*EPF304 07/14/2004
Text: Global Cooperation Needed to Fight AIDS, Tobias Says
(U.S. AIDS coordinator calls for unity at XV International AIDS Conference) (5050)

U.S. Global AIDS Coordinator Randall Tobias called for unity and greater global commitment in the search for solutions to the world's AIDS epidemic July 14 as he spoke at the XV International AIDS Conference being held in Bangkok, Thailand.

"Perhaps the most critical mistake we can make is to allow this pandemic to divide us," Tobias told an audience of several hundred. "We are striving toward the same goal -- a world free of HIV/AIDS. When 8,000 lives are lost to AIDS every day, division is a luxury we cannot afford."

Tobias, the U.S. AIDS ambassador, delivered his remarks despite demonstrators who attempted to disrupt his speech. U.S. officials participating in the meeting say the protests against the U.S. government campaign against AIDS and its newest program, the President's Emergency Plan for AIDS Relief (PEPFAR), are based in misinterpretation and mischaracterization.

In response, Tobias clarified U.S. programs for prevention strategies, inclusion of persons living with HIV/AIDS, and the use of generic drugs in the treatment of AIDS disease.

U.S. strategy, Tobias said, "aims to increase the overall chances of success by pursuing multiple approaches to this complex emergency -- supporting and partnering with individuals, community and faith-based organizations, host governments, and multilateral institutions like the Global Fund and the United Nations. We want to use every means at our disposal to address this crisis, and that is what we are doing."

The U.S. AIDS ambassador called on other nations to follow the lead of the United States and rise to the global challenge of the epidemic. "This year America is spending nearly twice as much to fight global AIDS as the rest of the world's donor governments combined. By its actions, the United States has challenged the rest of the world to take action."

Following is the text of the Tobias speech as prepared for delivery:

(begin text)

Ambassador Randall L. Tobias
U.S. Global AIDS Coordinator
Special Plenary Lecture
"The Global Fight Against HIV/AIDS: What Do We Need to Do Differently?"
IMPACT Arena
Bangkok, Thailand
July 14, 2004

Good afternoon.

The theme of this Conference is Access for All.

I have been thinking a great deal about that theme over the past week as I have met with different people coming from very different perspectives.

I have met with people living with AIDS in Vietnam, leaders of the world's international AIDS organizations, celebrities lending their names to this fight, a delegation from India, the Prime Minister of Thailand, a group of activist leaders at this conference, Senator Mechai who has done so much in this country, and Father Joe at Bangkok's Mercy Center - to name just a few. I have been listening and learning from each of these conversations.

And these conversations have led me to think of all of those dedicated souls from the less developed nations, who are face to face with this disease's devastation every day, but who could not afford to be here with us today. They could play such an important role in educating all of us and leading this movement if they were only given the opportunity.

Two days ago, I met with Clement Mfuzi of the Network of Zambian People Living With HIV/AIDS. He talked with me about the fact that a $1000 registration fee is out of reach for his colleagues at home who are fighting on the frontlines of this epidemic. He is not the first person from whom I have heard this during the week. I can only imagine what I could have learned - what all of us could have learned - from Clement's colleagues and many others who know first hand what the AIDS battle looks like in every corner of this world.

To that end, I call on the organizers of this conference to look for every possible means to reduce the registration fee for the Sixteenth International AIDS Conference in Toronto - including reducing the costs of conducting the Conference. We must ensure that those who can teach us the most about the realities of this disease are here to talk to us. This issue simply must be addressed prior to Toronto.

But Access for All is not just about this conference, it is a challenge that we must carry forward in our work every day. The United States is working to involve people living with HIV and AIDS in the work of our country teams implementing the President's Emergency Plan, and we have exercised our leadership in the Global Fund to help ensure that Country Coordinating Mechanisms will have not just representation, but the true involvement of people living with AIDS and HIV around the world.

I was in Vietnam right before arriving at this conference. As you know, Vietnam has been selected as the fifteenth nation to receive special focus in the President's Emergency Plan. I was there to hold inaugural meetings with our country team and the Vietnamese government.

Vietnam presents a different set of challenges from many of our other focus nations and I wanted to get a first-hand sense of the situation as early in the process as possible.

One of the first groups I met with in Hanoi was a group of young people living with HIV and AIDS. They spoke with great candor - not only about their own experiences but about the challenges their peers face in protecting themselves from this disease. The experiences and insight they shared with the U.S. country team and with me will be invaluable to us. As I told the young people upon saying our goodbyes, I look forward to the times I can sit and talk with them again as together we move ahead with our plans.

