HIV/AIDS: Converting Adversity Into Opportunity

Thank you for the honor of inviting me to speak here today. Let me extend a special greeting to those who are living with HIV/AIDS.

I wish to applaud you for holding this vital event. Speaking as an African, a medical doctor, an educator, an activist, and a human being, no issue is closer to my heart. Speaking as a World Bank leader, no issue is of greater concern to development. For we have a single mission: "Our dream is a world free of poverty." But we now know that until the world is free of AIDS, that mission will remain only a dream. As you all know, AIDS is already the leading cause of death on our continent. But more and more, it is also becoming the most prominent fact of life. As one Malawian farmer put it, "We are spending more time turning the bodies of the sick rather than turning the soil." AIDS has already devastated one generation, and it now threatens to thwart the hopes and dreams of the next. Mr. Chair, I believe it is time for us to say "Enough."

I am disheartened by the sad stories and so, I am sure, are you. I do not intend to belabor the horrors of AIDS. Nor am I here to do a commercial on the many ambitious things the World Bank is doing on HIV/AIDS. Instead, I want to propose that we take a new view of this crisis that allows us to convert adversity into opportunity.

Why am I saying so? Because AIDS shows us where our weaknesses are-such as in education, women's status, and the breakdown of communities. Because AIDS compels us to develop the tools to fight back. And because we can use this AIDS crisis to convert adversity into opportunity

How can we use it? We can use this crisis to redouble our development efforts in schooling, basic health, economic opportunity, etc. We can use this crisis to combat stigma and discrimination And-my main message today-we need to scale up HIV treatment as quickly as humanly possible.

In its first years, AIDS was a bolt from the blue. We had no defenses, no weapons. We were at its mercy. Today, all that has changed. We have an arsenal of prevention tools that have proven themselves around the world. We have far greater knowledge and understanding. And above all, we have highly effective anti-retroviral therapy. We know the price of losing adults. The recent famine in Southern Africa is partly a manifestation of the HIV/AIDS crisis. And we know AIDS has only begun to take its toll. Deaths to come could dwarf what we have already seen. Yet these drugs are rapidly converting what was a plague into a chronic and manageable illness. When AIDS killed before, we had only Providence to blame. Soon we will have only ourselves to blame. I'm also confident, working together, we can overcome famine.

Consider the lessons of experience: In Brazil, six years of widespread HIV treatment has cut the death rate in half and reduced illness by up to 80 percent. Hospitals have been spared more than 300,000 admissions. The cost savings have likely already exceeded a billion dollars. In Khayelitsha, South Africa, the treatment program has reduced opportunistic infections by 70 percent in one single year. Within a year, the virus has become undetectable in 85 percent of clients

In short, these therapies work. They save lives, they prevent illness, they keep workers on the shop floor, they reduce the burden of care on families and-of great importance for the countries of SADC-they keep mothers and fathers alive.

But to date, only a fraction of nearly 30 million Africans have access to therapies. It is time we put these therapies within reach of all those who need them.

Can this be done? Emphatically, yes. How? Again, by converting adversity into opportunity.

The first opportunity is financial. ARV drugs are expensive, it is true. But 90 percent cheaper than 2 years ago. And prices will continue to drop-through generic competition, new discoveries, more effective delivery mechanisms. This means over a lifetime, the average annual cost will be far lower than it is today. At the same time, resources are at record levels. $1 billion from the Multi-Country AIDS Program of the World Bank (MAP), another billion from the Global Fund are already on the table for Africa, and potentially multiple billions from the US and other donors. Given how few people are receiving treatment, money is not the limiting factor today. On the benefits side, the private sector has already found that treatment pays for itself in medical savings alone. Heineken, Anglo, de Beers, Debswana and Namdeb are all providing treatment. Overall benefits are far wider than the health system, of course.

The second opportunity is clinical. Health systems are weak. Caregivers are overwhelmed. HIV can become resistant if patients do not take drugs carefully and regularly. But as Brazil and Guyana show, treatment relieves pressure on health systems, and improves health worker morale. It also creates the strongest possible incentive for countries to improve health systems. Remember-HIV drugs are only a small part of the overall treatment agenda. Basic care, healthy living, reproductive health, TB services, and rigorous monitoring and evaluation are all part of the package. Pursuing treatment will therefore compel us to increase capacity in health systems as a whole-something we should have done long time ago. I dare say that, in the face of this adversity African leaders made a bold commitment in Abuja two years ago to devote 15% of national budgets to health systems. Now is our chance to deliver on that promise. A word about resistance. Yes, HIV drugs-like most drugs-can cause resistance. But the World Bank hosted a conference two weeks ago of the world's top researchers and practitioners in this field. The consensus, backed by evidence, was clear: there is no clear evidence that resistance or poor adherence are a greater problem in developing countries than in developed countries. In Brazil and Khayelitsha, resistance rates are actually lower than in many treatment sites in the rich countries. And thanks to the stronger new generation of drugs, resistance is likely to be less of a problem than ever before.

