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Though we still have much to do, the history of the HIV–AIDS epidemic in the United States and other industrialized nations is heartening. Prevention is widely practiced. Antiviral medication has turned AIDS from a death sentence into a chronic illness. Treatment with medication can prevent mother-to-child transmission. Mortality and infection rates have dropped dramatically. As a result, the 2.5 million people who are infected with HIV in the industrialized world — as well as the rest of us, whose lives are intertwined with theirs — have hope for the future.
To Turn the Tide
The future, however, is not hopeful for the nearly 40 million people living with HIV or AIDS in the developing world. There we have failed. Infection rates range as high as 38 percent, and 14,000 more people become infected every day. Twenty-five million people have died from AIDS-related illnesses, and 8500 more people die each day. AIDS has orphaned 10 million children, and 33 million more will be orphaned by the end of the decade unless we take immediate and decisive action. Although there is much talk about treatment, the reality on the ground is that very few people are currently receiving medication. In Africa, fewer than 30,000 of the estimated 4.5 million people who need treatment are getting it. Biomedical researchers have provided us with the tools that we need to turn the tide on this crisis. But we, the political leaders and citizens of the world, have not yet done enough to see that they are put to use.
Although the deaths of 25 million people should be cause enough for concern, this is not simply a humanitarian crisis. This disease has devastated not only the families of those who are infected, but the political, social, and economic structures of entire nations. When 80 percent of persons dying from AIDS are between 20 and 50 years of age, societies are left with the young and the old, with few to support them.
Educational systems are falling apart. Teachers are dying faster than more can be trained, and children are staying home to look after their dying parents. Meanwhile, funding for education is being cut to compensate for the rising costs of health care. Security forces are weakening. At a time when there is increasing international instability, trained soldiers and police officers are dying faster than they can be replaced. Agricultural production is dwindling. Farmers and farm laborers are dying, and farms do not have the workers they need to produce at high levels. No segment of society is left untouched. Doctors, nurses, factory workers, businesspeople, and government officials are all dying in alarming numbers. In today's increasingly integrated world, if these nations are allowed to disintegrate, the economic, political, and strategic consequences will be felt far beyond their borders. Today, this is happening in Africa. Tomorrow, it could happen elsewhere. The fastest-growing rates of infection are in the former Soviet Union, the Caribbean, India, and China.
Prevention, Care, and Treatment
I know that I am preaching to the choir. Physicians and health professionals are in the business of saving lives. I do not need to convince you that it is the right thing to do. There are, however, those who need convincing. Many of them are members of the donor community. It is not that they do not have good intentions. They do. They simply believe that it is more cost effective to fund prevention programs than to buy expensive medication. I need your help, as the experts, to convince them that although they are necessary, prevention efforts alone will not be sufficient to quell the spread of this disease. Prevention efforts cannot be effective unless people agree to be tested. People will not agree to be tested until the results provide them with more than just a death sentence. Less than 1 percent of those who need treatment in Africa are receiving it, and there is little hope that people will line up for testing until medicine is widely available. As your work in the United States and elsewhere has shown, prevention, care, and treatment are all part of the same package.
Once we agree that integrated programs are the answer, the question becomes how to develop these programs in resource-poor settings. When I left office, I agreed to chair the advisory board of the International AIDS Trust with Nelson Mandela, with the intention of focusing my efforts on lobbying other politicians to donate money to the Global Fund to Fight AIDS, Tuberculosis, and Malaria. I still think that this fund is important, and I still plan to participate. However, I am convinced that even if we could solve all of our money problems, we still would not be able to deliver treatment to the people who need it. Until we build the human and physical infrastructure needed to deliver effective treatment, programs will not be successful.
Building the Infrastructure
Nearly all AIDS treatment today in poor countries and most of the programs funded by the Global Fund for implementation over the next few years rely on pilot programs, often conducted by nongovernmental organizations that are separate from the mainstream health care systems. These pilot programs are important, but they cannot provide the solution for whole countries. Ultimately, capacity has to be built into the mainstream health care infrastructure.
Building the capacity to run effective programs for care and treatment in poor countries is very difficult. It requires developing protocols and organizing substantial treatment networks at the local and national levels. It involves procuring and distributing drugs while ensuring affordable prices, adequate security for the drugs, and compliance by patients in taking the prescribed medication. It requires regular testing. It requires that patients have food and clean water and that health care workers be trained and have access to transportation. Establishing effective programs requires strong and sustained political will and leadership, and it requires the management systems to carry out the program on a long-term basis.
