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AIDS:The Need For An Exceptional Response To An Unprecedented Crisis

Presidential Fellows Lecture
November 20, 2003
Washington, D.C.


James D. Wolfensohn
The World Bank Group


Peter Piot
Executive Director of UNAIDS
Under Secretary-General of the United Nations


MR. WOLFENSOHN:  Well, friends, some time ago, we started this Presidential Fellows Lecture Series with a view to bringing to our institution people of consequence on subjects of consequence.  And we have had a remarkable series of lectures intermittently throughout the years, and I have to say that there hasn't been a day when we have had a lecturer who is more remarkable in himself or on a  subject that is more remarkable than the lecture today.  And I want to thank you, Peter, very much for joining us.

UNAIDS is an organization that we have taken a small part in--we were one of the 9 founding partners--and I have to say that UNAIDS under the leadership of Dr. Piot since 1996 has been a remarkable institution because it has brought together so many of the activities and initiatives that are taken in relation to AIDS under a leader who really knows the subject, and that is wonderful.

I told Dr. Piot at lunch that we are very, very happy to be part of his team and acknowledge his leadership and look forward to it for quite some time to come.

I think many of you know that the relationship between this institution and UNAIDS has been growing; that Debrework Zewdie and her team are in constant contact; and that we have a joint activity in the measurement of what's going on in AIDS here already at the Bank, and it is our hope that sometime soon, we may have even a representative of UNAIDS resident in the building so that we can make more visible, more concrete, and more immediate the association that already exists.

At lunch today, we found a real community of views in terms of the issue of AIDS, in relation to its importance and its relation to the sense of urgency, in relation to the organization of the efforts, but most particularly on the fundamental subject that AIDS is not just another issue.  AIDS is an issue which gets to the very heart of development, with which we are concerned.  And therefore, it is important that AIDS not be something that is just the function of our health network but that indeed it be something that is totally integrated into the activities of our institution, because it does affect everything.

I recall that I was at the Security Council speaking--I think Peter was there, too, with Al Gore and some others--where the issue was elevated to be an issue of security, which it has been and which it continues to be.  And so it is that we are privileged to have someone who is leading UNAIDS who understands the issues, who happens to be a very good organizer, and who also has the background, because Dr. Piot is a microbiologist of distinction, having worked as a professor in Antwerp, and who was one of the discovers of the Ebola virus in the seventies.  He saw his first case of AIDS I think in 1979 and came to our institution in the eighties to tell us how important it was, but sadly, didn't make a huge impression on this institution--something that I understand very well, Peter.  It takes years is all I can tell you.

But very happily today, our institution has matured and is a keen and very active supporter of the work of Peter Piot.  He has been recognized in many places but not enough, recognized by the King in Belgium and created a knight of that country.

So it is with great pleasure and personal friendship that I introduce Monsieur le Baron, Dr. Peter Piot.


DR. PIOT:  Merci, Jim.  Thank you.

Thank you so much, Jim, for inviting me here this afternoon for this Presidential Lecture, but above all, thank you for your leadership on this issue and on AIDS, which started well before it was on the global agenda as it is now, and I think that is the very definition of a pioneer.

And I would say also thanks for the wonderful performance of Mozart and Mendelssohn last night.  I truly enjoyed that.  I was pretty stressed out yesterday for a lot of reasons, and that really was a moment of joy.  Thank you so much for that.  It was remarkable.

At the outset, I would like also to pay tribute to Debrework Zewdie and all your colleagues at the Bank for your really ground- breaking work on putting this issue at the Bank's agenda as much as at the world's agenda and for the collaboration that we have enjoyed over the years, as we just heard.

It is now exactly 20 years ago that I started investigating AIDS in Kenshasa, then Zaire.  I can recall the exact moment when I realized what we were up against.  It was I guess what Freud would call an "aha" alertness.  It was just something that rarely happens to you.  And when I saw all these young men, and in particular young women, which was then very unusual, with what was known as "the gay disease," when I saw all these young men and young women dying, emaciated, at Mamayaima [phonetic] Hospital, one of the biggest hospitals in the world, I became really convinced suddenly that this disease was a heterosexual thing, not "the gay disease"; that therefore, this would become an epidemic.  And I knew suddenly that Africa was in trouble, that the world was in trouble and would be in trouble, and that it would change my life--and that I was in trouble maybe.

A few years later--this was in '87, what Jim alluded to--is when my relationship with the Bank started, or was the first attempt.  I was determined to convince the Bank to confront AIDS, because I also felt that without the financial and intellectual muscle and the diplomatic muscle of the Bank, developing countries would not be in a position to confront AIDS.

