Brainstorming Session in Preparation for the High Level Segment on HIV/AIDS
Dr. Elaine Wolfson, Global Alliance for Women's Health: I think we should begin with a few informal things before we actually start the meeting. This is a brainstorming session, so we have no formal presentations. We really want to bring you to a point where we can actually talk face to face among ourselves, across the sectors. We welcome wide participation and exchange, something analogous to an Auberge Espagnole, where all bring something to the table.
The program agenda has three major topics. The first is "Access to treatment and affordability of drugs." The Global Alliance for Women's Health (GAWH) is very concerned about the treatment dimension of the HIV/AIDS pandemic, particularly because of the status of women in the world and the fact that women's health care is usually sub-optimal and sub-par.
In addition to making this an item on the agenda, we have taken the initiative to place a petition in front of you that we have been circulating among NGOs at the United Nations and among governments. I am pleased to report that so far we have 160 signatures. We are calling in this petition for some certainty that in regard to treatment for people living with HIV/AIDS, at least 50% of those treated will be women. We are concerned and troubled because we know in many circumstances women's needs come last where treatment is concerned. In light of the fact that in Sub-Saharan Africa 58% of the people living with HIV/AIDS are women, we want to make sure that at least 50% of those receiving treatment are women. We ask you to support us and join in our efforts to focus attention on the need for equal access. If you would like to endorse the petition, please add your name to the sign-in sheet being circulated.
In addition to that, we would like to thank our partners, both in the public and the private sector. This is all part of a campaign that the Global Alliance has undertaken since the beginning of last year to bring the issue of treatment to the table. We have undertaken some formal meetings. One of them was with many of the governments who have joined us today. Our meeting here at the U.N. on April 15th concerned drug donation and registration and involved the obstacles and challenges of getting HIV/AIDS drugs into countries. That was a very successful meeting. I think that the pharmaceutical companies that participated found their exchanges with representatives from developing countries fruitful and very informative. The proceedings from that meeting is on our website, www.gawh.org.
Then we were very fortunate to be funded by our partners in the Accelerating Access Initiative (AAI) to do two meetings abroad. Our first focused on reaching the health ministers attending the World Health Assembly in Geneva; the second, in Addis Ababa, drew the attention of the finance, and economic development and planning ministers who were attending the Economic Commission for Africa (ECA) annual meeting. We are pleased to report that both were very successful meetings. If you would like to read the edited proceedings, please go to our website and you can download them.
This summer, Ambassador Moutari, from Niger, who headed the United Nations African Group for the month of August, presided when we gave a briefing on those meetings to the African Group. Also, we are very pleased that today, because of some prodding by our partners, we are holding this meeting. And we are really delighted that the turnout is so great. It speaks to the seriousness with which the issue is considered here at the U.N. I think, the exchange of information here will enrich the proceedings that are going to take place next week at the high-level meeting on September 22nd. So, I am really pleased that you have been able to attend.
The format of the meeting will be as follows: Ambassador Moutari will lead off with a brief statement and Ambassador Lamba, from Malawi, will make a second statement. They are co-chairing the meeting. Since I have had many years of being a professor and a teacher, I decided that I am going to be the moderator. My only request is that we keep the information and the dialogue going and we keep our statements to a minimum. Everybody is being asked to talk for two minutes or less. We really have to move comments on some of these issues along. The goal here is to see where we can untangle the thickets, inform each other of what is happening, and learn if we can scale up the treatment. That is my goal, that is the goal of the Global Alliance, and I know many of you share it with me.
Ambassador Moutari will begin.
Ambassador Ousmane Moutari, Permanent Mission of Niger to the UN: Thank you very much, Dr. Wolfson. We have decided that this will be kind of an informal meeting where we will have interactive exchange. I will not really make a statement; I will make a few observations.
But first of all, I would like to thank the Global Alliance and Dr. Wolfson for their commitment and their perseverance in pursuit of those goals. And to thank our partners who are really fully committed, too, because most of them have participated in the meetings that Dr. Wolfson mentioned. Those meetings provided good opportunities—especially for those of us who represent our governments at the U.N.—to have direct interaction with members of the civil society and the pharmaceutical industry working on the ground who could give us direct information on how this fight against HIV/AIDS is going on. Today, as we are getting ready for the meeting on the 22nd of September—the high-level meeting on HIV/AIDS-this session is another opportunity to have some kind of exchange and to be updated on the various activities going on in different parts of the world.
With that said, I would like to welcome all of you here, to thank you, and to assure you that at the governmental level the political will is there, and we are open to any suggestions and even criticism as long as it will help us achieve our goals as quickly as possible.
Now I will give the floor to my dear friend, Ambassador Lamba.
Ambassador Isaac C. Lamba, Permanent Mission of the Republic of Malawi to the UN: Thank you my colleague co-chair, and thank you, Dr. Wolfson and distinguished ladies and gentlemen. Let me say something about the issue of HIV/AIDS today. We have, most of us, been concerned about HIV/AIDS, the many deaths resulting from HIV/AIDS, and the devastation left behind by those who die, a devastation which leads to diminishing returns of life for their survivors. One of the problems which I think we have not very often emphasized and which I hope will emerge on the 22nd of this month concerns the issue of HIV/AIDS orphans, both those infected and affected. What can we do to address the plight of orphans in their situation of hopelessness? What is it that communities can do? What is it that international aid agencies can do to assist local initiatives? Aid agencies want to respond to expressed needs and requirements. What is it that we can do in our own countries to convince aid agencies to come to our rescue?
I come from Malawi, a small country in Southern Africa, with about 12 million people and a land mass of about 118,000 square kilometers. Out of our 12 million people, 16% are HIV infected. We have 700,000 plus orphans, and we calculate that there will be an increase of 70,000 annually. Clearly, we are talking of a horrendous situation. Many orphans are HIV infected at birth and live as a challenging burden to communities and the government until their demise by their fifth year. But about 70% of these orphans can now live into adulthood if they receive effective mother-to-child-transmission interventions such as the administration of nevarapine to the mother and baby at delivery. For poor countries such as Malawi nevarapine is not easily affordable and its ready availability would mostly depend on international drug donations.
