The Global Pandemic: AIDS in Africa, China, and Russia

February 5, 2004

Unedited transcript prepared from a tape recording

10:15 a.m.	Registration
10:30	Opening Speaker:	Randall L. Tobias, U.S. Department of State
11:15	Panel Discussion
	Panelists:	Roger Bate, AEI
		Nicholas Eberstadt, AEI
		David Gordon, Central Intelligence Agency
		Marwyn Samuels, U.S.-China AIDS Foundation
		Jeffrey L. Sturchio, Merck and Co., Inc.
	Moderator:	James K. Glassman, AEI
1:00 p.m.	Luncheon
1:30	Keynote Speaker:	Tommy Thompson, Department of Health and Human Services
2:30	Adjournment

Proceedings:

MR. GLASSMAN:  --Africa, China, and Russia and the developing world.  My name is James K. Glassman.  I am a resident fellow at the American Enterprise Institute and host of the website techcentral.com.

The face of the AIDS epidemic has changed drastically.  In 2003, according to the best estimates, about 2.3 million Africans died of the disease, compared with 18,000 Americans and Western Europeans.  Overall, about 1 in 12 people in sub-Saharan Africa has the HIV virus, but in many individual countries, infection rates are far worse.  In Zimbabwe, one-fourth of adults have HIV, in Swaziland, the proportion has grown in a decade from 4 percent to 39 percent.  There are reports that the next wave of HIV/AIDS is already sweeping China, Russia and India, and we will hear more about that shortly.

Last year, President Bush pledged $15 billion in aid to combat HIV/AIDS, with the money focused on Africa and the Caribbean.  Now, one year later, what is the status of that commitment?  What is the best way to spend the money?  What is the role of infrastructure in fighting the virus, of antiretroviral drugs.  And on the subject of ARVs, in the face of intense political pressure, attacks by activists and raids on intellectual property, will the drug companies that developed the current generation of ARVs, which have probably saved millions of lives, be inspired to create the next?

On a personal note, I traveled to Africa last month with a delegation headed by Secretary of HHS, Tommy Thompson, whom we are pleased to have today as our luncheon speaker.  And several other people who are on that delegation are here today.  Also on the delegation is our opening speaker, Randall Tobias, whom I will introduce in a moment, as well as Elia Zerhouni and Tony Fauci of NIH, Julie Gerberding, the head of the Centers for Disease Control, as well as top officials of the World Health Organization and the Global Fund to fight AIDS, tuberculosis and malaria, CEOs of drug companies and leaders of charitable, including faith-based organizations that are fighting the disease.

Clearly, this administration is serious about AIDS, but what can it really do?  We will learn.  I also hope that our speakers today will address a broader issue.  AIDS, like other diseases, is rooted in poverty, poor sanitation, poor education, poor communications, bad roads.  Wealth makes health.  Yes, AIDS is an emergency to which we need to respond, but won't there be others?  And isn't economic and political development the answer to improving health?

Today's schedule will begin with an address by Ambassador Tobias, followed at 1:15 by a panel discussion with five panelists, whom I will introduce later, and then at 1 p.m., we will break for lunch, and at 1:30 hear Secretary Thompson.

Before we start, I just want to thank Dani Pletka, Heather Dresser, Assia Dosseva, Molly McKew, who made this event possible today.

It is hard to imagine a better choice as the first U.S. Global AIDS Coordinator than Randall Tobias, who was sworn into his new job in October.  He is responsible for overseeing all U.S. international HIV/AIDS assistance and coordinating efforts of various agencies and departments of the U.S. government.  He was formerly chairman and CEO of AT&T International, leaving in 1991 to become chairman and CEO of Eli Lilly & Company.

Upon his retirement in 1999, he was named chairman emeritus.  He has received numerous awards for corporate leadership, including being named the Norman Vincent Peale Humanitarian of the Year in 1997, and perhaps most important, he is a former member of the board of trustees of the American Enterprise Institute.

Ambassador Tobias has gracefully agreed to answer questions at the end of his talk.

Ambassador Tobias?

[Applause.]

AMBASSADOR TOBIAS:  Jim, thank you very much.  It's a great pleasure to be here.  As Jim said, nearly a decade ago, in one of my former lives, I was a trustee of AEI, and it is good to be back albeit in a very, very different role.

Thanks to all of you for being here this morning, many of you representing organizations that are fighting in the battle against HIV/AIDS, as advocates or as service providers or as policymakers or as influencers, in one way or another.  Many of you were among the first responders to this crisis, answering and assisting people and communities devastated by HIV/AIDS and generating some of the growing international momentum against this disease.