The involvement of small local organizations in the President's global effort, such as those representing people living with AIDS and HIV, is vital to the Emergency Plan's effectiveness. For that reason, we will soon be launching pilot programs in a number of countries that will allow small groups to apply directly to the U.S. Embassies' country teams for rapid approval on small grants. The idea of this program is to ensure that small and effective organizations that are doing some of the best work on the ground, can get money fast to address urgent needs within their communities.

Speaking of access for all, listening to one another and hearing what those on the ground are saying to us about the fight against this disease brings me to another point. When we say we are listening, and we say those on the ground know best, then we must surely listen and learn from the man who has led one of the most successful and pivotal battles against this disease.

Ugandan President Yoweri Museveni has, largely by sheer leadership and will, fought back this disease in his country with an A-B-C prevention focus. We must learn from his leadership in the fight against AIDS. Abstinence works...Being Faithful works...Condoms work. Each has its place.

I want to get something straight about the U.S. position on prevention, because there seems to be a lot of confusion and misinformation. Preventing AIDS is not a multiple-choice test - there is no one right answer to preventing the spread of this pandemic. Those who want to simplify the solution to just one method - any one method - do not understand the complexity of the problem.

And let me go further. Anyone who believes AIDS can be defeated by JUST these three means of prevention alone surely underestimates the challenges we as a world community face in trying to save people from the ravages of this disease.

The years ahead are going to require exceptional leadership to meet the special needs of individual countries. Prevention will require us to empower women. Prevention will require us to compassionately assist drug users in liberating themselves from their dark addictions. Prevention will require us to find many ways to give hope to communities devastated by pain, suffering and loss.

The President's Emergency Plan itself cannot be reduced to simplistic descriptions. It was designed to adapt to the needs of different nations, the trend of the epidemic in each nation and the needs of individuals within those nations.

From its foundational principles, our plan will grow and integrate into each nation and community, as host governments, local leaders, people living with AIDS and HIV, aid workers and activists help us to define the implementation of the plan for their people.

The President's Emergency Plan for AIDS Relief, from the very beginning, has recognized that to implement an effective prevention strategy, our approach must be based very specifically on what works in each place we are working, with the individuals and groups we are targeting.

For instance, unlike most of our other focus nations, Vietnam's HIV/AIDS epidemic has been fueled by intravenous drug use. As we develop our country plan, we will be looking at ways to educate those who inject drugs about the added risk of HIV/AIDS, and exploring means to support drug abuse prevention and treatment.

On another key issue, trafficking and prostitution facilitate the spread of HIV/AIDS. The U.S. Government is opposed to prostitution and related activities, which are inherently harmful and dehumanizing, and contribute to the phenomenon of trafficking in persons.

But to address another matter of some confusion, it is important to note that U.S. law - and the President's Emergency Plan - DO allow the provision of HIV/AIDS prevention, treatment and care services to the victims of prostitution or sex trafficking.

In Vietnam, for example, we hope both the President's Emergency Plan for AIDS Relief and the President's initiative to prevent sex trafficking will help people, particularly women and children, live safer and healthier lives.

So, you see, this initiative is not simply a matter of money - although $15 billion over five years is the largest financial commitment ever, by any nation, for any major international health initiative dedicated to a single disease.

This initiative is about action. President Bush has insisted that we stop talking about the reasons we couldn't do anything to stop AIDS, that we figure out what we can do, and then do it - with urgency. He has made crystal clear to me that "business as usual" can no longer be the order of the day. And stamping out business as usual includes many things - including the need to stop thinking about prevention in single-minded, one-approach-fits-all simplistic terms.

For instance, we believe that prevention messages are most effective when delivered in culturally appropriate ways. That is one reason why the President's Emergency Plan emphasizes working with indigenous organizations as partners. I am very pleased that at this point, 61% of the current partners we're working with on the ground are indigenous organizations.

When we speak of access for all, we must think about how we can best reach the places and people who most need access to our help. They cannot always find us.

When you think of the people who live in the most remote regions and in the most hopeless slums - who has been there to help them?

Who already has people on the ground who are trusted?

Who will help those who must persevere in the face of being stigmatized in their own communities?

And who will help replace stigma with compassion and understanding?

The fact is that among those indigenous organizations, the Buddhist temples and the monasteries, the churches, the mosques and the synagogues are among those who have gone where no one else would go. They have built trust and provided hope to generations of individuals in places where hope is scarce.

