Remarks by Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa,
delivered at the opening ceremony of the AIDS Vaccine 2005 International
Conference
Montreal, Canada
Tuesday, September 6, 2005, 6:00 PM (EDT)
- FOR IMMEDIATE RELEASE

This is a meeting of researchers and scientists. I am an advocate. It's
pretty
obvious that you can't turn me into a scientist, but I want to turn you into

advocates. To that end, I shall show my unbounded respect by refusing to
employ scientific jargon . nor dare I even attempt it when sitting on a
panel
with two such illustrious and knowledgeable colleagues.

Last month, in Maputo, Mozambique, I attended the annual World Health
Organization regional meeting of all the African Ministers of Health. Late
in
the afternoon of the second day of the conference, an hour and a half was
set
aside for a discussion of HIV/AIDS and prevention. A significant number of
African delegations participated, raising all the conventional responses
involving behaviour change, and a few responses somewhat unorthodox in
content, from male circumcision to bio-chemical sexual suppressants!

What was not mentioned, by any official delegate, throughout the entire
session, was a vaccine. It was as though the preventive technologies had
totally fallen off the radar --- microbicides and vaccines both. If it
hadn't
been for the presence of the former Prime Minister of Mozambique, Pascal
Mocumbi, attending as an 'observer', the word vaccine would not have
passed anyone's lips. And do remember, Dr. Mocumbi has a particular
interest: he's now the High Representative of the Clinical Trials
Partnership
in the Hague.

What was even more interesting than the omission of preventive
technologies at the Maputo conclave --- 'peculiar' might be a better word
---
was that the session was based on an actual report, issued by WHO, of a
conference on prevention attended by a large number of African and
international experts, held in Brazzaville over three days in June. The
report
contained every aspect of prevention with which we are all familiar, but the

word vaccine did not appear from beginning to end. Again, it was as if the
preventive technologies were somehow outside the fault lines of AIDS.

How can this be? Africa is the epicenter of the pandemic. Something,
somewhere is profoundly out of whack. The world needs an AIDS vaccine
more urgently than it needs any single medical discovery, and Africa needs
it more than any other part of the world. But for some inexplicable reason,
the consuming enthusiasm, the obsessive drive, the sheer, unrelenting
passion for a vaccine is simply not riveting the world at large as should be

and must be the case.

I would argue that the same kind of extraordinary commitment, in country
after country, to achieve '3 by 5', and then to progress to universal
treatment, is exactly what has to happen in the pursuit of a vaccine. And
that's why I opened with the emphasis on advocacy, advocacy that can be
embraced by everyone at this gathering --- advocacy that will move us closer

to breaking the back of the pandemic.

Within that broad rubric, let me make three points.

First, we clearly need a great deal more money in the quest for a vaccine.
As
you know, it's estimated that we spent $690 million in 2004, and should be
spending a minimum of $1.2 billion every year hereafter, virtually doubling
current annual expenditures. Even though there have been new monies
committed by the Gates Foundation, and significant additional funds
recently announced by Dr. Fauci, we're still several hundred millions of
dollars short on an annual basis.

I want to say, categorically, that this state of affairs is unconscionable.
There
was nothing more than a rhetorical nod in the direction of a vaccine at the
G8 meeting in Gleneagles: it's almost beyond belief that the political
aristocrats so solemnly gathered couldn't bring themselves to promise an
absolute funding guarantee, in perpetuity, until a vaccine is discovered.

After all, the entire Summit was driven by an agenda for Africa. The
promise was made of a doubling of foreign aid, to $50 billion a year for the

continent by 2010. The G8 political leaders all understand that AIDS is
decimating parts of Africa; they all know that none of the Millennium
Development Goals will be reached in the high-prevalence countries because
of the virus; they all acknowledge that whatever the combination of
treatment, prevention and care, Africa's future remains perpetually
compromised until AIDS is vanquished. But they couldn't bring themselves
to guarantee that those in search of the new preventive technologies of
microbicides and vaccines --- the most formidable potential weapons we
have against the pandemic --- would be given the keys to the vault of
scientific discovery.

I hate to say it, but the explanation might lie in the gap between promise
and
fulfillment. What has emerged, post-Gleneagles, is the unsettling news that
part of the monies promised for official development assistance are already
earmarked for debt relief, Iraqi as well as African. That profoundly
diminishes the money available for foreign aid, certainly from Japan, and
quite probably from others. And that, in turn, can help to explain why the
Global Fund, whose replenishment conference ended just a few hours ago in
London , has apparently fallen some 3.3 billion dollars short for the period

2006-2007. The allocation for the Global Fund was meant to come out of
ODA, but the ODA is already found wanting before the signatures on the G8
agreement are even dry.

Think about that for a moment. All of common sense would suggest that the
Global Fund to Fight AIDS, Tuberculosis and Malaria is exactly the source
from which should come some of the future funding for vaccine
development, particularly involving trials in African countries. If that
source
is arid, vaccines are the losers again.