The whole question of HIV/AIDS orphans has created a situation extremely taxing to policy makers especially in developing countries. Most countries, including Malawi, have formulated national policies concerning orphans, some of whom will live into adulthood. This issue has been strenuously addressed in Malawi by the Ministry of Gender, Youth and Community Services through its coordination of the orphan services currently in the hands of a number of players including Non-Governmental Organizations. Malawi needs ideas that will improve the implementation of policies surrounding this difficult challenge of HIV/AIDS orphans today and tomorrow.
The challenges include education. Now, this is on the advocacy level: who is prepared to come forward and advise us on how to promote effective education for orphans. Clearly, in countries where school fees are charged, the orphan is at a big disadvantage without parents. What can governments do to handle this situation? What can international organizations do to handle this situation? One can think of scholarships but that involves money. Feeding schemes in schools are extremely important. Where do we get the money from to feed those children? You need properly trained teachers to teach these children in an orphan-friendly environment that will ensure that these children are not ostracized in any social or cultural sense. There is need for community and government mobilization, and the involvement of the international community. It is a whole situation which calls for proper and concerted conceptualization and delivery. That is something that I hope we can perhaps brainstorm here and then address on the 22nd of this month. I think this is more than enough to introduce my pain about HIV/AIDS orphans.
Ambassador Ousmane Moutari, Niger: In regard to the training: I know that some international organizations are concerned about the problem. I think Dr. Delavelle could give us an example of Niger and Synergies Africaines, about what Boehringer Ingelheim is doing for the training of the trainers.
Dr. Didier Delavelle, Boehringer Ingelheim: Ambassador, as you may know, Boehringer Ingelheim as well as four other companies and several agencies in the U.N. system decided three years ago to join their efforts to accelerate access to HIV drugs, care and treatment, especially in Africa. With drugs available, we all discovered that training people became the most important challenge. And we consider that while the pharmaceutical industry is qualified to make drugs, it is not the best entity to train people. That is why we consider that we need to develop partnerships with qualified institutions or experts, and we are very open to finding out how we could work on very concrete training sessions with institutions like NGOs.
The first example I would like to share with you is our important collaboration with the French Red Cross in Congo. I previously had a discussion about it with the Congo representative here. The French Red Cross is training nurses who are using our drug Viramune ® (nevirapine) to prevent mother-to-child HIV transmission in Pointe-Noire. This program began last year, and a new training session will be held next week.
The second option we are trying to explore is close collaboration with an NGO called African Synergies, who organized the first prevention of mother-to-child transmission training session, in close cooperation with UNAIDS, WHO, and UNICEF, in July in Conakry, Guinea. The next training session will be held in Niger the first week of October. These two examples, I would like to say, could provide a path, a way to accelerate access to HIV drugs through training programs. As you know, while all of us attend a lot of sessions in Geneva and New York that discuss HIV/AIDS- related problems, we find it difficult to work effectively in the field, especially in Africa.
Dr. Elaine Wolfson: Would anyone else like to weigh in? Please introduce yourself.
Mr. Don Creighton, Pfizer, Inc.: I am Don Creighton with Pfizer. At Pfizer, we sponsor the Diflucan Partnership Program. Currently, we are involved in 20 programs, working in collaboration with 16 African countries and Haiti. We are in the process of expanding to another 22 countries in Africa, Latin America, the Caribbean, Eastern Europe and Asia to provide the product, to donate the product.
Dr. Elaine Wolfson: Could you tell us a little about what Diflucan is used for?
Mr. Don Creighton, Pfizer, Inc.: Diflucan treats fungal opportunistic infections for patients with AIDS. Similarly to Boehringer Ingelheim and other companies, Pfizer partners with several global organizations—including the Axios International and International Association for Physicians in AIDS Care—through which we are dispensing Diflucan and educating health-care providers within various countries. We hope that this funnels down to the patient.
In addition, we also work with the Interchurch Medical Association which provides outreach programs targeted to communities through faith-based organizations. In partnering with these organizations, we find that we are not only able to support product delivery but also are able to enhance the educational infrastructure, which is a vital part in trying to stifle the spread of HIV/AIDS. In conclusion, Pfizer believes the role of the private-public partnership is critical, and we find this is the best way forward as far as initiating these types of programs.
Question from Audience: Could you provide us a list of the countries concerned and can you tell us your capacity. Are you ever going to expand the list?
Mr. Don Creighton, Pfizer, Inc.: We work through the International Dispensary Association to provide the product, and we are above 100,000 prescriptions to date, after starting in South Africa as of December 2000. We have 20 programs in 17 countries currently. We will continue to partner with the global non-profit organizations as we expand to 22 other countries in Africa, Asia, Caribbean, Eastern Europe and Latin America. I will forward the complete list of countries in which we currently are running programs to Dr. Wolfson.
Dr. Elaine Wolfson: Once we have the list we will post it on our website. I just want to say that we have worked with Johnson & Johnson. They made a drug donation to the Global Alliance and we, in turn, passed their donation along to ambulatory care centers in Burkina Faso. Conrad, tell us about it.
Mr. Conrad Person, Johnson & Johnson: While Johnson & Johnson does not produce or market an antiretroviral (ARV) like Pfizer, we do have a variety of products that we feel are important for palliative care and extending life, and certainly for adding to the comfort of life. One of our products, miconazole nitrate MAT, has particular significance for oral candidiasis, and we have offered it to key organizations under several different programs. The Global Alliance for Women's Health and Burkina Faso provide a great example of a partnership capable of rapid action, having managed very quick identification of the health centers that ought to have this product. Of course, other groups such as Project Hope in Malawi and MEDS in Kenya are participating quite effectively as well. But for Johnson & Johnson, because we make so many consumer products, basic hygiene and infection control needs are also part of the community-based home health care programs we help support in South Africa.
We have worked with South Africa's HIVSA, which is part of Baragwana Hospital. A memorandum of understanding is now in place which funds HIVSA's coordination of material support for two home-based care organizations in greater Johannesburg. HIVSA will tie that support in with the procurement of products that are useful in the sick room. These are the very simplest of products: soaps and skin care, pain relievers and disinfectants. We believe that supporting such organizations is important because they refer people who are ill into the system of care within the country. That, obviously, is important too.