And as you heard, it was a total failure in 1987.  I used both the wrong vocabulary and the wrong arguments and didn't really know how to push an agenda inside the institution or inside any institution.  That's one of the things I have learned in my job.

That's why this morning, my meeting with the Africa Leadership Team, I think it's called, of the Africa Region really made my day, because I could hear from people who have at first sight nothing to do with human development let alone with health, but they have internalized AIDS in their agenda.  And that made me now believe that institutional behavior change is possible.

It is therefore really profoundly significant for me, and a great honor, today that I can address you in this Presidential Lecture.

Where are we with the epidemic?  I am definitely not here today to inundate you with figures, with numbers, on AIDS.  UNAIDS will release some new global estimates next week, as we do every year for World AIDS Day.

But I am here today to alert you of an unprecedented crisis, and this crisis is not about numbers--it is about human suffering, and it is about failings of development.  Let me highlight three points.

The first one is that the AIDS epidemic, HIV infection, is not leveling off.  New infections continue to grow as prevention fails or as the efforts remain small-scale, and millions of people need treatment.

Rapid globalization of the epidemic is also evident.  This has now truly become a globalized phenomenon, and the fastest-growing epidemic, as we know, is in Eastern Europe and Central Asia, in the countries of the former Soviet Union.  And here is potential for the epidemic to explode in China, in India, in Indonesia, in the biggest countries of this world.

Secondly, there is an increased feminization of this epidemic, not well-known.  Every year, we see an increase in the number of women infected with HIV and the proportion of people with HIV who are women.  And globally now, last year, we reached gender parity--not a thing to rejoice about.  And in Africa, the proportion of women is now actually reaching about 60 percent.

Women living with HIV often experience more discrimination than men.  They are the main caregivers, even if they are ill themselves, and the source of household labor.  And their illness means the collapse of family care and household production.

The third issue I'd like to draw your attention to is that AIDS is creating vast secondary impacts that we haven't seen for anything else.  We are already beginning to see the profound impacts these enormous demographic shifts are having on the fabric of societies.

Consider those left behind when adults die from AIDS--the million of orphans.  They will be at least 15 percent of all children in the West affected countries by 2002, adding to the growing number of street children and child-headed households.

And most worrisome is the impact of AIDS on the capacity of the state and the private sector to deliver services because of illness and deaths among service providers.  This in turn contributes to failings in development, a vicious circle.  AIDS is clearly a growing source of local, national, and international tension and insecurity.  And as we just heard from Jim, this is why it was so appropriate that the UN Security Council had its first AIDS debate in January 2000, and actually, on Monday of this week, I addressed the Council again on HIV in peacekeeping operations.

Ladies and gentlemen, I think we are really entering a time of great opportunity when it comes to AIDS.  We are entering into a new phase in the response, and there are three clear signs that the global response to AIDS is entering this new phase and that we are entering a time of great opportunity.

First, there is growing political momentum to respond to AIDS, actually, never before seen for a health issue, and indeed rarely for any international development problem.  And today when global leaders meet, AIDS is on their agenda.  Actually, as a matter of fact, this afternoon in London, President George Bush and Prime Minister Tony Blair announced that they will greatly intensify their collaboration on AIDS.

But let's face it also--particularly outside Sub-Saharan Africa and the Caribbean, and in many international institutions, AIDS is still not as seriously taken as it should be.  There remains a marked deficit in leadership which goes beyond political correct speeches.  And sometimes I think if words would do it, AIDS would be gone by now.  The speeches are great and numerous.

Second, there is a discernible momentum of evidence.  The hope that we can bring the epidemic under control is being bolstered by empirical evidence, not just modeling coming out of computers.  We are seeing more and more instances of prevention success on all continents.  And with the fall in prices of anti-retroviral medicines, the scaling up of effective HIV treatment is now a real possibility driving a number of national and international initiatives forward, including the Three-by-Five Campaign that WHO launched in September together with UNAIDS to provide 3 million people with anti-retroviral treatment by 2005.

I think we cannot underestimate the extent to which these efforts are bringing hope amid the despair that AIDS has caused.  So let's face it, for those who are still into the debate--the treatment train has finally left the station.

Third, there is a real momentum and greatly increased resources going to AIDS both from donors and from the governments of developing countries.  After all, it is about their survival.  And the Bank has shown the way together with several of the major donor countries.  The Bank has played a leading role in the financing of AIDS programs and in advocacy on AIDS as a development issue.

