November 27, 2006
Debrework Zewdie, Director, World Bank [HDNGA]: Good morning and welcome to the Meeting “Sustaining Treatment Costs- Who Will Pay?” As you are already aware, this meeting has been jointly organized by the World Health Organization, UNAIDS and the World Bank. So it will be my pleasure, without further delay, to introduce the representatives of these three co-sponsors to open the meeting. They are the President of the World Bank, Mr. Paul Wolfowitz, the Director of the WHO Department of HIV and AIDS, Dr. Kevin De Cock and the Executive Director of Joint UN Program on HIV and AIDS, and Undersecretary General of the UN, Dr. Peter Piot.
Gentlemen, we are delighted that you found the time to join us and show your support to the fight against AIDS. Let me hand the microphone first to Mr. Paul Wolfowitz.
Paul Wolfowitz: Thank you Debrework. If you will permit me to tell you a story, some of you may probably have heard this before, it’s a story about the man who was the victim of the famous Johnstown flood in Pennsylvania where a dam burst and several hundred people were killed – he gets to Heaven and… well, the first things he does is to say, “St. Peter, I have got this incredible story to tell, I would really like to have an audience and talk about the Johnstown flood,” and St. Peter said, “Well, we will try to work you into our social schedule” and every week the man comes in to St. Peter and said, “When is it going to be time for me to talk about the Johnstown flood.”
Finally, St. Peter gives up and says, “Okay. We will schedule you for afternoon talk next Tuesday.” Next Tuesday rolls around and there is a large group sitting out in audience, and as the man was about to speak, St. Peter taps on the shoulder and he said, “Just so you know that man down in front, that’s Noah.”
I really do feel like I am speaking to a group of AIDS experts here and I am not one, but I do want to underscore just how important this subject of HIV and AIDS is, and how it’s not only an individual human tragedy for millions of people, but it’s also an incredible obstacle to development in Africa.
For those of you who view it from the perspective of disease and individual suffering, let me just mention very briefly that the last quarter century has been a period of extraordinary progress in the fight against poverty that has seen some four hundred million people escape poverty in the last 25 years, most of them in East Asia. The one part of the world that’s actually gone backwards is sub-Saharan Africa. The number of people in extreme poverty there has gone from 150 million 20 years ago, to roughly 300 million today, that’s roughly half the population of Sub-Saharan Africa.
Of course, I think as you know the plague of HIV/AIDS and the story of poverty are unfortunately very much connected, and I think this is a time of much greater hope for sub-Saharan Africa, a time when at least a third of the population live in countries that have seen some sustained real growth over the last ten years and some real progress in social indicators. This disease seems to attack the most productive members of society in the prime of their potential contribution to life, and this is a problem for the whole of society and not just for the individual people affected.
So, I owe a special word of thanks particularly to Debrework, for the pioneering work that she has done in getting people to understand that connection between this disease and the challenge of development and I am grateful for this conference and appreciate the chance to just say a few remarks here at the beginning.
According to the statistics I have, 6.5 million people around the world need treatment for HIV/AIDS today, but only 1.6 million are receiving it. These numbers come from WHO, so I’m sure they are right but I did ask the question, ‘how come the 6.5 million is so much lower than the number of people who are actually infected?’ and of course as you experts know, that’s because many people are infected and are not yet candidates for antiretroviral treatment.
To me what that says is that number of 6.5 million can only grow and the shortfall, which is already large, will grow even larger. Unless of course we do more to meet that gap, and not only meet the gap for the 5.4 million people who don’t have treatment, but to be able to meet it for the potentially growing number. I’m very pleased to see a diverse group of stakeholder here in this room from communities of people living with AIDS, from the policy community, from donors, from governments, academia and industry and I know you are all committed to make progress on this critical issue. We can’t afford the ‘here today gone tomorrow approach’ to addressing urgent problems when governments and donors walk away from patients in the middle of treatment because of money simply isn’t there to continue.
The people who are on treatment today will still need treatment five years from now and ten years from now and so. Will those 5 million plus people who haven’t yet started? That means, we need to find a way to fund treatment not just for today, but for 10 and 20 years from now. I think the good news is that the international community has made real progress in making treatment more affordable.
Five years ago, the cost of antiretroviral drugs was almost impossible to afford. At roughly $10,000 for a single-use treatment, the cost is far beyond the ability of poor countries to buy in meaningful quantities. Today, that cost has been reduced to less than a $150 a year for a course of the latest AIDS drugs. It is the first time the international community has hoped that universal access could eventually become a reality but to do that, antiretroviral treatment programs must go hand in hand with effective programs to help prevent new infections.
We have the technical means to support all countries in their efforts to offer lifesaving treatment to their people, but first we must galvanize the political will of governments and donors to commit to long-term predictable financing and we must also identify innovative ways of dealing with the barriers that continue to stand in the way of widespread sustained treatment.
