Hillary Clinton: We must not waste this historic opportunity

The goal of an Aids-free generation is possible. Imagine what the world will look like when we succeed

'The goal of an Aids-free generation is possible. Imagine what the world will look like when we succeed' (Reuters)

The fight against AIDS began three decades ago in June 1981. American scientists reported the first evidence of a mysterious new disease. It was killing young men by leaving them vulnerable to rare forms of pneumonia, cancer, and other health problems. Now, at first, doctors knew virtually nothing about this disease. Today, all those years later, we know a great deal.

We know, of course, about its horrific impact. AIDS has killed 30 million people around the world, and 34 million are living with HIV today. In Sub-Saharan Africa—where 60 percent of the people with HIV are women and girls—it left a generation of children to grow up without mothers and fathers or teachers. In some communities, the only growth industry was the funeral business.

Thirty years later, we also know a great deal about the virus itself. We understand how it is spread, how it constantly mutates in the body, how it hides from the immune system. And we have turned this knowledge to our advantage—developing ingenious ways to prevent its transmission and dozens of drugs that keep millions of people alive. Now, AIDS is still an incurable disease, but it no longer has to be a death sentence.

Finally, after 30 years, we know a great deal about ourselves. The worst plague of our lifetime brought out the best in humanity. Around the world, governments, businesses, faith communities, activists, individuals from every walk of life have come together, giving their time, their money—along with their heads and hearts—to fight AIDS.

Although the past 30 years have been a remarkable journey, we still have a long, hard road ahead of us. But today, thanks both to new knowledge and to new ways of applying it, we have the chance to give countless lives and futures to millions of people who are alive today, but equally, if not profoundly more importantly, to an entire generation yet to be born.

From its earliest days, the fight against HIV/AIDS has been a global effort. But in the story of this fight, America’s name comes up time and again.

At a time when people are raising questions about America’s role in the world, our leadership in global health reminds them who we are and what we do, that we are the nation that has done more than any other country in history to save the lives of millions of people beyond our borders.

Our efforts must begin with the American public: from people living with the disease, to researchers in academic medical centres; to individual donors, businesses, and foundations; and philanthropies – two of my favourite ones, the Clinton Foundation which helped make treatment more affordable by supporting innovative ways to manufacture and purchase drugs; the Bill & Melinda Gates Foundation, which has underwritten breakthrough research.

But let’s remind ourselves no institution in the world has done more than the US government. We have produced a track record of excellence in science. The first drug to treat AIDS was supported by the United States. Today we are making major investments in the search for a vaccine; for tools like microbicides, which give women the power to protect themselves; and other lifesaving innovations.

Alongside our research and development work, the United States has led a global effort to bring these advances to bear in saving lives. When my husband was president, he appointed America’s first AIDS czar and more than tripled U.S. investments in preventing and treating AIDS worldwide. And in 2003, President Bush, with strong bipartisan support from Congress, made the momentous decision to launch the President’s Emergency Plan for AIDS Relief, or PEPFAR.

At that time, only 50,000 people in Sub-Saharan Africa were receiving the antiretroviral drugs that would keep them alive. Now, more than 5 million do, along with more than a million people in other regions of the world, and the vast majority receive drugs financed by either PEPFAR or the Global Fund to Fight AIDS, Tuberculosis, and Malaria, which the United States helped create.

And PEPFAR is having an impact far beyond AIDS. It has expanded on the World Health Organization’s efforts to treat and prevent tuberculosis, which is the leading cause of death among people with AIDS. PEPFAR has also helped build new facilities throughout our partner countries that see patients not just for HIV/AIDS, but for malaria, for immunisations, and much more. To staff these clinics, we have helped train a new cadre of professional health workers who are making their countries more self-sufficient. In some countries, the same trucks that deliver AIDS medicine now also deliver bed nets to prevent malaria.