In addition, I would say, which is equally important as far as I'm concerned, that the Bank's innovative MAP, Multi-country AIDS Programs, have pioneered new mechanisms to support local authorities on AIDS and NGOs, particularly in Africa and the Caribbean.  I saw it with my own eyes this year in Kenya and in Ethiopia--and Mr. President, I should say it may be a surprise even to you to learn that there are more than a thousand community groups in Kenya, and I believe 3,000 villages in Ethiopia, receiving World Bank support through that kind of mechanism.  So this should be an incentive for other donors to use these kinds of mechanisms that took quite a while to set up and are unprecedented in development.

At UNAIDS, we are really proud to have the World Bank as one of our nine cosponsors.  I truly believe also that we are spearheading UN reform and together are responsible to deliver on five key functions which are the essence of multilateralism and multilateral support.

Provide leadership and advocate for effective action is number one--that is still necessary; provide strategic information to guide action; track, monitor, and evaluate the epidemic and the response; fourth, engage civil society and business; and finally, mobilize resources.

And I don't know of a more advanced example of harmonization in practice.

This week's decision by the U.S. Congress to allocate $2.4 billion to international AIDS activities in the coming budget year follows a commitment of President Bush in his 2003 State of the Union Address--another clear sign that we are moving into a new environment.

And yesterday, the Government of South Africa made a very important decision.  It is after all the country with the largest number of people living with HIV--well over 5 million now.  Yesterday, the Cabinet accepted the plan to roll out universal access to treatment in the public sector.

However, it is not all that good news.  We are still falling short of the minimum of $10 million needed annually to mount an effective response in low- and middle-income countries.  But let's also recall that when we started with UNAIDS seven years ago, barely $200 million was spent on global AIDS efforts in developing countries.  This year, we estimate it will be something like $4.7 billion, including resources from the Global Fund to Fight AIDS, TB, Malaria, the World Bank, and others.

What have we learned from the response so far?  We have now nearly 20 years of experience.  I think for me the main lesson is that AIDS is not only a major problem, but it's a problem with a solution.  Frankly, otherwise, I wouldn't be in this job.  And worldwide experience in responding to AIDS has been accumulated over the past 20 years and has resulted in a body of effective strategies against AIDS.

As I mentioned, some developing nations have shown real success in their response to AIDS, particularly when it comes to preventing new infections, less so when it comes to access to treatment--and particularly preventing new infections among young people.  We know the successes of Uganda, Senegal, Brazil, Cambodia, Thailand, but there are now an increasing number of major cities in East Africa, like Kigali, like Addis Ababa, where we are also seeing a decline in the number of new infections among young people as a result of the impact of prevention effort.

However, these few successes will need to be sustained, and let me highlight five key elements which I believe can be found in every effective response and which should underpin our efforts going forward.

First, as for any problem, leadership.  No money can replace courageous leadership at all levels.  This is not only at the top of the country, it's at every level.  And the response to AIDS needs to be led from the highest level in the state.

Second, comprehensiveness.  Success comes from sustained and comprehensive approaches on prevention, treatment, and impact mitigation.  And the commitment by all states in the world to act on all fronts against AIDS was reached at the UN General Assembly Special Session on AIDS in June 2001.  That was a historic step forward at the political level.

Third, multisectorality and inclusiveness.  It is now clear that this epidemic cannot be brought under control by the health sector alone, as we just heard from Jim.  We need the broad engagement of all sectors and people of all walks of life, including people living with HIV themselves.

The fourth element is breaking down the stigma and discrimination.  Stigma and discrimination are major obstacles in encouraging people to take advantage of prevention and care services.  And as Mary Robinson put it so forcefully in her Presidential lecture two years ago, AIDS demonstrates very clearly that promoting human rights in development is cost-effective.

And finally, there are very few issues where it is so clear that either you act now or you pay later.  Africa has learned its lesson the hard way, and denial and ignorance don't reverse this epidemic.  But it's a lesson that the countries of Asia and Eastern Europe have got to take to heart now.

So what are the key challenges for the future?

As we all know, money alone will solve little--it is necessary, but it's not all.  If we are to succeed, we must come to grips with three overriding challenges.

The first is capacity--a major challenge.  One way in which the epidemic drives a vicious circle is by striking hardest at those countries with the weakest capacity for implementation.  In many nations, AIDS is now depleting capacity faster than it can be replenished, be it with teachers, health care workers, managers, miners, farmers--in a macabre mirror of what it does to the immune system, actually.

