It's Not Complicated: Money Will End AIDS

By Stephen Lewis
February 9, 2012

Remarks by Stephen Lewis, Co-Director of AIDS-Free World, delivered at the Dutch Postcode Lottery’s ‘Good Money Gala’ Amsterdam, The Netherlands, February 9, 2012

I’m unreservedly delighted to be here this afternoon, and to have the privilege of speaking. I will admit, with appropriate shame, that I didn’t know of the Postcode Lottery until 2010 when I participated in the Dream Fund submission from the Clinton Health Access Initiative and STOP AIDS NOW.

But now that I do know of the Postcode Lottery, and have had some further contact, I’m filled with admiration for the astonishing range of grants, and the huge amount of money that the Lottery distributes to good causes and the search for social justice. This is especially true at a time when governments are so begrudging about honoring their national and international humanitarian commitments. If the Lottery could only swallow up the G8 and the G20, we could probably fix this world.

And in part, fixing the world is exactly what I want to talk about. I know that the subject of HIV/AIDS is not uppermost in the minds of the vast majority of organizations in this room. In contrast, it’s uppermost in my mind because I’ve personally been consumed by the pandemic throughout the last decade, first as the UN Envoy on AIDS in Africa, and then with my colleagues in the NGO, AIDS-Free World, for the last five years.

But there is a truth about HIV/AIDS that should galvanize your attention: we will never achieve the Millennium Development Goals on the African continent unless and until AIDS is defeated. The monumental work of the international community will ultimately be subverted by the virus.

There is an assumption, widely held in western countries, that because AIDS has become a chronic disease in North America and Europe, it’s somehow over. Nothing could be further from the truth. Not only is AIDS creeping up in numbers in many high-income countries like the United States, the UK and Japan, and soaring in a jurisdiction like Russia, but it remains a devastating plague in the high-prevalence countries in Africa. World-wide, there are 34 million people living with the virus, there were almost two million deaths last year and almost three million new infections. How, by any stretch of the imagination, can that be described as the end of the pandemic?

But let me make an admission. I’m mad at myself for using abstract figures. We’ve robbed the force of the pandemic, we’ve undermined the impact of the pandemic by an endless spouting of numbers. The UN has too many catchy slogans to keep track of: zero this, and zero that, and numbers of this and numbers of that, and percentages that will be achieved by this date or that date, and then an endless orgy of graphs and charts purporting to show this percentage decline and that percentage decline in this country and that country and this region and that region, not to mention an avalanche of financial data that leaves the head spinning. Statistics can of course be useful, but the real human beings whose lives have been decimated by the pandemic have been allowed to disappear. As it happens, I teach a course on the Millennium Development Goals at a university in Toronto. In last Monday’s class, I invited a close friend, Ida Mukuka, a woman from Zambia who acts as a field representative assessing the impact of AIDS on communities, to speak to the students. Her older brother died of AIDS some years ago, her younger brother died in December, her niece died ten days ago leaving a four-year-old orphan … a little boy, frantic and desperate at the funeral to understand what had happened to his mother, mirroring the bewilderment of those little kids all over the continent, struggling with pain, anguish, uncomprehending; orphans isolated in their grief, sleep riven by nightmares: a whole generation of children. It seems inconceivable.

Ida then told the class that her sister was HIV-positive and she herself was HIV-positive and she was about to lose her doctor because of financial cut-backs. The throbbing anxiety never ends. What a world.

What’s so incredibly frustrating is that we now know how to defeat the pandemic. Thirty years into the scourge of AIDS, with untold suffering and massive death, we finally know how to subdue the virus. There’s a package of preventive interventions on which virtually everyone has agreed. Three of them are particularly critical. First, is the prevention of vertical transmission from the mother to the child during pregnancy, delivery, and breastfeeding which, with the right combination of drugs, can reduce transmission by up to 99 percent! And then we must keep the mothers on those drugs so that they stay alive, the mothers who, in the past, have been overwhelmingly neglected as though mothers were expendable.

Second, is male circumcision. Studies prove that up to 60 percent of transmissions to men can be prevented if those men are circumcised. There’s a new book out showing, conclusively, that if international agencies hadn’t been irresponsible, we would have energetically pursued male circumcision over a decade ago with countless lives saved as a result.

And finally, there’s the new centerpiece of the international AIDS response called Treatment as Prevention. The logic is unanswerable. Forgive me for reducing the concept of Treatment as Prevention to a simple-minded formula, but it goes something like this: if you’re on a full regimen of anti-retroviral drugs, the amount of the virus in your body will be reduced to undetectable levels, and therefore, the likelihood that your infection will be transmitted to others through sex will be similarly reduced. The more people who are tested and go on treatment, the more the numbers of new infections decline.