Last week I met with a Buddhist Monk in Vietnam who has started a home for children in Ho Chi Minh City. Many of those children are living with AIDS. He talked with me about the children's desperate need for treatment, but he also talked about how these children are finding hope and some relief through the work of his program.

Yesterday, I visited the Mercy Center to spend time with the HIV-positive children who have been taken off the streets of Bangkok by Father Joe's enormous compassion. While I was there, I also spent some time with people who are benefiting from a very innovative program created by Father Joe and Senator Mechai. With funding assistance from a United States initiative, this program is providing micro-loans for start up businesses in the Bangkok slums. What's also different about this program is that to qualify, the businesses have to involve a partnership between one person who is HIV positive and another who is HIV negative.

In Ethiopia, I met with the Patriarch of the Ethiopian Orthodox Church. About 40 million people are members of the Church - more than one-half of the people in the country. We're partnering with them because they represent a highly motivated way to reach people, including young people, with prevention messages, and because they have a level of credibility in the country that foreigners simply don't have.

If we were to work in developing countries but refuse to work with faith-based organizations, we would be harming our ability to save lives-and that is just incomprehensible to us.

Another reason to rely heavily on indigenous partners in all facets of our work is to ensure sustainability of the program. We will increasingly ask our large international NGO partners to provide "exit strategies" - plans for including training and capacity building in their work so they will eventually be able to turn over their efforts to local providers and move on to other projects. Local ownership of this fight is essential if the programs we build are to be sustainable in the long term, as they must be. As someone said to me very recently, we must provide both fish and fishing poles. And we intend to promote this philosophy in our own programs, and to advocate it through our leadership in the Global Fund and other international organizations.

But local ownership must be supported by local leadership, and the United States will continue to support leadership on this issue from public officials at all levels. I have a personal story that shows how what seems like a small, unique gesture can become a significant show of leadership.

Ethiopia is one of the focus countries in which America is making an especially large investment of resources and attention. On a recent visit there, I was invited to "cut the ribbon" at a new HIV testing center that has been established with U.S. support in a public hospital operated by the city of Addis Ababa. I was delighted to do so, because reducing the stigma around testing, and making it more widely available and a routine part of health care in severely affected countries, is simply essential.

In order to draw the attention of community leaders to their role in eliminating stigma, in my remarks, I reported that I had been tested myself the day before, in another center in Ethiopia. I urged the local leaders to do the same, and then to make it known that they had been tested, and that it was the thing to do.

The Mayor of Addis Ababa, who is a tremendous leader on HIV/AIDS, was there with me at the event. He promptly announced that he was going to be tested himself following the ceremony, and he encouraged all the other political leaders there to do the same. Now a visiting American getting tested might be an interesting curiosity to the local media. But when the Mayor of the capital, one of the most important people in the whole country, got tested - and publicly said so - well, that was a big story! It was all over the local media. And because of his leadership example, the effects multiplied as more and more leaders came forward to be tested in the days that followed.

On one level, that's a story about encouraging testing. But I see it as even more a story of leadership - leadership from within a society making the decision to fight the stigma and taboo that surround HIV/AIDS.

More money is necessary. Wise programming is critical. But without real leadership - on the part of everyone involved - we will lose this fight.

I believe any fair-minded person, looking at the history of the response over the last 20 years, would conclude that the world was far too slow to take up this fight with the focus it deserves. And when I say "the world," I mean in particular the developed world, including the United States.

In the past, we in the developed world displayed ignorance, or even apathy, about the global dimensions and intricacies of the AIDS crisis. Over time, I believe awareness grew and apathy turned to empathy. Empathy is important - but it is really not enough.

So I believe we all need to acknowledge the inadequacy of the world's response. But I also believe that it is time - in fact, it is past time - to move forward from this point. Too much time has been lost already.

At this point, perhaps the most critical mistake we can make is to allow this pandemic to divide us. We are striving toward the same goal - a world free of HIV/AIDS. When 8,000 lives are lost to AIDS every day, division is a luxury we cannot afford.

I recently visited Mozambique, one of the countries where the U.S. is dramatically increasing our investment. I visited a woman living in a very resource-poor setting. Tragically, she was on the verge of passing away from AIDS. Sitting on the edge of her mother's mattress was the woman's daughter, perhaps 5 years old. I asked the home-care volunteer who was present during my visit who would be taking care of that little girl when her mother was gone. She told me no one had an answer. Her father had also passed away from AIDS, and it was not clear that anyone in her extended family would be able to help.

A mother passes away.

A child is orphaned.