And already we face an unparalleled crisis in human resources, and I'm afraid it is only going to get worse.  We can't possibly keep pace by relying on traditional tools.  Many private firms have figured this out quite a while ago and are taking unprecedented steps to safeguard their human investments. We need to do the same.

How can we do this?

First, we can begin by preserving existing capacity.  In other words, it's the simplest thing to do--keep people alive.  This is why providing HIV treatment is so critical.  In the hard-hit countries, nothing else--nothing--will so directly or quickly arrest the plunge in public capacity as this single measure.

Anti-retroviral therapy, for example, has reduced mortality by 80--eight-zero--80 percent in Brazil.  What other capacity-building measure can show such a return?

We must then call in reinforcements, because they will be necessary.  In many countries, there are vast cadres of trained specialists who are sitting idle in the struggle against AIDS.  Kenya, for example, is said to have 4,000 nurses who are no longer practicing.  Can there be any higher priority for the nation than to lure these front-line workers back into service?

We can also expand our concept of capacity.  In times of crisis, many countries have developed unconventional capacity to compensate for formal skills gaps.  And this doesn't all require specialists.  In AIDS, so much of what makes for good practice requires little or no technical knowledge, particularly when it comes to prevention and even to supervising and dispensing treatment.

Enlisting a wider range of talents and untapped resources in the community--and again, particularly, I would say, the most underused and underutilized resource, people living with HIV--would swell our numbers and help break the silence on AIDS.

There are good examples already.  I am thinking of the National Cadet Corps in India, young people who are going from door to door about HIV prevention.  I am thinking of community outreach workers in Kuazulu Natal who are dispensing treatment for tuberculous and now also for HIV treatment.  These are examples that we could follow more, thinking out of our usual box.

Over the long term, of course, we must help countries build strong foundations to sustain capacity.  That is a longstanding challenge of development--it is nothing new here--but it has taken on new urgency in the age of AIDS.

And I must tell you that we in the international and the donor community bear much of the blame for this.  Weak capacity is one of the most crippling legacies of the past decades of development.  We can't repeat that mistake with AIDS.  In high-prevalence countries, AIDS calls for a complete rethinking of how skills will be built, retained, and sustained.  In low-HIV-prevalence countries, it underlines the importance of aggressive prevention efforts to preserve the vast investments in human and institutional development.

So, sometimes I wonder--we discussed this, Mamphela and I yesterday--aren't we paying the price now for decades of development donor practice in this rampant epidemic?

In my view, any donor AIDS program that neglects the capacity dimension should be rejected.  This job is bigger than any single agency, so no one should feel at liberty to abandon their share of the burden.

The second overriding challenge is harmonization and joint accountability.  This too is fast becoming a development cliche, but it is no less true for that.  In AIDS as elsewhere, program managers are often little more than data processors--I'm sorry, I don't want to offend anybody--for donors, spending obscene amounts of time trying to satisfy dozens of duplicative reporting requirements and hosting repetitive review missions month after month.  Transaction costs are skyrocketing and reducing program effectiveness.  And frankly, it's a bit rich for donors to complain of absorptive capacity when they are the ones absorbing so much of it.

So it's time for donors of all types--multilateral, bilateral, philanthropic--to formally agree to work together under national leadership.  I call this "the three ones"--one national AIDS strategy that drives alignment of all partners; one national AIDS authority to coordinate it; and one nationally-owned monitoring and evaluation system to serve the needs of all.  And here I must say we are making progress.  Kenya now hosts regular joint program reviews in which all donors take part.  And in Malawi, eight donors are supporting the national AIDS program in a unified way, and four of them are even pooling their funds through the UNAIDS mechanism with the World Bank.

We need to make sure there are such common causes in every country so that the officials entrusted with AIDS can spend their time contending with the pandemic and not with paperwork.

This is not just important for practical reasons.  It is also a means of enforcing the joint accountability that all of us share for what happens on our watch.  What on earth can a funder be thinking when we report that our project succeeded in a country where the national program simultaneously fell apart?  Where a country fails, all of us have failed.

But this means also that we must stop planting flags and set aside childish hopes of instant gratification, such as producing remarkable results by the end of the next fiscal quarter.  This is a generation-long struggle, not an invitation for a quick fix--forget it.  We must instead take on the really difficult challenge of improving our modalities of support, as this year's World Development Report so convincingly showed.

So let's think programs, not projects, and let's take the long view.

If we succeed, there will be plenty of credit to go around.  It reminds me of the riverblindness control program in Africa, where dozens of organizations joined forces, and all of them today deservedly share the glory of having saved millions.