Florence Deacon, Franciscans International: I am Florence Deacon and I represent Franciscans International. I am also part of an NGO working group on HIV/AIDS here in New York. Although we did not intend it that way, we are ending up being heavily faith based. At our meeting yesterday, we were almost entirely Catholic sisters. But, what I am seeing is a way we can communicate with you. We did not actually tally it, but we have members all over the world. Franciscans are in almost every country in the world. We also do health care a lot in Africa, so I see lots of ways we can coordinate our activities here, possibly be contact people for each other, get the word out. We certainly want to work with the governments any way we can. We are just in the beginning stages of this group, but I am seeing lots of ways we could collaborate.
Dr. Elaine Wolfson: Rihanna Kola, from Merck, is next.
Ms. Rihanna Kola, Merck & Co., Inc.: Thank you, Dr. Wolfson. Thank you, Ambassador Ousmane Moutari and Ambassador Isaac C. Lamba. I would like to share with you Merck's current experiences and programs in relation to HIV/AIDS, particularly the African Comprehensive HIV Partnership in Botswana. This is a tripartite partnership with the Botswana government, Merck and the Gates Foundation. In view of one of the topics for discussion today, orphans, we are in the process of setting up initiatives to improve the lives of affected children in Botswana. Reflecting on the Botswana example is important for us. We need to learn and understand both the strengths and weaknesses of the program if we are to improve HIV/AIDS prevention, care and treatment.
Other Merck intervention that I would like to focus on are our clinical training programs in Africa. I have a list of the countries where we have trained physicians, and I have executive summaries which I will pass around. To date, we have trained 2,075 physicians in treating HIV/AIDS. We hope and plan to empower health-care workers for long-term sustainability in delivering quality health care in the countries with which we are partnering.. I think there are several examples in this handout that should give you additional information about Merck's programs.
Mr. Joshua Ng'elu, National AIDS Control Council, Kenya: I think that those cases that we have heard so far are good, but my concern is with scaling up. I think we need to get the best stories from the countries represented here as to what route to follow.
We would like to know what percentage we are talking about, because we may say that we are making interventions, but what percentage of people with AIDS living in those countries have access to this. If you follow the route my neighbor was saying, working with home-based organizations, how many of those women in the rural areas can be able to access the drugs that we are talking about?
Let me say two things, Madam Moderator and the two co-chairs. I think the root problem in many of the African countries, and I stand to be corrected, is access to the drugs. However, first and foremost, you need to agree on the kind of regimens we are talking about. And the training that was talked about: you need to come up with the curriculum and say who we need to train. Do you need to train the doctors? Do you need to train the nurses? Do you need to train the clinic officers? Do you need to train the paramedics? Down there in the rural areas, who are the people who are going to administer those drugs? It is not the doctors, because in many African countries look at the ratio: the number of African doctors vis-a-vis the population that you could be talking could be about one doctor per 1,000 or 10,000 people. Therefore, the person you are likely to reach in the community or the village is a nurse or a clinic officer. How many of them will you be able to train to be able to administer the care? So, I think we need to know, for example, the numbers we are talking about. What percentage of the people living with AIDS, in Kenya for example, are we talking about? For example, what happens when 200,000 people need ARVs, but only 7,000 people will be able to access those drugs? I think we need to talk about those particular numbers.
Dr. Elaine Wolfson: I am delighted you have made this intervention. I think that this is one of the most pressing issues facing the African and other countries in the world. We know the figures are very clear. We are talking about 30 million people in Sub-Saharan Africa who are infected and about 5 million are ready for antiretrovirals. We are talking about a situation where anti-retroviral prices have come down. We are talking about a situation where the Bush Initiative is projecting an expenditure of about US$15 billion, of which about US$2 billion will be released in 2004, some of that amount to go for drugs. We are talking about the World Bank which has a multi-country program, and we are talking about the Global Health Fund. We know there are now several billion dollars, pots of dollars that will be assigned not only to prevention, care, and training but also for treatment. Access to treatment is a very pressing issue to discuss, whether it will be made available and to what extent. We also know that fewer than 60,000 people, maybe it is 50,000, maybe it is 65,000, I'm not sure, are receiving antiretrovirals in Africa, Sub-Saharan Africa. So the real issue, from my perspective, and I share it with you, is scaling up. How can we do it? I hope that you will all join in and discuss this.
Mr. Don Creighton, Pfizer, Inc.: In scaling up, there are several considerations. Infrastructure, both in terms of facilities and education, is of major concern. There is also a concern about educating caregivers regarding appropriate care. Inappropriate care can allow HIV strains to develop resistance. This is a critical area where we have to be concerned because I think the industry and everyone are involved. Finally, we must think globally on HIV/AIDS. This is not only an issue in Sub-Saharan Africa.
Dr. Elaine Wolfson: Some of you may be familiar with Paul Farmer's work. He is from Harvard, and he has been working in Haiti. Although I have not seen the reports about his direct observational treatment efforts, there is a lot of discussion about it having worked well in tuberculosis treatment and seems to be successful in the administration of antiretrovirals (ARVs). Indeed, the people in South Africa who have participated in pilot projects for ARVs have been taking their drugs regularly. In fact, there was a story in The New York Times about two weeks ago that suggested that people with HIV in South Africa were taking their medications better than even people with HIV in the US. So, there seems to be some examples and models that perhaps could help us scale up to address the issue in rural areas.
Ms. Tamara Raven, International Council of Women: I just have a small contribution to make. My name is Tamara Raven and I am with the International Council of Women. I am also a member of the board of the Organization for Tropical Studies, and in that relationship I met Fr. Harold Bradley who is now at Marquette University. Using money granted by USAID, they have had nurses from Kenya come to Marquette, a Jesuit university in Wisconsin. After being trained there, the nurses then go back to Kenya and work in the field. I just offer you that as a connection for some people who may be interested in this work in Mombassa, Moi, and in Nairobi. In addition, the program is trying to make a connection with the University of Wisconsin at Stephen's Point. One of the things that I have been trying to encourage Fr. Harold Bradley to emphasize while he is trying to raise funds is to stress the potential for helping orphans in an agro-ecology farm-type gardening food situation. The Ambassador from Malawi mentioned the need for there to be a rich curriculum for students and, of course, we know that one of the big gaps is food and nutrition. It seems to me that it would be important to intensify our knowledge of really productive food systems in the tropics. This is on the biodiversity agenda as well.