One family's tragedy reflects the devastation that this epidemic is bringing to bear. Every day, thousands are suffering and dying like that woman, but each one has a name. Thousands are losing their parents - and much of their hope for a better life - like that little girl.

When I insist that we put our differences aside and focus on the real enemy, I do not ask that we do it for our own benefit. I ask that we do it for that woman, that little girl. They deserve nothing less.

Let me say this as directly as I can: HIV/AIDS is the real enemy. The denial, stigma, and complacency that fuel HIV/AIDS - these too are real enemies. It is morally imperative that we direct our energies at these enemies, not at one another. We may not agree on every tactic employed by every donor and we may have passionate opinions about how things can be done better, but we must work with each other to find the best solutions, while knowing that every person in this fight simply wants to save lives. That is a noble calling, and should be appreciated and respected.

The United States has decisively turned the corner, from the eras of apathy and empathy, to a new era of compassionate action. We have willingly assumed the leadership role in this fight.

The President's budget to fight global HIV and AIDS for next year, Fiscal Year 2005, reflects an increase of almost three and a half times from that of Fiscal Year 2001.

And we're moving with urgency. Almost exactly a year ago, the President asked me to become the United States Global AIDS Coordinator. Five months ago, we received the first funding from Congress. Three weeks later we began to commit those funds. Already we are seeing results.

We have not even hit our first reporting period, but we do have some anecdotal information-so please do not consider this to be all inclusive of our activities.

Within days of receiving funding, we were traveling by motor scooter to deliver antiretroviral drugs to people in their homes in rural Uganda. Within weeks, we were doubling the number of patients on ARVs in urban Uganda. We put 500 people on therapy at just one site in Kenya. One of our treatment partners has begun therapy for another 500 hundred patients in just two countries, and they are enrolling more patients at a rate of 220 per week. Another partner mentioned to us just yesterday that they will begin delivering ARVs at multiple centers next week, expanding to nine countries rapidly. We have ordered and are receiving drug treatments in nearly all of our focus countries.

America is providing leadership in the fight to keep HIV-positive people alive by providing anti-retroviral drugs. Not just any drugs, but safe and effective drugs. I have consistently and repeatedly expressed our intent to provide, through the Emergency Plan, AIDS drugs that are acquired at the lowest possible cost, regardless of origin or who produces them, as long as we know they are safe, effective, and of high quality. These drugs may include brand name products, generics, or copies of brand name products.

The United States has a stringent regulatory authority to assess the safety and efficacy of the drugs sold within its borders. It is a moral imperative that families in programs funded by the United States in the developing world have the same assurances as American families that the drugs they use are safe and effective. America will not have one health standard for her own citizens and a lower standard of "good enough" for those suffering elsewhere.

In order to speed drugs to the fight against HIV/AIDS, the Bush Administration has taken action to allow any drug company in the world to seek accelerated review of AIDS drugs from the U.S. Food and Drug Administration.

This new FDA process includes the review of applications from companies who are manufacturing copies of antiretroviral drugs - alone or in fixed dose combinations - for sale in developing nations, as well as applications from the research-based companies that developed the already-approved individual therapies and want to put them into fixed dose combinations. The FDA has reached out to manufacturers in both categories and will even waive the application fee when necessary, in light of the global AIDS emergency.

When a new combination drug for AIDS treatment receives a positive outcome under this expedited FDA review, I will recognize that result as evidence of the safety and efficacy of that drug. Thus the drug will be eligible for funding by the President's Emergency Plan, so long as international patent agreements and local government policies allow their purchase.

I call on each of you today to urge every company manufacturing these drugs to file their applications as soon as possible so we can begin funding these drugs as soon as possible.

At this point in the development of our bilateral plan, as well as the multilateral programs we support, the availability of drugs - though very important - is far from being the main constraint on our work. The major challenge is one that is becoming widely recognized: the need for human capacity and infrastructure that can accommodate our investment. Ignoring those limitations means wasting money and failing to solve problems.

In places like Africa, the Caribbean, and Southeast Asia, there is a desperate lack of health care workers and infrastructure. African leaders understand this, sometimes better than we from the developing world do. All the AIDS drugs in the world won't do any good if they're stuck in warehouses with no place to go to actually be part of the delivery of treatment to those in need.

In the U.S., we have 279 physicians for every 100,000 people.

In Mozambique, however, there are only 2.6 physicians for every 100,000 people. That means that just 500 physicians serve the needs of the entire country - a population of 18 million.