But if we fail, especially by tripping over each other and over ourselves, we and our institution will all be held accountable, and history will rightly consign us to disgrace.  And what happens to our reputation will pale beside what will happen to tens of millions of people around the globe.

The third great challenge and the most daunting is the exceptionalism of AIDS.  Those who know me know that I don't normally use such words, but "exceptional" is the only word that fits.  AIDS stands almost alone in human experience.  Many diseases and natural disasters create their own brutal equilibrium, a self-regulating mechanism that eventually enables society to cope if not to overcome.  But AIDS thus far has been different.  Virtually all its impact serves to weaken our defenses and accelerate its spread, not to limit it--very different from others.  Moreover, because AIDS preys on the most private human behavior and stays invisible for years, it has silenced us from acting.

In short, AIDS has rewritten the rules.

And after long reflection, I have really concluded that in order to prevail, we too must rewrite the rules.  I once believed that it would be enough just to simply do more and to do better.  Today I believe we have to act differently as well.  And an exceptional threat demands exceptional action.  As Abraham Lincoln once remarked:  "The dogmas of the quiet past will not work in the turbulent future.  As our cause is new, so we must think and act anew."  We must apply this to AIDS.

So I believe the time has come to take exceptional action in the way we finance the response to AIDS as well.  For example, when I hear that countries are choosing to comply with medium-term expenditure ceilings at the expense of adequate funding of AIDS programs, it strikes me that someone isn't looking hard enough for sound alternatives.  And I recognize that such principles of fiscal discipline are in place for good reason, but surely there must be means of accommodating vast new inflows without stirring economic demons.  I am sure the Bank agrees, since you have been arguing so eloquently for a dramatic increase in development aid.  And this is the one institution, along with your sister organization across the street, that can show a new way on issues such as this. 

For countries emerging from conflict, the Bank has pioneered a careful program of exceptions, running a calculated risk on the grounds that inaction would be riskier still.  So let's now do something similar for AIDS, a risk far greater than conflict in many countries.

And above all, countries, communities, families, individuals need to rewrite the rules of how we deal with those sensitive issues at the heart of this epidemic--sex, adultery, homosexuality, rape, how men and women relate to each other, drug use.  Each community needs to find its own language for addressing these painful truths.  And this is already happening in many places around the world with encouraging results.  But what is now exceptional needs to become commonplace. Nothing spreads HIV faster than silence.

Now let me conclude by taking a look into the future.  Where do we go from here, and how can we get our minds around the greatest natural challenge ever to confront humanity?

I would propose that we look to the future and at 20 years from now, what can we expect from the epidemic, and what should we expect from ourselves.  From AIDS, I can only say that we should expect the unexpected.  Frankly, the virus has made fools of us at every turn.  Ten years ago, the World Development Report, the Bank's publication, forecast the worst-case scenario for Africa of 2 million new HIV infections per year by 2000.  But by 1999, Africa had already hit 4 million new infections per year.  And I remember we had tremendous fights--I was involved in this report--where those of us who said 2 million is not enough were accused of being doom-thinkers and irresponsible.

And globally this year, the number of new infections will be greater than the total number of HIV cases that were worldwide in 1987, the year of the first World AIDS Day, December 1.

So almost no predictions have proven too pessimistic in practice, and what the epidemic will do next is beyond our power to say.

But what lies entirely within our power is how we respond.  At first glance, AIDS seems to create a dilemma of managing under uncertainty for the vast part of the developing world, where it is only getting started--for Asia, parts of Latin America, for Eastern Europe, Central Asia.  But if you don't know how much risk you face, it's hard to know how much to invest in guarding against it.

But I would argue the opposite.  This is not a dilemma--it is an opportunity.  For AIDS is more than anything else an invitation to redouble our efforts on development.  Poverty, ignorance, unemployment and inequality are the handmaidens of the epidemic.  They help spread HIV.  And AIDS in turn undermines development.  So already in Africa because of AIDS, hopes of reaching most of the Millennium Development Goals have been dashed.

By the same token, however, most of what is good for development is good for defeating AIDS and vice versa.  Twenty years on, if we have helped the developing world to achieve these Millennium Development Goals, I can assure you that AIDS will be in retreat.  Indeed, the epidemic has created an opening for us to do more in development.  For example, in Africa, AIDS inspired a commitment by leaders two years ago to devote 15 percent of their national budgets to health--a far greater proportion than most had ever spent before.  And globally, AIDS has given rise to a new Global Fund which addresses other mass killers as well--malaria and TB.