Ambassador Stanislaus, Permanent Mission of Grenada to the UN: I am Ambassador Stanislaus from Grenada. As I listen to the interventions made thus far, I just want to point out that the Caribbean is second only to Sub-Saharan Africa in the incidence and mortality of HIV/AIDS. So, I am hoping and appealing to the leaders here from the pharmaceutical industry to think of the Caribbean, too. This is not to detract from Mother Africa, but remember we are part of the separated brethren.
Our hearts go out when we hear mention the plight of orphans, but I want to talk a little about the grandparents. You know, so many grandparents have become parents now, and if we can give some help there, we would be helping both the orphans and the grandparents.
Finally, I hope we have the time to divert discussion from treatment and talk a little about prevention, but I will leave that for another opportunity.
Mr. Charles Vincent, World Food Program: I am Charles Vincent with the World Food Program. The previous two speakers have really made a good introduction to my contribution. Mr. Morris, the executive director at World Food Program, spoke at UNICEF earlier this week, and his speech really focused quite a bit on HIV/AIDS in southern Africa where he has been a special envoy, as the Ambassadors know. That speech should be available on the website of World Food Program, and you will see a lot of other HIV/AIDS-related items there as well.
You spoke, Ambassador, about 700,000 orphans. Mr. Morris spoke about 11 million orphans, and the enormous burden that it puts on older people, grandparents taking care of 14, 16 children, and on children-headed households all over the world, particularly in Africa. Good nutrition has become an important issue. We see food as an essential element, along with drugs and social community care to help the communities, to help the individuals, to help the mothers, the women, and the children to move on and try to have a near normal life. Mr. Morris has also been advocating quite a bit for trying to get as big a school feeding program as possible and for getting those orphans into schools, because a lot of times they are excluded from school, and to give them training. What the World Food Program has been doing, in collaboration with UNICEF, WHO, NGOs, and the governments, of course, is to try to introduce training, to introduce a sensitization of the children, in the school curriculum.
There are urgent measures to be taken today in the short term; but there are urgent measures to be taken today also for the long term. So we have to work on all fronts at the same time. We also need to find a way to support the women who are the main household providers in Africa as food producers, as food preparers. We need to get water closer to their homes. We need to get better agricultural assistance. So, in general we are appealing for help. We are trying to work concretely with really hundreds or thousands, if not millions, of people, to get training, to get support for better techniques, to get school feedings integrated into all government programs.
Ms. Christine Kapalata, Permanent Mission of the United Republic of Tanzania to the UN: Thank you, Dr. Wolfson. I also want to thank the co-chairpersons for their introductory remarks. Madam Moderator, I am participating as somebody who is, if I can say it, removed. I heard the interventions that were made before me by representatives from Johnson & Johnson, Merck, Pfizer, and the World Food Program. These are people who are really hands on. We, the diplomats at the United Nations, we read the documents, we read about the pandemic, we experience it by hearing of people that are affected or who are infected, and most of us, especially in Sub-Saharan Africa, cannot claim to not have contact at least with one or two individuals who have been infected with HIV or have lost their lives because of the disease.
My contribution, Madam Moderator, to this interactive brainstorming session, is to look at this situation and assess what is really on the table. What I can say with a lot of certainty is that regarding private-public partnership, synergy is really crucial. We heard the Franciscan sister speaking. We heard the pharmaceutical industry speaking, and we heard governments speaking. There is nobody who can afford to stay away.
The Ambassador from Grenada just made mention of the fact that the Caribbean, too, is affected. Just this morning I was reading that the pandemic now is really spreading at an alarming rate in Eastern Europe and parts of Asia. Really none of us can, at this point, claim to have the most affected populations.
What is really needed, Madam Moderator, in my opinion, is something drastic. We have heard about the orphans, we have heard about the mother-to-child transmission, we have heard about the palliative care, we have heard about the ARVs, we have heard about the poor infrastructure, we have heard about the paucity of resources. Maybe the 22nd of September meeting is an occasion to do more than access the goals. We had goals for 2003, 2005, and 2008. But while we are looking at goals, peoples lives cannot wait. Something drastic has to be done. Somebody said maybe we need somebody to walk on their head to really make us realize we have to do this differently. We have made a lot of headway, but it is also alarming to read that the pandemic is on the rise. So something else other than what we have been doing needs to be done. I cannot sit here and pretend that I have that magic something else, but this kind of interaction, Madam Moderator, is really useful in that we bring different synergies from different areas and aspects of society to the exchange ideas. So maybe somewhere we will find a way of dealing with this because you cannot deal with it in only one aspect of health. It is also an economics issue; it is a developmental issue; it is a social issue; it is a cultural issue; it has permeated all facets of life. So, Madam Moderator, I just wanted to share my frustration and hope for the future as we approach the special session on the 22nd of September. We should all aim at coming up with creativity in how to deal with this pandemic because it is all pervasive.
Mr. Lefu Manyokole, Permanent Mission of the Kingdom of Lesotho to the UN: Thank you, Madam Moderator. I also want to thank in a special way our two co-chairs who met us and made the wonderful preface of our discussion, and to thank our partners, particularly the pharmaceutical and other companies and the NGOs who are trying to help us with this problem we are facing. In speaking now, I am following the Ambassador of Grenada and the Representative of Kenya and my colleague, Christine Kapalata from Tanzania. I am touched hearing so many people talking about this problem. But, like my colleague from Kenya said, we are more worried about what kind of assistance we can get from our partners, or the pharmaceutical companies, and whether they consider the statistics and scale of the scourge. We are concerned about what kind of assistance is given and whether it also aligns itself with our social cultures.
I heard my Ambassador from Malawi talking about orphans in our region, and I remembered that in Lesotho, in particular, we have only 2 million people or a little more. We are also highly affected because the percentage of people suffering from the HIV/AIDS scourge is high. Secondly and most importantly, our area is also affected by drought, which has caused serious famine. I know that countries like the United States and our big developmental partners, big powers, know how much we have been affected by that, and they are doing their best to answer that challenge. I believe sometimes we need to put things into perspective, in the sense that we have social cultures there that are not easy to deal with. My Ambassador spoke about the importance of educating the orphans and the difficult conditions under which they live; the Ambassador of Grenada talked about the grandparents, who have just automatically become parents. Some relatives have had to leave their jobs to come and stay in houses or in small shelters to house and try to care for those children. How can you even think of a medicine or a treatment if you cannot even have anything to eat? This is a very serious situation.