I stand before you today, as the first United States Global AIDS Coordinator, with the extreme privilege and the awesome responsibility of leading a 5-year, $15-billion effort to combat global AIDS.  The president's plan represents the largest commitment ever by a single nation for any international health initiative.  In fact, there has probably been nothing like this program for any humanitarian purpose, perhaps since the Marshall Plan.

As Jim has told you, late last year, he and I, and my friend and colleague, Secretary Thompson, who will be with you later today, and a number of others visited Africa, for me, the second trip to Africa since I was confirmed in early October.  And, again, as in my trip in October to Africa, I was struck in every country we visited on this trip, this time Zambia, Rwanda, Kenya and Uganda, by the amazing work being carried out in partnerships among communities, nongovernmental organizations, governments and donors.

Regardless of the barriers imposed by stigma, silence, lack of leadership or very limited resources, I saw yet again that results can be achieved in the battle against HIV/AIDS and the new possibilities there are for interventions that have been illuminated.  In part, I believe that President Bush's decision to launch this initiative is a testament to the work of many of the organizations represented here this morning because you brought voice to the devastation of this pandemic, and you have helped to develop strategies to combat the disease.  You've helped to provide armies of women and men serving people and communities in need.

And I know that many of you are very familiar with the statistics on the global devastation of HIV/AIDS, but I think they bear repeating as an affirmation of our commitment and in recognition of the people who suffer the greatest burdens of this disease.

During 2003 alone, 3 million people died from the complications of AIDS, leaving behind anguished loved ones, orphaned children, ravaged communities and an impact that we're only beginning to understand.  At the same time, 5 million people became newly infected, bringing the total to 40 million people infected worldwide.  Do the math.  We are losing the war.  In claiming the lives of society's most productive population, ages 15 to 45, HIV/AIDS threatens a basic principle of development, that each generation should do better than the one before.

This disease has deepened poverty.  It has reduced life expectancy, diverted resources, and left a generation to grow up without the love, and guidance and support of parents and teachers.

This year, however, may bring the hope of a new approach because the global community seems to be coming into alignment to focus on HIV/AIDS as never before, with increasingly every sector--public, private, religious, nongovernmental, multilateral, bringing more and more focus to this fight.  We do need to engage the developed world in making a greater commitment of resources to this effort.

In 2002 and 2003, the United States government's international HIV/AIDS contributions totalled more than those of all other donor governments combined.  And if one assumes that the contributions of other donor governments remain flat in 2004--and I certainly hope they do not--but if they do, then in this current year, U.S. government international contributions to HIV/AIDS will be approximately twice those of the rest of the world's governments combined.

Now, as you may be aware, the budget request for combatting global HIV/AIDS just announced in the president's budget for fiscal year 2005 is another 16 percent above what has just been appropriated for 2004.  So we need more help from the rest of the world, but, nonetheless, increasingly, the world is rallying, and national leaders of the most afflicted nations of the world are admitting that they do, in fact, have an HIV problem in their country and will, in fact, devote more resources to fighting it and generally will welcome the assistance of those who are willing to help.

Lessons have emerged and leaders are beginning to take heed.  We now have proven methodologies for combatting HIV/AIDS, including effective prevention and behavior change strategies that have produced real results, approaches to fighting stigma and discrimination and proven programs that partner government with civil society.

We know that global and, in particular, national leadership is essential, that early and effective action can contain and even roll back epidemics and can reduce the burdens of disease on families, and communities, and nations.

The United States clearly has stepped up to the challenge of global HIV/AIDS with President Bush's emergency plan for AIDS relief.  As the president has stated, "In the face of preventable death and suffering, we have a moral duty to act, and we are acting."

The president's plan brings unprecedented resources to bear against HIV/AIDS, but as importantly, I think, the plan's implementation will not be business as usual.  Coordination, innovation, results-oriented implementation and a focus on achieving some very real goals in the area of prevention, care and treatment, are all hallmarks of the president's plan and the intent of the United States Congress.

The president's 5-year initiative targets $9 billion in new funding to 14, soon to be 15, countries in Africa, the Caribbean and elsewhere, countries representing over 50 percent of the world's population living with HIV/AIDS.  The president has identified the ambitious goals of providing treatment to at least 2 million HIV-positive individuals in this 5-year period, preventing 7 million new HIV infections and providing care for 10 million people, those living with HIV/AIDS, and orphans and vulnerable children who have been directly impacted by the disease.

The plan provides $5 billion to continue our bilateral assistance in early 75 countries worldwide, and it also includes $1 billion in contributions to the Global Fund, bringing total U.S. contributions to the Global Fund to nearly $2 billion through 2008, more than a third of all pledges to the Global Fund to date.