For all these reasons, PEPFAR is one of the strong platforms upon which the Obama Administration is building our Global Health Initiative, which supports one-stop clinics offering an array of health services while driving down costs, driving up impact, and saving more lives.

What’s more, our efforts have helped set the stage for a historic opportunity, one that the world has today: to change the course of this pandemic and usher in an AIDS-free generation.

By an AIDS-free generation, I mean one where, first, virtually no children are born with the virus; second, as these children become teenagers and adults, they are at far lower risk of becoming infected than they would be today thanks to a wide range of prevention tools; and third, if they do acquire HIV, they have access to treatment that helps prevent them from developing AIDS and passing the virus on to others.

HIV may be with us well into the future. But the disease that it causes need not be. This is, I admit, an ambitious goal, and I recognise I am not the first person to envision it. But creating an AIDS-free generation has never been a policy priority for the US government until today, because this goal would have been unimaginable just a few years ago. Yet today, it is possible because of scientific advances and new practices put in place by this Administration and our many partners. Now while the finish line is not yet in sight, we know we can get there, because now we know the route we need to take. It requires all of us to put a variety of scientifically proven prevention tools to work in concert with each other. Just as doctors talk about combination treatment – prescribing more than one drug at a time – we all must step up our use of combination prevention.

America’s combination prevention strategy focuses on a set of interventions that have been proven most effective – ending mother-to-child transmission, expanding voluntary medical male circumcision, and scaling up treatment for people living with HIV/AIDS. Now of course, interventions like these can’t be successful in isolation. They work best when combined with condoms, counselling and testing, and other effective prevention interventions. And they rely on strong systems and personnel, including trained community health workers. They depend on institutional and social changes like ending stigma; reducing discrimination against women and girls; stopping gender-based violence and exploitation, which continue to put women and girls at higher risk of HIV infection; and repealing laws that make people criminals simply because of their sexual orientation.

Even as we recognise all these crucial elements, three key interventions can make it possible to achieve an AIDS-free generation. First, preventing mother-to-child transmission. Today, one in seven new infections occurs when a mother passes the virus to her child. We can get that number to zero. And we can save mother’s lives too.

In June, I visited the Buguruni Health Center in Tanzania, and there I met a woman living with HIV who had recently given birth to a baby boy. She had been coming to the clinic throughout her pregnancy for medication and information because she desperately wanted her boy to get a healthy start in life, and most especially, she wanted him to be born HIV-free. When we met, she had just received the best news she could have hoped for. Her son did not have the virus. And thanks to the treatment she was getting there, she would live to see him grow up.

The world already has the necessary tools and knowledge. Last year alone, PEPFAR helped prevent 114,000 babies from being born with HIV. Now, we have a way forward too. PEPFAR and UNAIDS have brought together key partners to launch a global plan for eliminating new infections among children by 2015. And we continue to integrate prevention and treatment efforts with broader health programs, which not only prevents HIV infections, but also keeps children healthy and helps mothers give birth safely.

In addition to preventing mother-to-child transmission, an effective combination prevention strategy has to include voluntary medical male circumcision. In the past few years, research has proven that this low-cost procedure reduces the risk of female-to-male transmission by more than 60 percent, and that the benefit is life-long.

Since 2007, some 1,000,000 men around the world have been circumcised for HIV prevention. Three fourths of these procedures have been funded by PEPFAR. In Kenya and Tanzania alone, during special campaigns, clinicians perform more than 35,000 circumcisions a month.

In the fight against AIDS, the ideal intervention is one that prevents people from being infected in the first place, and the two methods I’ve described – mother-to-child transmission, voluntary medical male circumcision – are the most cost-effective interventions we have, and we are scaling them up. But even once people do become HIV-positive, we can still make it far less likely that they will transmit the virus to others by treating them with the antiretroviral drugs. So this is the third element of combination prevention that I want to mention.

Thanks to US government-funded research published just a few months ago, we now know that if you treat a person living with HIV effectively, you reduce the risk of transmission to a partner by 96 percent.