Governments are doing their best with the little resources they have in our area. We do not know how to cope when we look at the challenges ahead. In most cases even when these pharmaceutical companies and NGOs join in the effort, the main, heavy problem is faced by government. They have to see what they can do with the little resources they have. Sometimes big companies from big countries come and say they want to work with NGOs and this and that, and not with governments because governments may take the resources to apply to other priorities. It is always that kind of battle when we have to talk about who has the power to do what. Yet, in the final analysis, governments are responsible for the people who voted for them to be in power and have to deal with the problems of the society. They are the ones who have to bear the consequences more than anybody else.
I am appealing to the pharmaceutical companies and the private sector to look at that aspect because, as I said, the social cultures and settings are different. We do not have as many powerful NGOs as we would like. We have communities who have contributed to putting the government in power, who expect the government to do something that works. They would like to work with the government to help the people who are affected and infected alleviate their problem. I would like to appeal to the private sector to look at our situations in a different manner.
And finally, I would just like to say to Merck: I recognize and appreciate the effort you are making, but I would like to pose a question to you. When you say you have a specific program you are doing in Botswana, that you are trying to learn from that program so that other states can better handle similar problems, all I want to know is: is it a pilot project you are doing in Botswana and when are you going to expand to a wider horizon? This question is also just a little challenge.
Ms. Rihanna Kola, Merck & Co. Inc.: I appreciate you asking that. We have a fully integrated, comprehensive program with the Botswana government. We are in partnership with them. Through relationship building, we have succeeded in initiating a HIV/AIDS program that is in the interest of the Botswana people. We are hoping to be able to use some of the lessons we have learned there and use them in new partnerships with others. Going forward, we will apply our expertise and work with the respective governments to deliver to their people what each government believes is in the best interest of getting to the grassroots level. That is our intention.
Ambassador Moutari, Niger: I would just like to come back to the issue raised by our colleague from Kenya and our colleague from Lesotho concerning the level, or the scale, of the intervention of the pharmaceutical industries, and find out whether you are giving medicine, treatment, or the training. I think we, as representatives of government, should not expect too much from the private industry. In the sense that they are private, they are for-profit organizations.
Probably what we could ask them is, how can we help? How can the government help them to expand their intervention? For instance, training of trainers is a good thing; it will give us a base from which to start, to expand. How can we spread the number of people trained? We can go in and train a trainer who will train another trainer, and so on and it will multiply. The same could happen with the medicine at the start. It is a very important job Merck is doing in Botswana, but we probably could not expect Merck to expand to all Africa because they simply cannot do it. What can we as governments do, for instance, at the next meeting, on the 22nd of September? What can we do to help you do as much as possible? What are you expecting us, as governments, to do? It would be very interesting to know that.
Ms. Rihanna Kola, Merck & Co., Inc.: We are looking to build long-term relationships with government, and we also are very keen to understand how much we can help you. We want to use our resources to serve your interests and your populations' interests in the best possible way. My personal view is that the empowerment of women to change this pandemic around and education regarding women's reproductive health are crucial to changing the way HIV/AIDS prevention is implemented. Further, what is needed is a meaningful partnership with the men in their own communities that would afford the women the opportunity to be part of an important behavioral change.
Mr. Georges Alabi, Permanent Mission of Nigeria to the UN: I really want to thank the organizers of this meeting, the Ambassador of Malawi, and the Ambassador of Niger. My concern is about the situation of children in Africa. I want to raise the example of my country, where the government is committed to the provision of antiretroviral drugs to those living with HIV/AIDS. A lot of progress has been made in this area, but we note that these drugs are not getting to children that already live with HIV/AIDS. We have close to 850,000 children that are presently living with this pandemic. I do know we do have the very great presence of Johnson & Johnson and Pfizer in Nigeria. I would like to know what these companies are really doing to get these drugs to children, in particular, not only in Nigeria, in Africa. Thank you very much.
Mr. Conrad Person, Johnson & Johnson: We do not manufacture these antiretroviral drugs, but I will say that our attitude is that we should take our products which have application for the treatment of people who have AIDS, even though they are not curative, and try our best to make them available to programs for sustainability. To Johnson & Johnson, sustainability means the programs are not overly dependent on our support, and we have had some success in identifying such programs. We see it as our task to find ways to make products that we produce available in a manner that fits within the existing structures that support health-care providers in that society. Our goal is to find a way for our donations to reach those in need without disrupting the normal economic systems for procurement and rational drug use. Our relationship with MEDS in Kenya around miconazole MAT is an example. MEDS serves many health-care providers on a not-for-profit basis. Donated miconazole is one item they offer with an understanding that they will use accumulated revenue for local health programs. Rather than being distributed free, the drug is sold at a very low cost, with the money received dedicated toward community health activities. So, that is the model that we are pursuing and working on. We think it has high potential to support community health projects that affect children.
Dr. Elaine Wolfson: May I make an intervention here. There is a model that might be considered by Nigeria. Romania had a particular problem with children being infected with HIV/AIDS, and their services for them are now up to scale. I think in 1997 they had under 10% of the children in treatment; now I think they have about 98%. Whether the children are ready for antiretrovirals, I cannot answer, but I think you might want to talk to the Ambassador from Romania. We did a program last year with Merck and Romania honoring its president, and we addressed the issue of scaling up in Romania. Their treatment problems were relatively small compared to some of those in Africa, but they were dealing with several thousand infected children who are now at a stage where they are being treated. That might be of help to you.
Dr. Didier Delavelle, Boehringer Ingelheim, GmbH: I would like to go back to what you said, Mr. Ambassador, and try to clarify in a very transparent manner the debate today. If the question is, What is the industry doing?, I think that the answer is very clear. The industry, since 2000, is doing a lot of things. Our Accelerated Access Initiative is a very good example of a concrete action. Reducing the price of antiretroviral drugs and initiating a donation for a free program are also very concrete. If the question is, What can we do all together, on a large scale, to accelerate access to HIV care, especially to provide for those populations who do not have access?, I do not think that the industry is the qualified structure that can alone answer this question.
