Jenda: A Journal of Culture and African Women Studies (2001) ISSN: 1530-5686 INTERVIEW WITH STEPHEN LEWIS, UN SPECIAL ENVOY FOR HIV/AIDS

PLUSNEWS

December 3, 2001

Stephen Lewis is the UN Secretary-General’s Special Envoy for HIV/AIDS in Africa. In an interview with PlusNews, 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 the 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. 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. In Part Two, 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”.

Part 1

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 Organization’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 recognize 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.

Part 2

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 introducing1 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 recognizing 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.

Copyright 2001 PLUSNEWS

Citation Format

, PLUSNEWS (Reprint, 2001). INTERVIEW WITH STEPHEN LEWIS, UN SPECIAL ENVOY FOR HIV/AIDS. Jenda: A Journal of Culture and African Women Studies: 1, 2.