Now, this great institution, the World Bank, and the larger UN family which we serve are living reminders of the vision of those who resolved half a century ago to prevent another world war by eradicating the causes that would give rise to it.  Let's remember that.  They recognized the international system was irrevocably broken and proceeded to rewrite the rules of trade, of aid, and collective security forever.

But today, with more people already infected and died than in both world wars and no end in sight, it should be clear to all that the challenge confronting us is no less compelling.  As a virus, HIV is likely to be with us for a every long time I am sorry to say.  But how far it spreads and how much damage it does are entirely up to us, and we should always ask the question:  Does the organization and does our action pass the AIDS test?

So 20 years from now, let it be said of us that we not only saved the second generation from this catastrophe, but that we planted the seeds for a world where nothing like AIDS could ever run rampant again.

So let me conclude, Mr. President, with our own words in Dubai:  "It is time to take a cold, hard look at the future."  And because of AIDS, that future will look much bleaker certainly in Africa, part of the Caribbean, but also countries in Asia and Eastern Europe, if we don't take exceptional actions immediately.

So the stakes are high, very high, but the agenda is clear, very clear.  AIDS forces us to do business differently, because this is not only about personal behavior change, this is also about institutional behavior change.

AIDS is the great moral cause of our time, and effectively rising to the challenge will be a key test for the w hole of the international system, including the Bank.

Thank you very much for your attention.


MR. WOLFENSOHN:  Thank you, Peter, for a truly brilliant exposition.

We have just a few minutes for questions if you don't mind answering them.

Anyone who would like to ask a question, if you'll come to the microphone, say who you are and ask your question.

QUESTION:  Hello.  I am Mary Araboga, from the Voice of America.

Dr. Piot, we met, actually, in Addis Ababa in Ethiopia last year on World AIDS Day.  And on the question of World AIDS Day, this year's theme is "Live and Let Live:  Trying to Overcome the Stigma of AIDS."  How can we as individuals and at the grassroots level help change people's minds about people who are suffering from HIV/AIDS?

DR. PIOT:  Well, there is really that stigma.  The fight against stigma is a theme of World AIDS Day this year.  As I mentioned before, I believe this is one of the most fundamental reasons we have an epidemic and makes our collective job very difficult in addition to being a violation of the rights of people who are victims of it.

We can do a lot, but it is a long-term work.  One in general is changing legislation.  Legislation is still discriminatory in many countries.

Two is creating space for people living with HIV to come out, to be public, so that the epidemic becomes visible and that the silence can be broken.  There has been a campaign, actually, in a number of countries where the president, prime minister, a bishop or a cricket player figures together with a person living with HIV on posters to show that, look, people like you and me are brothers and sisters--but particularly supporting groups of people living with HIV and starting at home.  I think nothing beats good practice at home.

MR. WOLFENSOHN:  Could I just add to that, since I have the opportunity now of saying something--we in our own institution have a comprehensive program for our colleagues who are affected by AIDS.  And the terrible thing is that only a very small proportion of the people who are affected are seeking help.  And this addresses the very issue of recognition, of ostracism, of lack of sensitivity.  And I would simply urge you, since you must have been moved by this statement by Dr. Piot today, that we need to start in our own house, and I would urge you to take your first step by living the philosophy that was expressed today.  It is crucial that we deal in an evenhanded and equitable way with our colleagues who are affected.  I am really disheartened to tell you that only a fraction of the people who should be helped are currently being helped, and that has to do with the environment that all of you can contribute to.


QUESTION:  I am Barbara Pillsbury from the USAID-funded Synergy Project.

You mentioned the feminization of the epidemic, and in other venues, you have emphasized the importance of empowerment of women for addressing it.  I wonder, as you emphasized today the need for "exceptional action," if you have any vision about exceptional action that can be taken to speed the empowerment of women, which many of us in the development community have been struggling to achieve without nearly as much success as is needed for a long time.

DR. PIOT:  I think that with AIDS it's really clear now that gender inequality--discrimination of women--let's put it that way; I think sometimes we use euphemisms to often--that that has become a vital issue, and I think we need to work far harder on a number of issues like property rights and inheritance rights for women, zero tolerance for sexual violence, which is in most cases going to women but sometimes to men--sex with men, for example--that we need special programs for HIV prevention among girls and young adolescents.

And I concern I have here also is that if we let market forces do it in terms of access to treatment, it is men in power who are going to get the anti-retroviral treatment.  So there, we need also affirmative action to make sure that women also will have access to treatment.