On behalf of Boehringer, I would say we, alone, cannot answer this question. We do not have the budget for that because the budget is used to manage the Donation Program. But I really think that we can collectively answer this question. For the moment, in our donation program we have two ways of proceeding. The first way is to work with any organization that we consider effective in order to prevent mother-to-child transmission. That means it can be the Red Cross, MSF, faith-based organizations, the Elizabeth Glazer Foundation, whatever. The only thing we want to be sure of is that the drug is given to the mother and the baby with the official authorization of the government.
On the other hand we try to collaborate on a large scale with governments, for example, the governments of Senegal, Cameroon, and so on. And, of course, today we do not have a large-scale program because those governments do not have large-scale public health programs. This is not a criticism; it is a fact. So, we consider that if we want our donation program to be more effective, the national HIV/AIDS program of the country must be helped; only bilateral multilateral collaboration can help to access this goal.
You mentioned that there is now a Global Fund. That is one way. The World Bank has a lot of money, and I have many examples of their money not being used by the local government. I can tell you that in Cameroon today they have only used 12% of the funds they received from the World Bank. This is not a criticism; it is a fact because of the lack of infrastructure, too few trained people, and so on. My personal contribution to our meeting today will be that I think there are qualified persons in a lot of organizations, private and non-private organizations, and I think that in the HIV/AIDS field, it would be easy to pick up an adequate person, an expert, and try to create a network with money given by those international institutions established for that. But do not ask the pharmaceutical industry to give money. It will be reluctant to give, since significant efforts have been made to reduce the HIV/AIDS drug prices.
Ms. Caroline Themm, Soroptimist International: I would like to congratulate the pharmaceutical industry on all of their efforts and on their individual programs, but I see it as a scattershot. I would like to challenge the industry to work together, all of you, combine your programs and offer a program, a complete comprehensive program, that could be given to countries, NGOs, everybody, and we could all work together.
Issa Konfourou, Permanent Mission of the Republic of Mali to the UN: I am always pleased to see Elaine chairing our meeting, and I have to commend her efforts, her personal effort to fight this pandemic. I have also to thank our co-chairs for their dedication to this goal. I ask for the floor, first to pose one question and then to make one comment. The question is about resources, sufficient resources to fight HIV/AIDS. It is really clear that governments by themselves cannot afford the resources to fight this pandemic. Civil society, the private sector, and industry also do not have the resources. I think, if I am not mistaken, that in 2001 the international community created a Global Fund to Fight Tuberculosis, Malaria and HIV/AIDS. I wonder if it is not time now to go back to this fund for more donations, although I am not sure they have sufficient resources. But they have some, and they are helping certain countries to fight this scourge. My question: Is it now time to go back to the Global Fund to see if they can provide more help to certain NGOs, private sectors, and governments in order to realize better results in the battle against this pandemic?
My comment is about the need for coordination of effort of government, private sector, industries, and NGOs, because in certain countries there are several NGOs working on the same issue, but there is no coordination of their efforts. I think the time has come to try to think of coordinating the efforts of all the stakeholders on this matter.
Ambassador Isaac Lamba, Malawi: Briefly, Madam Moderator, from all that has been said here, one thing has struck me. And it is, to summarize, that even if we get all the required international aid and assistance we need, unless we have the capacity in the receiving countries, all those donations are not going to be effective. We need the physical infrastructure, the trained personnel to handle the specialized vocabulary related to new treatments such as the ARVs. I think Didier made this point. We need training for capacity building. The United Nations Global Fund to Fight Tuberculosis, Malaria and HIV/AIDS has been quite generous in so many ways and if indeed Cameroon has spent only 16% of what was donated to it, the training aspect is indeed crucial.
I know Boehringer made a very provocative statement that was quoted in the press. I do not know if it was a misquotation, but the press reported that in Africa only two countries have accepted ARV drugs. It could have been put probably differently; it might be that in Africa only two countries have been forthcoming in the actual delivery of the drug donation from Boehringer to the patients perhaps for lack of capacity. The point remains that unless we train our people in ways of handling the ARVs, the administration of the aid will remain ineffective. Today any discussion addressing HIV/AIDS must focus on both prevention and treatment. Prevention may not be as specialized as treatment although it has its own areas of specialization. But it is the treatment side where the training is more crucial here. I will give you an example: the Global Fund gave quite a bit of money to a country and, just like in the case of Cameroon, that country is failing to use the money. Why? Because of the lack of trained personnel and skills. My plea now is that as donors coordinate their efforts to come up with assistance and aid to the infected in developing countries, the project document must include the component of training to ensure that whatever is given will be effectively utilized.
Dr. Didier Delavelle, Boehringer Ingelheim, GmbH: I would like to answer the suggestion which has been made by a representative here. Of course, industry is trying to collaborate. For example, at the beginning of this year, we initiated a partnership with Abbott in prevention of mother-to-child transmission. This means that Abbott is giving for free the HIV test and Boehringer Ingelheim is providing the drug for free.
Once again, I would like it to be clearly understood: I really think the solution of scaling up for a large-scale access to HIV drugs means having a public-health strategy. The pharmaceutical industry is not the best-qualified institution in public health to do this. The industry is relevant in making and developing drugs and eventually selling or giving them away, but not in making public-health strategies. But, I do think, and once again I suggest in this open meeting, that international organizations such as the World Bank or WHO or UNICEF or NGOs like yours, Elaine, or like MSF, or like faith-based organizations, pick up experts in the industry to help you. You can be an MD working for a pharmaceutical company and be a good guy. You can also try to get expertise from aid agencies. You have in the United States the National Institute of Health, the Center for Disease Control, you have a lot of aid agencies involved for many years in Africa in the HIV field. You have in Europe the AIDS agency, you have also bilateral cooperation such as German GTZ. The Netherlands also has a lot of expertise in cooperating with the developing world. I think if you try to create a network that can draw on the experience of so many, you could have access to the various funds, especially to the Global Fund. I know, for example, the French are cooperating with countries like Mali, Gabon and others to support their efforts to submit dossiers to the Global Fund in order to get money.
Joshua Ng'elu, National AIDS Control Council: I think the industry should not misunderstand and feel that we are forcing them into a marriage. I think we are living in a world of partnership and whether or not our friend Didier thinks that we are living responsibly, I think in the world today, we live in a world of partnership. That means trying to help one another. Yet, how is it that in the US or in the western countries there is a coordinated approach to treating the people with HIV/AIDS living there. They are able to access the drugs that we are discussing today. These people will be able to live longer. The pharmaceutical industry has a role in the entire coordinated approach that we are talking about. Really, we are not blaming you, but we are saying that you, the industry, have a part to play. Please hear us loud and clear.