Of course, not everyone takes the medication exactly as directed, and so some people may not get the maximum level of protection. But even so, this new finding will have a profound impact on the fight against AIDS.

For years, some have feared that scaling up treatment would detract from prevention efforts. Now we know beyond a doubt if we take a comprehensive view of our approach to the pandemic, treatment doesn’t take away from prevention. It adds to prevention. So let’s end the old debate over treatment versus prevention and embrace treatment as prevention.

There’s no question that scaling up treatment is expensive. But thanks to lower costs of drugs, bulk purchasing, and simple changes like shipping medication by ground instead of air, we and our partners are reducing the cost of treatment. In 2004, the cost to PEPFAR for providing ARVs and services to one patient averaged nearly $1,100 a year. Today, it’s $335 and falling. Continuing to drive down these costs is a challenge for all of us, from donors and developing countries to institutions like the Global Fund.

Treating HIV-positive people before they become ill also has indirect economic benefits. It allows them to work, to support their families, contribute to their communities. It averts social costs, such as caring for orphans whose parents die of AIDS-related illnesses. A study published just last month weighed the costs and benefits and found that – I quote – “the economic benefits of treatment will substantially offset, and likely exceed, program costs within 10 years of investment.” In other words, treating people will not only save lives, it will generate considerable economic returns as well.

Now, some people have concerns about treatment as prevention. They argue that many people transmit the virus to others shortly after they have acquired it themselves, but before they have begun treatment. That is a legitimate concern, and we are studying ways to identify people sooner after transmission and help them avoid spreading the virus further. But to make a big dent in this pandemic, we don’t need to be able to identify and treat everyone as soon as they are HIV-positive. In places where the pandemic is well established, as it is in most of Sub-Saharan African countries, most transmissions come not from people who are newly infected, but from people with longstanding HIV infections who need treatment now or soon will. We already have the tests we need to identify these people. If they receive and maintain their treatment, their health will improve dramatically, and they will be far less likely to transmit the virus to their partners.

None of the interventions I’ve described can create an AIDS-free generation by itself. But used in combination with each other and with other powerful prevention methods, they do present an extraordinary opportunity. Right now, more people are becoming infected every year than are starting treatment. We can reverse this trend. Mathematical models show that scaling up combination prevention to realistic levels in high-prevalence countries would drive down the worldwide rate of new infections by at least 40 to 60 percent. That’s on top of the 25 percent drop we’ve already seen in the past decade.

As the world scales up the most effective prevention methods, the number of new infections will go down, and it will be possible to treat more people than are becoming infected each year. And so, instead of falling behind year after year, we will, for the first time, get ahead of the pandemic. We will be on the path to an AIDS-free generation. That is the real power of combination prevention.

But success is not inevitable, nor will it be easy. Coverage levels for many of these interventions are unacceptably low. And we know from experience that to scale them up, we have to be able to deliver them not just in hospitals, but in clinics located in communities of every size and shape. If we’re going to make the most of this moment, there are steps we must take together.

First, we need to let science guide our efforts. Success depends on deploying our tools based on the best available evidence. Facts are stubborn things, and we need to keep putting them out there, even though they might, in the short term, be dismissed. Eventually, we will prevail.

Through PEPFAR and across the government, the United States is using scientifically proven results to inform our policy, which leads to real change for programs on the ground and maximizes the impact of our investments. For example, we need more research to identify the most effective ways to combine these interventions in different contexts. We know HIV is a complex pandemic that varies from country to country, district to district, from urban areas to rural. It’s the same in our own country. Combination prevention needs to reflect this complexity. Which combinations are most effective in areas where the virus is concentrated in especially vulnerable populations? What about places where it is more widespread in the general population?