So I think, yes, let's make sure that there is a connection made between those working on gender equality, on women's issues, the women's movement, and the AIDS movement.  That connection has not been there until recently, surprisingly.

QUESTION:  Good afternoon, Doctor.  Thank you for coming.

My name is Michael Scott.  I am the director of the HIV/AIDS Office for the Catholic Archdiocese of Washington under Cardinal Theodore McCarrick.  I just had a quick question.

Could you comment very briefly on UNAIDS' new relationship with CARITAS International and other faith-based organizations?

DR. PIOT:  Well, when I got into this job, I was convinced that the response to AIDS has to be led by governments, but governments can't do it alone.  So I turned in the first place to three groups--people living with HIV, supporting them; secondly, business; and thirdly, faith-based organizations, organized religion.  And actually, with CARITAS, we already signed the first memorandum of understanding--it must be five or six years ago, before there was any talk about faith-based organizations' involvement--and since then, we have had a really very productive relationship not only in terms of service delivery--let's put it that way--but also in formulating messages, in mobilizing groups that, when you think of capacity and expanding capacity, there is an enormous untapped source in addition to the fact that for many people, religion is an important drive in their lives.  And CARITAS was the first organization to sign that with, but in the meantime, we have been doing this with faith-based organizations of various origin.  Our absolute bestseller in UNAIDS in our Best Practice Series is called "The Role of Imams in the Fight Against AIDS."  It has already had three reprints, and it was made with the Medical [inaudible] Association of Uganda.

So it is something where I have changed my mind--10 years ago, I thought that organized religion was one of the biggest problems in my job, obstacles.  Today I think it is one of the biggest allies.

MR. WOLFENSOHN:  Could I just add that institutionally, our own institution, which had some difficulty in contemplating relationships with faith-based organizations, to put it mildly, we are now moving aggressively in terms of dealing with faith-based organizations on the question of AIDS and AIDS treatment, also with Community of Sant'Egidio, the Catholic agency in Rome; but far beyond that, we have just recently had an all faiths conference in Uganda and are reaching out.  It's a highly prospective area for us, and we look forward to it.

QUESTION:  Thank you, Dr. Piot, for a very nice, informative speech, and inspiring as well.

My name is Julie Hantman, and I am an independent consultant involved in the global AIDS area.  I am also here representing the International Health Section of the American Public Health Association.

I have a question that probably belongs in one of these meta-strategic kinds of issues you have brought up today.  If I am a program director domestically or globally on almost any issue, I always struggle with short-term money flows--grants, contracts, et cetera--that are terminal, three, five years.  When we speak about anti-retroviral treatments, I think the stakes are very high when it comes to the kinds of funding patterns that programs will be receiving to do this work, and we have large initiatives, including the Three-by-Five, that are set to do fantastic work.

And yet as we go forward, to frame it in the most human terms possible, how could we ensure that anyone who will finally begin anti-retroviral treatment, let's say in January '04, will still receive that treatment five, seven, nine, eleven years from now?  We talk convincingly now--and I think the fight is being won--that adherence is not an issue at an individual level, Africans will adhere, others around the world will adhere at high levels.  Procurement is a challenge, but people are working on it to ensure that drugs will flow smoothly.  But the money behind those drugs, behind the programs in general, may shift, of course, from program to program it seems to me within a small time frame, and then the beneficiaries again of those programs may shift in terms of who is getting that.

Can you comment on that, please?

DR. PIOT:  If I may reformulate your question--is there donor adherence?  One of the big problems in international development has been predictability of funding, and you heard me in my speech that I really tried to make a plea to go away from the short term, the quarterly results.  As much as people around me know that I am pushing for results--I am a results man--but we need to take the long-term view.

I don't think we can--how to say it--predict what will happen, but this is where it is so important to have this continuous political pressure and action.

And secondly, one of the concerns I have is that today, decisions have been made behind closed doors, for example, on treatment, on big programs, which in essence are binding a country for a generation because treatment has to be there for decades.  Let's hope it's that long effective.  And that means that we need a societal debate on this, from the question who comes first in terms of treatment; two, how are we going to ensure predictability.  But if we wait until we have all the guarantees for that, I'm sure that all of us will at least be retired or dead.  So go for it at the moment, and then we have to work on it.


QUESTION:  Hello.  I am Hans Binswanger.  I am the resident representative of ACT-UP at the World Bank.

You know I have worked for the past couple of years trying to get associations of people living with AIDS to do what is done routinely in the United States at the Whitman Walker Clinic or by the Gay Men's Health Crisis--to run their own treatment programs for HIV/AIDS.  And both you and Mr. and Mrs. Wolfensohn have actually supported us.