Today we are talking about Africa. Someone talked about the infrastructure being missing. I think we do not have to repeat what has been done in Botswana; we can just lift what has been done in Botswana, adjust it to the cultural aspect of another country-whether for Lesotho or Tanzania or Kenya. Train those people and then, please, industry can come in. That is why we are saying we need a coordinated approach.
My second point, Madam Moderator, concerns what has been said about the Cameroon Global Fund not being able to use the money. I think we need to leave this conference room with a very clear understanding. Kenya is one of the countries able to get Global Fund money. I do not think that it is just a matter of walking in and getting it. There are conditions that you have to fulfill. If the capacity is not there to effect prevention of mother-to-child transmission, you cannot just use the money to meet other needs. If you are talking about having a prevention of mother-to-child-transmission class, it is not just a matter of women going there. There are procedures that have to be followed: the pregnant woman goes there. If she has been found to be HIV positive, you need to bring in her spouse. They have to agree to participate because these are special programs and it is not a question of "walk in and get it" if you do not meet the requirements.
All we are saying is that there are conditions and capacity building, and I believe, co-chairman, that you put it very well, it has to do with a lot of training. There are NGOs in Botswana, in Lesotho. Why don't we get the benefit of their experience? Why does it take so much time—one year, two years, more-just to repeat the same thing that has already been done in Nigeria or in Botswana? These countries are very similar, just different in culture.
Unidentified Female Speaker: My point is very small. It relates to what you, Madam Moderator, and a few others around the table have pointed out: the way forward is scaling up of our initiatives. My point is mainly related to voluntary testing and counseling. My belief is that we would not have all these programs if people do not come forward to say, "This is my status." One of the problems we are facing in our countries is that people are not really coming forward. Of course, more and more are coming forward, but not enough are coming forward to state whether they are HIV positive. The point I am trying to emphasize is the need for partnerships. If a state points out that its problem is capacity, there is a need for partnerships with the industry, the private sector. And, indeed, as my colleague from Tanzania pointed out, everybody has to be involved in this reaction and national coordination, if I may put it that way.
The other point that I was trying to bring forward to my colleagues around the table is that we need to share experiences from our countries. How do different countries deal with the question of the stigma and discrimination against orphans and other people who are HIV positive? My plea to people around this table is to share ideas of how their countries have dealt with these problems.
Jacqueline Oubida, Permanent Mission of Burkina Faso to the UN: Thank you, Global Alliance, and I thank all the delegates here for this discussion. My delegation would like to thank everybody and let you know that we appreciate the aid of all the partners in the treatment of HIV/AIDS in our country. I would like to discuss one point. I think Dr. Delavelle raised the matter of Cameroon. I think that Cameroon did not have the opportunity to use all the money. I think it is our concern to know why money is available for the people who need it and why it is not used. It is a problem for us, for all partners to address this concern. We need to make funds available and make sure that we reach the people who need treatment, who need help with HIV/AIDS.
Mr. Don Creighton, Pfizer, Inc.: I have a few comments as to what government officials can do to help support the fight against HIV/AIDS. You must think about what are the expectations in the short, medium, and long term within your countries, with an emphasis on the goals set by the World Health Organization in terms of the money distributed from the Global Fund. Countries must identify what are the hurdles at this point toward meeting these expectations. What do you foresee as the hurdles in your particular country? We have heard much in regards to capacity as being the primary issue. You must develop a comprehensive strategy to overcome this hurdle. As we have heard today, this may be done by looking at examples of countries that have introduced programs to overcome these issues, then modifying these programs to your own country's specific needs. On an organizational level, this type of strategic framework is critical. As Dr. Delavelle has mentioned, what the industry can do and has done is to provide antiretrovirals and other medicines. In addition, we provide professional training, and we partner with NGOs to disburse treatment. The countries must address the public-health concerns that may impede prevention and treatment of HIV/AIDS. Development of a strategic framework to manage the forthcoming goals, showing how expectations will be met, would be of great benefit.
In reference to the Tanzania Ambassador's comments regarding the overall economic impact of HIV/AIDS: the pharmaceutical industry should not be the only focus of support in the private sector. There are severe economic repercussions that HIV will have on the entire world. I think one of the primary strategies that government should develop and implement is garnering support through private-sector partnerships. There are many companies and organizations that have a vested economic interest in treating and preventing HIV/AIDS.
Unidentified Male Speaker: The last few interventions moved over into the terrain of governance. Basically, I had a feeling about many of these interventions, in particular the depletion of professional people. Mr. Morris was talking to one of the presidents or prime ministers of one of the countries represented around this table and he said he is losing 2,000 teachers a year. We are talking about doctors, we are talking about nurses as well as talking about teachers. That is part of the reason why the capacity is not there to spend the money that Didier was speaking about.
I know that the United Nations Development Program, in collaboration with a number of member states, is trying to look at a way of kick starting on a large scale, because we cannot be talking about small things now. We really have to be talking about large-scale interventions, such as how to replenish that brain drain. Of course, we know it takes years, but we have to start today. If we do not start today, doctors who will be needed five years from now will not be there. Sure, people will die in the meantime, but we have to work also on the long term.
I want to bring in another issue of governance, one that affects women indirectly and, of course, the whole food security issue: the armed forces. Let us not forget that some units in some countries are 100% infected. Clearly that is a governance issue, for the government controls the military, hopefully, and obviously rules and guidance have to be given to soldiers.
And finally, to the industry, a personal comment. In a way I would have to say that if you want to make money you have to spend money. This is a classic good-investment type of issue. As an example-again, this is my personal observation-look at the recent discussion of the price of HIV/AIDS generic drugs and the price of brand drugs. Does that lead to more confidence? I think the industry has to make that extra step to say, "Hey, we can be good partners." I know this is something that maybe the industry does not want to hear. Of course, there are a lot of good people who work in it, but there needs to be a closer partnership. I think one of our colleagues said this earlier: more training, getting more doctors out there, needs support in a bigger way. Sure, governments are responsible, sure the World Bank has a lot of money, but the industry also has a lot of money.