The third opportunity is to support communities. We all know the heart-breaking stories of stigma, violence, and social exclusion that AIDS has caused. Yet expanding treatment would help turn each of these around. Treatment is not just about drugs. It is mostly about support-from families, colleagues, and communities. This is why programs are succeeding even in the poorest precincts of developing countries. Treatment converts victims into victors and removes the stigma of an "incurable" disease. Support for people living with HIV lets everyone play a role in keeping a community healthy and intact. Community involvement brings people together and breaks down the walls of silence that help the virus spread and put young people especially at risk. It also builds community solidarity for a host of other ventures, many of them far removed from AIDS.

What do we need to move forward? Three things.

First, we need to act now. We have learned key lessons from Brazil, Haiti and other countries with good programs. We have no illusions-the job will be long and tough. We need capacity, but it can only be built through experience. So the sooner we start, the sooner capacity will grow. We have learned important lessons from the World Bank conference I referred to-we need not wait for any further pilot studies.

Second, we need leadership. NGOs, CBOs, and the private sector are already providing treatment. But they can only do so much alone. Governments must also play the critical role expected of them. We need more leaders to set expectations and drive faster and better implementation. Good models are available. Many approaches are possible. Each country can choose its own path. But without leadership, nothing can happen on the scale necessary to avert the worst. Yes, it will cost money. But now that we begin to see the full cost of the epidemic, it is clear we can no longer regard investing in HIV/AIDS programs as just one among many policy choices. That is a false choice. Investing adequately in AIDS is a precondition to virtually any other investment a developing country may wish to make. The choice is stark and simple: Pay now, or pay a lot more later. Beyond their commitment of funds, personnel and programs, leaders need to shape new attitudes and mindsets. Those few who have dared have made AIDS a subject of public conversation in their countries, with dramatic results.

Finally, we need partnerships. No one expects poor countries to overcome this challenge alone. No one expects countries to pay for this alone. If AIDS has taught us anything, it is that we must work together. The World Bank is committed to this struggle for as long as it takes. We will bring money, of course. We have already provided more than $720 million to 21 African countries, and thanks to a recent decision by our shareholders we can now provide future support in grants. But we will also bring our expertise in program design, our long experience in implementation support, our convening power, our tools to stimulate inter-country learning and knowledge exchange. And the World Bank is only one partner. It is true we have no "soft" money to offer to several of the countries of SADC. But other bilateral donors and the Global Fund do, and the Bank is already working to link our implementation expertise with their resources so every country can enjoy the full benefits of both. Some of the most important partners are those without money: UNAIDS as the leading global partnership; the NGOs who have led the way in treatment; the researchers who have derived the important lessons. All of them have a central role to play.

I do not wish to underestimate the scope of the challenge ahead. This will be a vast and demanding task. But let us remember that it is not within our control to decide whether treatment will expand. It already is. Anti-retroviral use in Africa has increased two-thirds in the past year alone. The only question is whether it expands with public sector support and oversight, or without it. The experts at the World Bank workshop assured us that the greatest risk of treatment failure will come from unregulated expansion. What is within our control is to ensure that this expansion takes place in a controlled and well-supported way

Mr. Chair, in closing, let me quote some moving testimony from Augustine Chella, the former Premier League footballer from Zambia, who is living positively with HIV/AIDS. During the World Bank conference, he said: "If we were told that there was a river with life-giving waters in Africa, we would all be flowing to it regardless of the distance or the hurdles along the way." Today, that river beckons. The road is long and rutted, but the destination is clear. We can remain here while Nature takes her course with us. Or we can rise and begin our journey to the river together. Africa is not rich in money, and its riches beneath the earth have often brought more grief than gain. But there is one asset we possess in abundance and which has never failed once we resolved to use it-our capacity for solidarity. Call it Africa's "comparative advantage." Acting in solidarity, Africa has already overcome droughts, floods, global economic upheaval, colonialism and apartheid. In every case, we emerged the stronger for it. So it can be with AIDS. Let us turn adversity into opportunity. Let us spare the next generation what we have suffered. And above all, let us set out today.

I thank you.