However, in four years, I have completely failed to convince ministries of health to let us even test this particular treatment model in most of the countries.  So it's like a huge, idle latent capacity sitting there, just like the 4,000 retired nurses.

How can we break through these types of bottlenecks?

DR. PIOT:  I am very familiar with it.  I think--to give a little bit of a cynical answer, I think you were ahead of your time, although the problem was as acute five years ago as it is today.  Today, the whole climate around treatment is changing so that I would encourage you to give a new boost on these efforts, and let's talk about it, because I think now there is a better probability of doing it; you are clearly a pioneer in this.

MR. WOLFENSOHN:  I think we have time for two more quick questions.

QUESTION:  Hello, and thank you for that wonderful speech; very inspiring.

My name is Rachel Winter-Jones, and I work for the World Bank in their European office.  It's good to see you here in Washington after having seen you speak many times in Europe on this issue.

Just a couple of points.  With the anti-retroviral treatments pushing in now, which is wonderful, also, I hear young people saying, "There is now a cure."  I am quite worried about this, and I think the treatment is there, but I think this is something that we have to be very concerned about, and I have been here at our Human Development Forum and listening to my colleagues who are working on the MAP programs, and this is something they are very worried about well--that young people think this is a cure, and it's not.  It is a way to maintain people, but it's not a cure.

Another point that leadership is, as we all know, extremely important.  but I am very concerned that some of the European leaders that I see back in Europe are saying, "Well, this is a developing country problem," and infection levels are going up in my country and the in the UK and others, and I really think this is a global problem.

Just finally, I completely agree with you on the whole governance side--there are lots of different initiatives now, which is great, but I think we do have to try to work in a different way.

Thank you.

DR. PIOT:  Thanks, Rachel.

I would say first, yes, in Western countries, what happened was that when treatment was introduced, the ball on prevention was completely dropped, and we are seeing what happens in the United States, in the UK, in Belgium, in France--an increase in new infections.

That's why it is so important that we walk on both legs.  At the moment, the treatment leg is totally short, though, so we have to make sure that prevention is expanded and treatment is introduced.

The problem is also that for some in power, in government, it is so much easier to deal with treatment--not how to do it, but it avoids talking about sex, dealing with the problem of injection drug use, and so on.

So I think we need to make a strong commitment that one cannot go without the other, and I think that's a very important message.  If the developing world is going to make the same mistake as Western Europe, as North America made, then we are really headed for trouble.

QUESTION:  My name is Wilberforce Sagamgara [phonetic], Minister of Agriculture and Industry and Fisheries from Uganda.  I am just here visiting in Washington with the International Food Policy Research Institute.

At home, we are trying to work out action research to integrate HIV/AIDS in agriculture, but the problem we are finding, which you have alluded to, is that it is difficult to prioritize these programs as a Minister of Agriculture because of medium-term expenditure framework ceilings.

What suggestions do you have to see to it that this can be elevated, because, as you know, normally, it becomes difficult, and yet we are also subscribing to macroeconomic policies, and we don't like to [inaudible] them.

What is the way forward?  Thank you.

DR. PIOT:  Thank you, Minister.

This is exactly one of the points I made, and during lunch, Mr. Wolfensohn and myself discussed this.  I think we need to really look into that, we need to come up with practical solutions, because it would be really obscene and immoral if that would prevent a country like Uganda, which has done such a good job reaching out, to go further and to be successful in a sustainable way in dealing with AIDS.

So we are going to take this up--this is where the IMF has to be brought in--but also the country level with the ministers of finance.  We need to come up with a strong framework and a process to deal with that, and I know that Jim--we are all very prone to that--and for those who were at lunch, I didn't plant that question.


MR. WOLFENSOHN:  Just a footnote on that--we are currently, and for the last several months, working with the Fund on this issue of limits on medium-term expenditure framework for things that cannot be put aside and for which grant funding very often is available.  And I hope quite soon that we will have some movement on that issue, because it is a very real issue.

Well, Peter, it has been a true privilege to have you here.  I started by saying that you were our leader; I think if anyone was in doubt at the beginning of the session, they now know why you are the leader.  It is a lecture that I don't think any of us will forget, and it will also be simulcast throughout our organization and overseas.

I just very simply want to thank you on behalf of everyone here, our colleagues from the Bank and our guests who are with us, and say that we wish you strength and good results, and we can assure you of our total cooperation.


[Whereupon, at 3:33 p.m., the proceedings were concluded.]

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