We're already working to answer these questions. We recently granted more than $50 million to three of the world’s leading academic institutions to develop rigorous studies that test what works in various settings. Today, I’m pleased to announce that we’r e stepping up our efforts. The United States, through PEPFAR, will commit an additional $60 million to rapidly scale up combination prevention in parts of four countries in Sub-Saharan Africa and to rigorously measure the impact.

The results will have implications for every country where we work and for our partners as well. They will help ensure that we are translating the science into services that deliver the most impact and will allow us to take bigger steps together in our march toward an AIDS-free generation. I want to challenge other donors to join us in this effort. Go out and find partner countries that will work with you to test the most effective combinations of tools. Scale up support for treating as many people as possible. Measure the impact and share the results, so we can all learn from each other.

The second step is to put more emphasis on country ownership of HIV/AIDS programmes. Our partners – including governments, NGOs, and faith-based organisations – need to own and lead their nation’s response. So we are working with ministries of health and local organisations to strengthen their health systems so they can take on an even broader range of health problems.

Country ownership also means that more partner countries need to share more responsibility for funding the fight against HIV/AIDS within their borders. Some countries have allowed money from outside donors to displace their own investments in health programmes; well, if PEPFAR or the Global Fund or another donor is going to be giving us money for health, we can just take that money out of health and build some more roads. That has to change and we have to demand that it change. More countries need to follow the lead of South Africa, Nigeria, Senegal, Rwanda, Zambia, and others that are committing larger shares of their own budgets to HIV/AIDS.

Finally, we’re calling on other donor nations to do their part, including by supporting and strengthening the Global Fund. Consider just one example of what the Global Fund has already done. In 2004, virtually none of the people in Malawi who were eligible to receive treatment actually received it. As of last year, with significant help from the Global Fund, nearly half did.

This kind of progress deserves our support. The United States is the largest individual contributor to the Fund, and the Obama Administration has made our country’s first multiyear pledge to it. Some donors are, unfortunately, considering reducing their contributions. Some emerging powers and nations that are rich in natural resources can afford to give, but choose not to. To sit on the sidelines now would be devastating. It would cost lives, and we would miss out on this unprecedented opportunity. When so many people are suffering, and we have the means to help them, we have an obligation to do what we can.

And for its part, the Global Fund has its own responsibilities to meet. The United States has supported reforms at the Fund to ensure that its resources are reaching those in need and that they are focused on cost-effective, evidence-based solutions. The Fund is conducting a number of audits and investigations that have surfaced reports of fraud and corruption. It is the Fund’s responsibility to root out these abuses and end them as quickly as possible.

But let’s remember, uncovering problems is exactly what transparency is supposed to do. It means the process is working. So let’s not put the Global Fund into some kind of catch-22. Go be transparent, go be accountable, and when you find problems, we’re going to take money away from you. Now, from day one, the United States Congress has insisted that our contributions to the Global Fund support accountable programmes that produce measurable outcomes. And it’s been my experience that the American people are happy to support lifesaving programmes if they know they really work. And this is how we show them.

The goal of an AIDS-free generation may be ambitious, but it is possible with the knowledge and interventions we have right now. And that is something we’ve never been able to say without qualification before. Imagine what the world will look like when we succeed. Imagine AIDS wards that once were stretched far beyond their capacity becoming outpatient clinics caring for people with a manageable condition, children who might have been orphaned and then trafficked or recruited as child soldiers instead growing up with the hope of a better future, communities where despair once reigned filled instead with optimism, countries that can make the most of every single person’s God-given potential. That is the world that has always been at the core of American belief, and we have worked toward it in our own history. It’s the world I think we all would like to live in.

We’ve made a lot of progress together in the last 30 years. It hasn’t been easy. It hasn’t been without controversy. In these difficult budget times, we have to remember that investing in our future is the smartest investment we can make.

Let’s not stop now. Let’s keep focused on the future. And one of those futures that I hope we can be part of achieving is an AIDS-free generation.

Hillary Rodham Clinton is the US Secretary of State

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