As many of you know, even when patients adhere to their therapy, a certain number will eventually develop resistance to their medications. They will need to switch to a second-line therapy regimen to control their HIV, and second-line medications today are considerably more expensive. The patients and their doctors also need special blood test to help decide whether and when to make the switch from one treatment to another, and these blood tests too are expensive.
The costs carry critical implications for international efforts to make treatment more sustainable and those are just the funding-related challenges. If we really want to make treatment sustainable we’ve got to go beyond putting drugs into the hands of patients. We need to strengthen overall health systems in a way that gives people wider, more dependable access to prevention, care, and treatment. We must also help people infected with HIV lead fulfilling and productive lives. I still recall vividly a woman I met in Nigeria last year, who was part of a HIV/AIDS self-help group, who said to me, ‘the stigma killed me before the disease. I lost my job, I lost my home, I lost my husband, I lost my family, I really had nothing left to live for until these people took me in’ -- these people, she meant this informally organized group actually led by a former colonel in the Nigerian army who was himself HIV positive.
Treatment is indispensable as that woman expressed so eloquently, feeling the stigma is nearly as vital. She was lucky, she found that self-help group, but others are not so fortunate. The World Bank is committed to doing our part to address the diverse challenges in the fight against HIV/AIDS. We wear our commitment on the outside of our headquarters with our AIDS ribbon; that ribbon can be seen by everyone passing our front doors day and night. We also stand behind with money and development goal which appeals to all of us to “halt and begin to reverse the spread of HIV/AIDS.”
At the World Bank Group, we are committed to putting those words into action. We are prepared to provide countries with the tools they need to address the challenges of sustained treatment, whether with drugs or with health infrastructure, and we stand ready to support country efforts in removing the bottle-necks that hamper the flow of assistance not only from us, but also from other donors.
But even in just the time I have been at the Bank, I have been impressed by how important it is to work on developing the overall health systems of countries; merely providing drugs is important but just a part of what has to be done. I had the privilege to see for myself some of the treatment programs we support, and to meet some of the patients when I visited Rwanda and visited the Biryogo Health Center in Kigali that treats about 300 patients a day in one of the poorest neighborhoods of one of the poorest countries in Africa.
That health center is just a part of a larger effort by the government of Rwanda to tackle the HIV/AIDS epidemic. It affects more than 400, 000 Rwandans. I had the opportunity there to meet the head of the national AIDS council, a charismatic woman, Dr. Agnes Binagwaho. She told me with great pride that if a man shows up alone at her clinic, he is sent home to bring his wife and children before he can receive care. In fact, through discipline like that Rwanda’s government has made remarkable progress in building itself infrastructure since the tragic genocide of the mid 1990s and the Bank has supported those efforts with a $30 million grant for prevention, treatment, care, and support.
We face enormous challenges in treating those who are already infected in Rwanda and elsewhere in Africa and around the world, but we must not lose sight of the importance of prevention and prevention can work. We are starting to see a downward trend in HIV prevalence among young people and some of the hardest hit countries such as Botswana, Cote d’Ivoire, Malawi, and Zimbabwe. Last year, the Bank published our global HIV/AIDS program of action. This program reaffirmed our commitment to strong long-term support for comprehensive national HIV/AIDS responses. Comprehensive means that we recognize the prevention, treatment, and care are all critical and related elements of effective action. Your meeting here is specifically about treatment.
You will hear a presentation on the Bank-funded treatment acceleration program later today. In your discussions, I urge you to remember the importance of coordinating treatment programs with effective and evidence-based prevention. The Bank is not as large an AIDS donor as the Global Fund or PEPFAR today, but we remain a long-term AIDS funding agency and a key player in the development of country-based systems. We also can help share lessons, policy advice, and technical know-how learn in one country to another that can use it. That knowledge can help achieve measurable lasting development results.
This meeting here is one example of such knowledge sharing. Every two years we have chosen a problem that’s both critical and controversial in the field of HIV/AIDS. We bring together the top global experts in a small meeting like this and facilitate your efforts to work through these problems. Of course, no single player can achieve results on its own. We very much value our partnership with WHO and UNAIDS with whom we share a long history of working together. The Bank is in fact one of six founding members of UNAIDS and it is thanks to the support of UNAIDS that we have a global HIV/AIDS program here in Washington as well as strong regional programs including most notably at Africa.
I would like to personally thank Peter Piot for his leadership and his unwavering support for HIV/AIDS within the Bank and international community at large. I also appreciate the warm and collegial relational we have with our friends at WHO with whom we work closely in projects such as accelerating access to treatment, and we will continue to turn to you for technical leadership. To conclude, I hope your meeting will further strengthen partnerships between the Bank and the organizations represented here. Your thoughts and contributions over the next three days will be critical for the global dialogue and how we can not only deliver treatment but make it more sustainable.
Nearly 7 million people in their communities are waiting for the outcome of the global dialogue on treatment sustainability. We have a responsibility to meet their hopes and expectations. I look forward to the results of your meeting. Thank you very much.