I attended the AIDS conference in Nigeria in 2001 and talked openly about the obstacles to capacity building. After Kofi Annan made his eloquent call for $10 billion per year for the Global Fund, I took on the role of bad cop to his good cop. I stood up and told participants that although I had great respect for them, I was afraid that they would waste this money if they had it, because they refused to establish the systems and train the personnel to do what needs to be done.
Now, at the request of a number of African and Caribbean heads of state, I am trying to help solve these problems. My foundation has formed partnerships with several leading research organizations and care providers to develop best practices and to share experiences from the field. These organizations have been engaged in this work for years and are perfectly suited to helping us achieve our ambitious goals. They include the Pangaea Global AIDS Foundation, the Harvard AIDS Institute, Health Alliance International at the University of Washington, Partners in Health, Médecins sans Frontières, and the Columbia University School of Public Health.
Mobilizing the Resources
We have signed memorandums of understanding with several heads of state, including the prime ministers of Mozambique, Tanzania, and Rwanda in Africa and the Caribbean Community (CARICOM), which represents 15 nations. Plans are in the works with several others. We have secured the volunteer services of scores of businesspeople and health professionals to assist governments on the ground in developing operational business plans to scale up treatment. In each of these countries, the government is taking the lead, and my foundation is providing technical assistance, mobilizing human and financial resources, and facilitating the sharing of learning among projects.
Our intention is not to duplicate work but to build on existing plans and to ensure that these plans become operational. Once these plans are in place, I will help to raise the funds needed to implement them. In the two years that I have been out of office, I have met with several donor governments. Their message has been clear: they will not fund large-scale government programs until they have confidence that they will be successfully managed. They are concerned about the administration of funds, about the security of drugs, and about the sustainability of programs. On the other hand, they recognize the need and are excited at the prospect of investing in programs that do address their concerns.
An experience during the first week of our work in the Bahamas reinforced the need for someone to assist in the planning and administration of these programs. One week after our arrival, we discovered that the government was buying generically produced antiretroviral medication from a third-party distributor for $3,600 per person per year. In one week, simply by cutting out the middleman, we were able to cut the cost of medication by $3,100, to less than $500 per person per year. This means that they can now serve more than seven times as many people for the same amount of money. Although that is a small victory, the experience confirms the value that those with experience in managing large-scale programs can bring to a struggling country.
Time for Action
Our goals are ambitious, and there are risks involved. However, the presence of risk cannot be used as an excuse for timid action. The crisis demands that we act boldly and give our best efforts for a comprehensive solution.
The efficacy of this initiative will be measured by the numbers of people enrolled in successful treatment programs and in the declines in the rate of infection in the countries in which we are active. However, our long-term goal is to establish models that can be replicated in resource-poor settings all over the world. The long-term success of this initiative will be measured by the number of countries that adopt the methods and lessons of the direct initiatives that the foundation creates.
The nations of the world have much work to do to combat this global crisis, but I am encouraged by the sense of urgency that is beginning to develop on every continent. I am grateful for the announcement that President George W. Bush made in his State of the Union address, in which he recommended that we increase spending from $1 billion to $3 billion per year for the next five years to fight the global AIDS epidemic. It is now our duty to lobby Congress so that the money is appropriated at the proposed levels, without irresponsible restrictions to limit its use.
It is also important to press Congress on the source of the funding. We do not want to see money taken out of other health care initiatives. Medicaid takes care of 40 percent of persons with AIDS in the United States. There are 18 states today thinking about cutting Medicaid funding because they have such terrible budget problems. It is therefore very important that this be new money, not money taken away from other programs, including our other commitments to developing nations. I must also advocate on behalf of the Global Fund. President Bush's current proposal is to allocate only $200 million to the fund — even less than we are giving this year. I would like to see more money used for that purpose.
As the leaders in this fight against AIDS, you in the medical community deserve our thanks for your tireless efforts. You have made it possible for us to prevent the modern-day AIDS crisis from wiping out entire nations. We now need to turn that possibility into a reality. I call on you to continue your efforts to combat this catastrophic pandemic, both through your work as medical professionals and through civic action as citizens of the world. Together, we can ensure that this money is appropriated and that we spend it in the right way.
My pledge to you is that you will not be alone in your fight to combat this growing crisis. I am committed to working in partnership with the governments of developing countries, experts in AIDS research, public health, education, and health care policy, and all citizens until, together, we turn the tide on the AIDS pandemic.
Presented at the 10th Conference on Retroviruses and Opportunistic Infections, Boston, February 10–14, 2003.
Source Information
From the William J. Clinton Presidential Foundation, New York.
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The AIDS Pandemic
Fielder J. F., Gribble R. K., Mujeeb S. A., Altaf A., Reynolds S. J., Quinn T. C., Bollinger R. C.
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N Engl J Med 2003;
349:814-815, Aug 21, 2003.
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