more distressing is that we know how to turn the disease around and we have fundamentally the capacity at this moment in time to prolong and improve the lives of millions and to prevent the infection from spreading to other millions and at the heart of it is largely the question of resources which still isn't resolved. And therefore on the one hand one has despair and frustration and on the other hand one has a really strong quotient of determined optimism because you know it can be done and it is just a matter of fashioning the will and the commitment to do it and that's partly my job.