The argument I'm building towards is this: Your pursuit is in jeopardy. Your

collective voices must be heard on the funding dimensions of a vaccine. It
can't be left solely to activists. You're the influential professionals. You

should give no quarter; the world depends on it.

Which brings me to the second item: allied with the question of resources is

the question of broadening the base of scientific enquiry in the search for
a
vaccine. It seems to be widely accepted that the private pharmaceutical and
biotech companies must be brought on board. Their participation hitherto,
with one or two notable exceptions, has been, quite simply, paltry.

There are, of course, a number of explanations. The science is
supernaturally
complex and difficult; the exploratory investments are huge; the monetary
risks are great; and undoubtedly the biggest obstacle to urgency of all, the

market lies overwhelmingly in the poorest countries of the world.
Throughout the AIDS pandemic, pharmaceutical companies have shown a
remarkable financial narcissism when it comes to preserving their balance
sheets. But clearly, the expertise of the private sector, with its
successful
history of producing vaccines for a vast range of diseases, is desperately
needed in a vibrant web of public-private partnerships.

Thus there has emerged the inventive idea of an Advance Purchase
Commitment, designed to guarantee market and price for those companies
who discover, manufacture and distribute a vaccine. It has the imprimateur
of the UK Chancellor of the Exchequer, Gordon Brown, and has even been
subject, as you doubtless know, to calculations of the possible numbers of
courses of vaccination at a price which would guarantee a respectable rate
of
return. I shall not venture into the complicated calculus.

The so-called APM is designed to make things attractive enough to engage
the multinational drug companies. I will admit that under normal
circumstances, this kind of fiddling with market forces to satisfy the
private
sector (a private sector that pretends to such reverence for the free
operation
of the market) would seem revoltingly rank. But normalcy is the furthest
thing from the present circumstance. We're dealing with a communicable
disease that dwarfs every illness since the Middle Ages. In that context, it
is
legitimate to make room for special privilege in the service of human
survival.

I have but one caveat. In my respectful submission, the architects of the
APM are aiming too low. The discussions are premised on two hundred
million or three hundred million courses of vaccine, requiring three staged
injections, with the related costs carefully calculated. Two to three
hundred
million doesn't begin to meet the need, or recognize the capacity that
already
exists to provide the vaccine. UNICEF and WHO have legendary experience
in immunization: they've learned to orchestrate national immunization days
in countries like India where millions are inoculated in one twenty-four
hour
period. We should be looking at five hundred million courses at an absolute
minimum. This is not a time to trifle: this is a time to think on a scale
worthy
of humankind.

Third, as everyone in this room recognizes, the pandemic's greatest toll is
amongst women. It took us all a staggeringly long time to realize the
disproportionate vulnerability of women, but now that we have, much of the
work in prevention has turned to that excruciating reality. The problem is
that we're making infinitesimal progress. It seems as if every time another
ante-natal survey is taken, whether in South Africa or Swaziland, the
prevalence rates for women have increased. Indeed, I can say with woeful
and desolate confidence that on the ground, the responses to this growing,
lethal threat have touched the lives of women barely at all. The inability
of
women to govern their own sexuality, the sheer degradation of gender
inequality dooms vast numbers of women in Africa to the status of an
endangered species.

A vaccine then becomes the liberating hope for women. Assuming for the
moment universal access for women, should a vaccine be discovered,
women would be able to protect themselves from transmission with no
interference or involvement at all by current or prospective sexual
partners.
Now, there's a prospect devoutly to be wished, cherished, treasured. The
millions of women in their teens, twenties and thirties who stand the
gruesome risk of being infected, the millions of orphans left behind when
their mothers die, the carnage and devastation visited on one sex in
appalling
numbers . all of this would have a chance to become a thing of the past.

And because women are the poorest members of society --- and AIDS does
nothing more efficiently than to make the poor poorer --- the availability
of a
vaccine is a battle won in the war against poverty. There is almost nothing,

on the face of it, which is pejorative about a vaccine.

Allow me, if you will, to make a few other necessary points, and then wind
my way to the end.

While the search for a vaccine continues, there can be no lessening of our
determination to resist the virus on every imaginable front. The 3 by 5
initiative has unleashed a galvanizing momentum for treatment: it must not
be allowed to abate. What the World Health Organization and UNAIDS
have done is to provide the greatest single trumpet of hope in the crescendo

of treatment rollout. If, as the G8 suggested, we can attain universal
treatment by 2010, we will have broken the back of the pandemic, although
we will not yet have subdued it. What is true for treatment must be made to
work for prevention (including targets for voluntary counseling and testing,

and targets for the prevention of mother to child transmission), and what is

then true for prevention must be made to work for home-based care. Despite
the millions of deaths and new infections every year, we have
psychologically shifted gears. The publics of Africa and of the world seem
aware as never before of the need to tackle the pandemic: if only we could
cross the Rubicon of political will.