Now, while the plan has a particular focus on turning the tide in some of the most highly impacted countries in the world, we recognize that no country in which we currently support HIV/AIDS' activities is unaffected by the problem, and some of the countries clearly face emerging epidemics of spectacular proportions.

The president's plan offers a fresh opportunity to harmonize HIV policy and management across all of our bilateral programs to create momentum that will truly begin to turn the tide against HIV/AIDS, as well as to provide leadership and other kinds of support to the rest of the world.

The plan begins in fiscal year 2004 with $2.4 billion in funding, rising to $2.8 billion in the 2005 budget request and steadily increasing to reach the total of $15 billion over the 5 years, exactly what the president committed in his 2003 State of the Union address a little more than one year ago.  And I might add that these annual budget requests in the start-up years have been a source of contention in ways that I think are very unfair to the president.  Some have done the simple division of dividing $15 billion by 5 years, and  have assumed the president had committed to $3 billion in each of the 5 years, and then criticized him for making a commitment that he has never made.

The president committed $15 billion over 5 years, to be deployed in a way that increases expenditures over time in order to spend the money as efficiently and as effectively as we know how, and that is exactly what we believe we are on course to do.  We know that we are embarking on an effort unprecedented by any other nation with a mission of turning the tide.  We also know that we are taking a focused health care approach that will, in fact, require working with target countries to develop necessary human and technical infrastructure to use these funds in efficient and innovative ways.

In the four months that I have held this position,  I am pleased to report that I believe we have made good progress in laying the foundation to achieve the goal of the president and the Congress to bring prevention, treatment and care to millions of adults and children who are courageously living with HIV/AIDS and to do that in a way that will replace despair with hope.

On January 22nd, the Senate passed the appropriations bill that provided the initial funding for this program.  On January 22th, we sent forward congressional notification that we are now ready to deploy more than $350 million from the emergency plan, through mechanisms that we have been aggressively putting in place in anticipation of this appropriation, mechanisms that will allow for the rapid expansion of existing effective, accountable and sustainable prevention, care and treatment programs that are already on the ground and can be scaled up rapidly.

Now, the programs that we are initially funding are in five target areas: HIV/AIDS prevention through abstinence and behavior change for youth; antiretroviral therapy programs for HIV-infected persons; safe national blood transfusion programs; programs for orphans and vulnerable children; and programs to reduce the transmission of HIV/AIDS by unsafe medical practices, including, particular, the promotion of safe medical injection practices.

But these five program areas are only to get us started.  At the same time, we are putting in place our plans for longer term and more diversified programs that will involve both current partners and, hopefully, a large number of new partners.

As we do that, I think we need to keep in mind what Albert Einstein once said, and that is, "Stupidity is doing the same thing over and over again and somehow expecting that the results will be different."  I think that applies here.  To do this job effectively, in some cases, we need some new paradigms.  The battle against HIV/AIDS has historically been fought with only the weapon of prevention, and the numbers clearly tell us not very effectively at that.

The integration of prevention, treatment and care, one of the fundamental principles of this overall plan, represents one of our one paradigms.  This comprehensive and unparalleled approach is essential if we are to be effective.  This is a disease that is 100-percent preventable.  So prevention, in the long term, has to be the chief weapon in the spread of HIV, and it's got to be our number one priority.  And testing, knowing one's status and what to do about it, is one of the keys to prevention.

Tragically, very tragically I think, most of the 40 million people worldwide who are infected with HIV do not know it.  Far too few people are being tested, and this is an issue that must be addressed and must be changed urgently.  Because, without knowing their status, people can neither protect themselves nor others from the ravages of this disease.

Stigma, denial and fear, however remain enormous barriers to testing.  Discovering one's status, in many places, is thought to be just the beginning of living with stigma and abandonment and a certain sentence of death.  Thus, prevention is not the only answer.  The provision of life-saving antiretroviral treatment can provide hope and the incentive for people to be tested and to learn their HIV status, and that, in turn, can contribute to prevention efforts.

Thus, where there used to be a prevention versus treatment debate, I think, today, few dispute that these are not either/or issues.  We need to do it all.  There are no bright lines between prevention, and treatment, and care because they all contribute and all are interconnected in achieving the results against HIV/AIDS.

Another new paradigm is our focus on evidence-based, results-oriented approaches to prevention, treatment and care.  We need to take a fresh look at the evidence-based results, at what has worked and what has not, and we need to do that in the variety of countries, and communities, and populations that will be served by this program.