Mr. Lominy Charles Hervé, Permanent Mission of Haiti to the UN: Thank you, Madam Moderator and thank you to the co-chairs. I understand that this meeting is mostly about the African model, but I am really concerned about the Caribbean, particularly Haiti. So my question to the pharmaceutical partners is, "What can you do to extend your donations to the Caribbean?" And also, in regard to the concerns of Dr. Delavelle and Mr. Creighton, "What can we do, our government, to help the process?"
Dr. Didier Delavelle, Boehringer Ingelheim, GmbH: Thank you for your comments. Of course, Caribbean islands are okay to join our donation program. I personally met in May 2002 in Geneva, during the General Assembly, all the health ministers of the Caribbean Economic Association. So, they know that our donation program is open to them. Elaine, you mentioned the possibility of giving HIV drugs on the directly observed therapy (DOT) basis. We all know that Dr. Paul Farmer in Haiti has had a very positive experience with treatment combinations given on that basis. So we are totally open to giving our drug or to participating in chronic infection treatment programs in the Caribbean region.
Mr. Joe Annan, UNDP HIV/AIDS Group: After just listening carefully to the whole discussion, I think it is clear that capacity is a huge problem. Capacity underscores all of the major challenges that we are facing. In fact, UNDP has been working in Botswana with the African Comprehensive HIV/AIDS Partnership, together with Merck and the Gates Foundation. One of the biggest challenges in a country like Botswana has been getting even the basic capacities in the health field. Even the importation, if you like, of health skills, took an extremely long time. So what we have recognized there is that the role, the response to HIV/AIDS, particularly regarding access to drugs, is that we need to think differently. We need a new kind of leadership at all levels. At UNDP, we have an HIV/AIDS leadership program that actually starts to unpack what the issues are, from the central level right to the decentralized level and to communities. We have a community capacity enhancement program that looks at increasing the demand by getting the communities themselves to devise ways in which they can promote voluntary counseling and testing. Without that we cannot actually access treatment. So overall, the fundamental, bottom line is whether or not we can find in time for the September 22nd meeting new ideas that we can put on the table that will unpack some of the bottleneck.
I would just like to add that we at UNDP work closely with the Global Fund. So far, we are in about 15 countries working collaboratively and we find the capacity issue there again and again. The challenge really for the Fund to survive is that we must increase capacity utilization. We must be able to use the available funds credibly. That brings me to the last point. What we try to do is increase the level of partnerships, those between the U.N. agencies, with the bi-laterals, and with the private sector, and to work very closely with governments to find new ways of bringing on board previously untapped human resources and skills that can now be brought up to where it is actually possible to scale up.
So, in a nutshell, if you are looking at scaling up, we really have to think out of the box, think about new ways to function particularly in some of the worst affected countries.
Dr. Elaine Wolfson: We will be closing the meeting after summaries from our co-chairs, Ambassador Moutari and Ambassador Lamba.
Ambassador Ousmane Moutari, Niger: Well, I am really glad that we had this opportunity to exchange ideas. What I have gathered is that there is really good disposition from the private industries and from civil society sectors to work closely with governments to do everything possible to scale up access to treatment. Obviously, there is a question of capacity to absorb the funds available, capacity with regard to infrastructure, and so on. I refer back to what Didier said: the industry is doing a lot. We need to continue to mobilize the funds available, whether from the World Bank, the Global Fund, wherever possible, to develop capacity and continue working for what is available in terms of medicine, in terms of financing, in terms of treatment accessible to those people who need it. There is a question regarding funds being raised as well as the question of the military. The military is an area where you have the problem of public health. It also has a big impact on national security and international security because we have now many countries that are reluctant, for instance, to send their military into some regions with large rates of HIV/AIDS prevalence for peace-keeping operations because they are afraid that when they come back home they will be a danger to national health. These are some of the issues that I would like to direct toward our colleagues from the U.N. Missions and say to them: work hard on September 22nd so that these issues will be brought up again and discussed and be a focus of the documents drafted then.
Dr. Elaine Wolfson: An invitation will be offered now before Ambassador Lamba's summary.
Michael Sipos, Business Council on International Understanding: We are holding a working lunch on September 22nd, on Monday, on behalf of the pharmaceutical industry, to review the lessons learned from the Accelerating Access Initiative, the first public-private partnership in this field, and we are extending an invitation to our distinguished guests from the missions and governments to attend and to all people who have valid U.N. passes for that day. The luncheon will be held on the West Terrace in the U.N. at 12:45 p.m. You are all welcome.
Ambassador Isaac Lamba, Malawi: I feel relieved that my job has already been done by my colleague, Ambassador Moutari, in summarizing the discussions of this morning. However, let me just go down into the wild to quickly go through what should be considered as the important areas to think about, to bear in mind as we sit down to strategize our approaches to HIV/AIDS and, indeed, to the issue of orphans. As we all know, the countries affected and infected have heavy responsibilities to shoulder. I think the starting point here, now that the problem is so vast in our countries, is to consider the area of legal framework. Whatever we do in our countries, we must bear in mind the need for a legal framework.
It is equally important to work hard in raising awareness, and I come back to the issue of children infected with HIV/AIDS. Awareness in our societies of the need to create an environment that will provide a safe and productive haven for these children is critical. Beyond that, there will have to be a concerted effort to develop a strategy for economic coping by the societies and communities that handle these children. This is one area that came out in our discussions. It is not only the psychological benefit that must be provided to the children but also they need economic benefits and security. This is an area that will need a lot of interaction between the societies and those with new ideas.
I also wanted to mention, this is reiterating really, the importance of ensuring that children of this nature are not discriminated against in our societies. In other words, we should ensure that the environment is, as it were, orphan friendly. They are affected by gender discrimination, also discrimination based on disease or status, and so forth. Such discrimination is something we need to get rid of because it has a devastating effect on the development of these children. Schools are crucially important. Any discrimination against these children there will stigmatize them and render the learning environment unproductive. In conclusion, the importance of partnerships must be underlined as we address this particular problem of HIV/AIDS and, indeed, the issue of orphans.
Dr. Elaine Wolfson: Thank all of you for coming. I hope that our discussion has been helpful and that it will enrich the U.N. meeting on Monday. I look forward to meeting with you again in the future because it seems that there are, indeed, so many, many unresolved problems related to this issue that we are going to have to spend more time in sessions like this. Thank you again.