I again appeal to everyone in this room to make your voices heard. The
problems in dealing with the virus are admittedly enormous; the
reconstruction of societies, infrastructure, and shortages of human capacity

are all overwhelming. But if we keep at it, in unrelenting fashion, we'll
succeed. The potential Achilles heel is, as always, resources. In 2005, it
is
estimated that we will allocate $8.3 billion to fight AIDS internationally.
UNAIDS released a monograph just last month, in which they noted that $15
billion is needed for 2006; $18 billion for 2007; $22 billion for 2008.
We're
nowhere near those figures, and those figures are low estimates. What's
more, if vaccine research and development is to be fully funded, a minimum
of another billion dollars must be added to the total requirement between
2005 and 2007. The world desperately needs your voices.

And the developing countries desperately need your collaboration. One of
the chief reasons why a vaccine was not raised by the Health Ministers of
Africa is that they see research and development as the purview of the
North. Africa, in their eyes, is only invited to enter the equation when
it's
time to do the clinical trials. That's simply not good enough. The
scientific
community in the industrial world must make an herculean effort to engage
the scientific community in the developing world in the entire apparatus of
research and development. Health research and development in Africa, for
example, can build capacity and infrastructure as nothing else, as well as
making real the partnership between South and North, which has more often
been a scurvy relationship of neo-colonial manipulation.

It's just not good enough to involve Uganda, and Kenya, and South Africa
and Rwanda solely in the clinical trials. They must be involved in a great
deal more.

But when those trials take place, it's vital that consultation with African
governments be the sine qua non of collaboration. They must participate in
every decision from the process and practice of enrolment to the measure of
risk. I'm not suggesting that it hasn't been done hitherto; I'm suggesting
only that as the pace accelerates, there is no room for unilateralism.

But there is room for champions: political champions, scientific champions.
Just as the universe of AIDS is filled with the clamour for antiretroviral
drugs and behaviour change and home-based care and professional training
and solutions for countries awash in orphans, so must it also be filled with

the noisy, insistent protagonists of preventive technologies, microbicides
and
vaccines alike. It is both troubling and self-defeating when vaccines and
microbicides fall off the agenda.

Let me speak with utmost candour.

I don't think the world yet realizes the carnage that is to come. I don't
think
the world yet realizes the full, incomparable horror of AIDS, and its
inexorable spread around the planet. I don't think the world yet realizes
that
when we talk of the struggle for survival, it's not some facile phrase: it's
the
bitter truth for country after country in Southern Africa, and a truth that
may
spell the death for some of those countries before this century is a quarter

complete.

It's fascinating how we talk so yearningly of the Millennium Development
Goals. And it's right, of course, that we should move heaven and earth to
achieve them. But what, I ask you, happens after 2015? What happens to all
the countries for whom the goals are a hapless quest? What happens to all
the countries still counting the bodies and the infections of a pandemic
which has laid waste to their hopes and prospects?

For those countries, a vaccine is the best hope for salvation, because the
world doesn't stop in 2015. And if we work collectively, in a fashion at
least
equivalent to the space initiatives of NASA, then we will launch a working
preventive vaccine that will save and protect the lives of millions, right
at
the point where the MDGs leave off. There can be no greater legacy
bequeathed by the scientific community.

I'm an ignoramus when it comes to the nature of vaccines. But I've sat at
the
feet of Seth Berkeley of the International AIDS Vaccine Initiative, and I've

read speeches and articles by Dr. Fauci, and I have a pretty good sense of
how incredibly tough the slog will be towards the discovery of a vaccine.
We know that when all is said and done, a vaccine is the ultimate answer to
this devilish pandemic, and when all is said and done, human ingenuity will
one day trump the Machiavellian mutation of the virus. It always does.

My counsel, then, is one of unrelieved hope, and the determination never to
give up.

Back on June 2nd, at the United Nations in New York, there was a daylong
special session on AIDS to visit the progress (or non-progress) made since
the famous 'Declaration of Commitment' of 2001. It was a remarkably
mournful, desultory, almost pointless day. It was clear that the virus was
running ahead of the response.

But there was one protracted episode of hope. The International Partnership
on Microbicides and IAVI jointly sponsored a luncheon meeting on the new
preventive technologies. It was attended by many ambassadors and senior
members of the secretariat and a large number of interested parties. It was
addressed by cabinet ministers of Brazil, India, Rwanda and the United
Kingdom. It was also addressed by Kofi Annan, Peter Piot, Zeda Rosenberg
(the CEO of IPM) and Seth Berkeley.

The room was electric with interest and commitment. The sense of
expectation and of hope was palpable. It was a great moment.

It's that expectation and hope that I beg you to carry forward.