One of the distinctions of the president's plan is its promotion of abstinence, being faithful and the use of condoms, but that is not a multiple-choice strategy.  Research indicates that the ABC approach, as it is known, when it's correctly understood and implemented, is a powerful tool against the spread of HIV.

The ABC approach was pioneered with success in Uganda, and recently, on this most recent trip, I had the opportunity to see the program at work in a primary school in Uganda outside Kampala.  It is a straightforward, relatively inexpensive and enormously effective program.  And the message that they use in their primary schools has three components: be abstinent until marriage, don't associate with people who will harm you or who will try to convince you to do the wrong things, and be a strong person and stick to what you know will keep you safe and healthy.

Each and every one of the interventions selected for rapid scale-up in the first phase of our plan is a proven approach that has borne results against HIV/AIDS.  And while we will actively pursue innovation, these innovations too will be subject to rigorous review to ensure their effectiveness.

We have been granted in this program the decisionmaking control and flexibility to leave no stone unturned in our fight against HIV/AIDS, but we will be guided by evidence and by our experience gained over two decades of fighting HIV/AIDS internationally in order to make progress against these goals that have been established.

Finally, we have brought a new paradigm to how we organize to attack this issue.  I have asked all of the departments and agencies to leave their uniforms at the door, to come together into a single United States government team.

I have asked the ambassador in each focus country to take responsibility for pulling together all of the resources of our government in the development of an integrated plan to implement the president's initiative in that country and to provide leadership to all elements of the United States government on the ground in that country in making it happen.

Our activities in this area will now be U.S. government programs, drawing on the strengths, and the capabilities, and the experience, and the knowledge, and the know-how, and the processes, and the procedures and the infrastructure of individuals and organizations in whatever way makes the most sense as we proceed.  And while the policy decisions and the strategic direction will be my responsibility here, I am mindful of the statement by the late Tip O'Neil that "all politics is local" applies equally I think to public health.

The battle against HIV/AIDS will, in the end, be won or lost in the small places, places so small that in many cases we won't even find them on a map of the world.  I feel very strongly, from my experience in the private sector, that the implementation of our programs must be field-driven such that people on the scene can be responsive to  the specific circumstances and the available human and material resources in each country and that they can leverage the innovation of field staff, and communities and others to join the fight against AIDS.

We are well along in this process, and I am very pleased with the work that is underway in almost all of these countries, with the attitudes of the people involved in putting our efforts together and the extraordinary energy and dedication that people are exhibiting.

A second aspect of how we organize to attack this issue is coordination with all of the other organizations who are making vital contributions to the fight against global HIV/AIDS.  The crisis of global AIDS is greater than any one agent can solve.  Turning the tide will require a sustained, collaborative effort from a multitude of international, national and local organizations in the public sector and the private sector, leveraging their comparative strengths together.

Not only are there extraordinary resource needs, but the diverse drivers and consequences of the disease and its many complicated interactions with a variety of other social, political and economic circumstances demand an equal number of diverse actors with various expertise.

The president's emergency plan focuses unprecedented resources on achieving targeted goals within prevention, treatment and care and doing that by strengthening the capacity and infrastructure of health care systems to respond.  But what the president's plan is focused on doing is not enough.  It is not the whole picture.  While we maintain our focus on the task at hand, we need to coordinate with multilateral institutions, other donors, other parts of the United States government, and international organizations  working with great dedication to combat HIV/AIDS so that we can build a comprehensive and amplified response to global AIDS.

As but one example, this is not a food program, but it does no good to put someone on antiretroviral therapy if, at the same time, they are starving.  And so we need to coordinate this efforts of this health care program very closely with donors and others who are providing other very needed components and elements in the broader fight against HIV/AIDS.

An example of our efforts here is our support of the Global Fund to fight AIDS, tuberculosis and malaria.  As many of you know, the United States led the creation of the Global Fund and was its first contributor.  The United States leads the world in donations to the fund, accounting for 37.4 percent of total pledges and 31.1 percent of contributions to the fund to date.

The Global Fund, with its unique partnership structure, has the potential to achieve great results against HIV/AIDS, and we are committed to the fulfillment of this vision and to the fund's full potential.  As many of you know, Secretary Thompson is currently chairman of the board of the Global Fund.  And through his extraordinary commitment to this issue--a very personal and very dedicated commitment, as I'm sure you will detect when he speaks to you--on behalf of the United States, he is giving special leadership to the fund that I think is very important in its formative stages.

There is no doubt that HIV/AIDS represents one of the greatest challenges of our time.  Experts predict that, without intervention, 100 million people could lose their lives to AIDS by the year 2020.  I have witnessed, however, the amazing work being carried out in partnerships among communities, nongovernmental organizations, to private-sector governments and donors.