It’s an astonishingly sensible theory. Back in 2006, at the International AIDS Conference in Toronto, a renowned Canadian scientist specializing in HIV, Julio Montaner, whom we’re lucky enough to have on our AIDS-Free World advisory board, said at a press conference that his years of cumulative evidence showed that Treatment as Prevention worked and should be implemented everywhere as soon as humanly possible. As you can imagine there was skepticism. But in the intervening years, Julio’s assumptions were confirmed time and time again, leading to the most unequivocal, definitive confirmation of all released just last year. And it’s not just sensible as a preventive measure. It’s humane. It’s ethical. There is no good reason to delay treatment until people’s immune systems are already failing.

A study called HPTN052, dealing with discordant couples — where one partner is HIV-positive and the other HIV-negative — showed that where the HIV-positive partner is on treatment, the decline in transmission is 96 percent. It’s fair to say that the world was stunned. It’s of course a credit to the scientists who labored for many years in the research trenches to have come up with such unambiguous results. But I must say that from my point of view, the five years between 2006 and 2011 should have been used to implement Treatment as Prevention with unflagging urgency … many more infections would have been prevented, many more lives would have been saved.

I can’t get over the fact that some scientists are now calling for caution until even more research is done. I’ve spent much of the last decade watching people die: I’m fed to the teeth with the endless delays and lack of resolve that has characterized the international response to the pandemic. The research is now indisputable. Get on with it. We’ve sacrificed too many on the altar of scientific waffling and bureaucratic paralysis.

That’s why we have to get over our obsession with numbers. We’re talking about flesh-and-blood human beings … whole communities on the continent of Africa where that flesh and that blood, with catastrophic consequences, is being corroded by the virus.

And that’s where the Postcode Lottery comes in, because in three powerful ways, you are to be saluted.

The Dream Fund award last year makes it possible for Swaziland to become the first-ever developing country to give full expression to Treatment as Prevention. Not only will the theory be further verified, but the effort will be made, over three years, to test the entire country, and get a truly significant additional number of people into treatment. Everyone is determined to achieve universal access to treatment. In the process, Swaziland is inevitably engaged in an extraordinary community mobilization to bring services to the people and people to the services. All things considered, this is an amazing undertaking … reaching an entire country. Swaziland has the highest prevalence rate in the world … over 25 percent of its adult population is living with the virus, and for pregnant women, it rises to nearly 50 percent. It’s an unspeakable horror. And as if things aren’t bad enough, Swaziland is ruled by an absolute monarch whose interest in the health of his citizens is negligible. It’s really a crime.

But partly as a result of the King’s indifference, there just isn’t enough money coming from the royal coffers to fight AIDS. That’s the second powerful reason to applaud the Postcode Lottery. Your Dream Fund award will make it possible to save tens of thousands of lives that might never have been saved without the Lottery.

Because you see, the only other potential major source of resources at the moment is the Global Fund to Fight AIDS, Tuberculosis and Malaria. The Global Fund has been going for exactly ten years. It’s bitterly ironic, brutally ironic, that on its tenth anniversary, the Global Fund has had to cancel its next round of grants as the money from the donors dries up. Solemn commitments were made by donors in October of 2010, and those solemn commitments are not being honored. There will be a terrible price to pay in human terms. Bill Gates makes the point that for $300, drugs can be purchased and a person kept alive for a year. For every $300 we don’t have, someone dies. A human life for three hundred dollars. And we can’t find the money … although we can find the money for Iraq, Afghanistan, bank bailouts, corporate bonuses and American election primaries.

The moral test is $300 for survival and the international community flunks the test. But the third and most important tribute to the Lottery’s support in Swaziland lies in the help for women. It’s women, hugely disproportionately infected, who will be the singular beneficiaries. I cannot adequately explain how significant that is. Most women in Swaziland have no sexual autonomy; they can’t deny sex; they can’t insist that their partners wear condoms; if a woman tests positive and discloses to her husband or partner, she risks being beaten or thrown out of the house. Whether or not they’re HIV-positive and sick unto death, women still provide all the household care, or work, gratis, as community caregivers for those who are ill in the village. They do the cooking, haul the wood, haul the water, do the farming. They run the family, and look after the orphans, discarded and left behind. And women are regularly subject to horrendous sexual violence … violence that transmits the virus: intimate partner violence, marital rape, gang rape … it never ends.

At least, thanks to the Postcode Lottery, women will be tested and treated. Thanks to the Postcode Lottery, some money will be available so that women won’t be completely overwhelmed and oppressed by the job of sustaining family life. Thanks to the Postcode Lottery, women will have the opportunity to stand up to the King and demand their human rights. The women of Swaziland are not women to whom the adjective ‘helpless’ applies. They’re strong, resolute, sophisticated, and courageous. They’ve just never had a chance. This is all part of the most important struggle on the planet: the struggle for gender equality. And the Lottery should be enormously proud to be at the heart of it.

I know there are a thousand competing global health priorities. But once in a rare moment, civilization has the chance to confound a disease: smallpox vanquished; polio on the brink. Thirty years is enough. Let HIV/AIDS be next. The Postcode Lottery has shown that it believes it can be done: would that governments were principled enough to share that conviction.

Download a copy of the speech here (PDF, 143KB)