In some countries, the "brain-drain" of trained medical personnel is an enormous problem. In Ethiopia, where there are only 2.9 physicians for every 100,000 people, a physician there told me recently that there are more Ethiopian-trained physicians practicing today in Chicago than in all of Ethiopia.

We have to find solutions for these human resource issues, including the development of new models for the treatment and care of patients. Obviously, without making progress on the capacity issue, our ability to deliver prevention, treatment and care is quite limited. That's why, especially in these early years, the President's Emergency Plan is making a tremendous investment in training and infrastructure. Improving capacity is essential for all efforts to be sustainable in these countries for the long term.

After 20 years fighting HIV/AIDS worldwide, America has a wealth of experience, infrastructure and relationships. Thus we are in a particularly strong position to help address the capacity issue. Our experience on the ground is allowing us both to implement our own Emergency Plan with urgency, and to assist our multinational partners, such as the Global Fund, in building their programs.

To cite just one example, the U.S. has quickly trained 14,700 health workers and built capacity at over 900 different health care sites, as part of our "prevention of mother-to-child transmission" programs. But let's look beyond the numbers, at what that training and capacity-building has meant to one woman in Guyana.

Brenda, already a mother of one child, attended her first antenatal visit in her second pregnancy. During group counseling, her health visitor - trained by the United States - discussed transmission of HIV from mothers to infants and ways to reduce the risk of this transmission. In the individual session, Brenda who was about twelve weeks pregnant, went through pre-test counseling on HIV, and agreed to be tested.

Brenda did not attend the clinic for two months, because she was experiencing great difficulties in finding a stable place to live, since she had severed her relationship with her partner. During her second visit, the nurse shared her HIV test result. Unfortunately, the form was stamped "HIV antibodies detected."

That was a difficult moment - one that I know many in this room have experienced. Brenda reacted with disbelief and then hurt, as anyone would. But caring health workers calmed her, reassuring her that she could live a healthy life with HIV. When Brenda told her mother and siblings, they overcame their shock and encouraged her to go through the U.S.-supported program to protect against transmission to her child.

Brenda received further counseling at the clinic and joined a support group of HIV positive mothers. Four hours before delivery, Brenda received the single-dose anti-retroviral prophylaxis, and the baby received a pediatric dose of nevirapine. Her baby is now HIV free.

After giving birth, Brenda became an advocate and community educator for the Network of People Living with HIV/AIDS in Guyana. Brenda says, "Today, I can use myself as an example to talk to other women about HIV/AIDS. I am not ashamed of my condition, and I feel that I can use my experience to help others."

Once again, it all started with training health visitors - without those people, and the places for them to work, none of this would have been possible. That's exactly the kind of effect we want our capacity-building work to have - to save people from HIV and its effects, and to build sustainable leadership in their communities. America is proud to be a partner in building a better life for people like Brenda - and her baby.

Since I mentioned our multinational partners, let me note that bilateral U.S. programs, while a critical part of the President's Emergency Plan, are by no means all of it. Our strategy aims to increase the overall chances of success by pursuing multiple approaches to this complex emergency - supporting and partnering with individuals, community and faith-based organizations, host governments, and multilateral institutions like the Global Fund and the United Nations. We want to use every means at our disposal to address this crisis, and that is what we are doing.

The Bush Administration took the lead in helping to found the Global Fund. The U.S. Secretary of Health and Human Services, Tommy Thompson, serves as the Chairman of its Board. The Global Fund is a young venture and still maturing, but we consider it a very promising vehicle and a critically important part of the work that all of us are doing - including the implementation of the President's Emergency Plan. The U.S. is working with the Global Fund to build capacity on the ground so that more of the Fund's money can begin to flow and to reach those who need it.

America is the world's largest contributor to the Fund - making thirty-six percent of all pledges to date. The Fund offers a vehicle for other donors to substantially increase their commitment to this fight, as the United States has done.

Once again, I must speak directly. This year America is spending nearly twice as much to fight global AIDS as the rest of the world's donor governments combined. By its actions, the United States has challenged the rest of the world to take action.

PLEASE - join with us in our deepened commitment to the global fight against HIV/AIDS.

My hope is that in the future, we will look back at the year 2004, and this Bangkok conference, as a turning point into an era of compassionate action - not only by America, but by the whole world.

All of us share a great responsibility, and time is short.

May we all come together, in a spirit of heightened commitment and cooperation, to focus our energies on doing what we must to win this fight - on behalf of the people of the world who so desperately need our help

Thank you very much.

(end text)

(Distributed by the Bureau of International Information Programs, U.S. Department of State. Web site: http://usinfo.state.gov)

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