Regardless of the barriers imposed by stigma, and silence, and lack of leadership or very limited resources, I am convinced that our efforts will result in real gains in the fight against HIV/AIDS, a fight in which every battle won is measured in lives saved, families held intact, nations moving forward with development, and the future secure.

Now, I am an optimist.  It is  my very nature, and so I want to leave you today with a story that I think is very much a story of hope.  On my most recent trip to Africa, along with Jim, I visited a tiny farm settlement in Uganda, just outside a small town called Tororo.  There, the Centers for Disease Control, under the Department of Health and Human Services, is partnering with TASO, a community-based support organization of persons living with AIDS, providing in this program for patients who have AIDS safe water, an antibiotic to prevent opportunistic infections and, very importantly, antiretroviral drug therapy.

While I was there, I visited two of those patients and their families in their homes--mud structures with straw roofs and dirt floors.  Community health workers who are part of this program visit each patient weekly on small motorcycles to monitor their condition, their adherence to therapy regimen, and to deliver their supply of medications.

Their progress in this program since beginning treatment is quite amazing, and their adherence to the therapy regimen is nearly 95 percent which, by the way, is much higher than our experience here in the United States.

Now, some have opined that ARV treatment is too complex to try to administer in these kinds of environments.  I believe those people are mistaken.  What's been reassuringly demonstrated by this project, and others, is the ability of these community health workers who are not health care professionals, but people who have been trained to do a segment of what needs to be done here.  They have demonstrated their ability to impart very complicated information to people who are living with no electricity, no water, no transportation, in very primitive environments.

One of the patients I visited, a man named John, is HIV-positive and on the antiretroviral therapy program.  His wife, also HIV-positive, is not.  When I asked John, through the translator, if there was any conflict in the family, any temptation because he had access to these lifesaving medicines and his wife did not, was there any temptation to share his medication with her, through the interpreter, after he understood what I was asking, he said, no, it was not an issue, and the reason was because his CD-4 cell count was 162, and he needed the medicine now, but his wife's CD-4 cell count was 312, and so she didn't need the medicine now.  But he said that they understood that when her CD-4 cell count dropped below the threshold of 200, she too would be put on the program.

Understanding can be conveyed, and ARV therapy can be effectively administered in some very primitive places.  It's going to take innovative approaches, it's going to take dedication, it's going to take patience, but it can be done, and so can care and so can prevention.

So, with our support and leadership, people like John, and his wife, and their children will be able to continue to do what they are doing--working, parenting and contributing--and the future has the possibilities of again appearing on a horizon where we can bring what's probably more important in all of this than anything else, and that is hope.

Thank you very much.

[Applause.]

MR. GLASSMAN:  Thank you very much, Ambassador Tobias.  I think all of us who were there in Tororo, and I know there are a few here in the audience, were tremendously moved by what we saw and encouraged.

We have time for some questions from the floor.  So, please, ask your questions.

Yes, wait for the microphone, which is right behind you, and identify yourself.

QUESTION:  Thank you, Ambassador.  My name is Garrett Reese.  I'm working at the South African Embassy here in Washington.

My question, Ambassador, is mainly around the provision of antiretrovirals, in terms of the emergency plan.  I would appreciate hearing a little bit more, some more information on the provision and sourcing of the medication, the drugs and so on, how that will be done, will that include generics, will it be done primarily through companies in the countries that you are focusing on or where will they be sourced from?

AMBASSADOR TOBIAS:  Well, we are still sorting through some of that, but let me try to address some of the questions that do come up most often.

Often the questions are asked about this in terms of generics or products from branded research-based companies.  I don't think that's the right question because what we're going to do is to provide financial support for the purchase of pharmaceutical products that meet the technical standards of safety and efficacy and that we can get at the lowest possible price.

Now, we have some work underway to bring the Food and Drug Administration and the regulatory bodies of your country and other countries together coming up I think it's either in March or early April, to come together to figure out how do we put some standards together around this so that the products that are being purchased do, in fact, meet an accepted standard of safety and efficacy.

For those of you who know something about this drug therapy, it is easy for very well-intentioned people, doing what they believe to be the right thing to do, to end up doing more harm than good.  If you start people on drugs that turn out not to have the kind of consistency that is needed, then you can end up building resistance to the drugs, you can end up creating circumstances where the resistance will cause the virus in someone's body to actually mutate.  If that person then spreads HIV/AIDS to another person, they can spread a version that is going to exacerbate the problem and so forth.

So we need to be careful and thoughtful, but aggressive and get moving, in what we're going to do here.  But there's certainly no political agendas behind what we do and how we do it.  In the meantime, the good news is the prices have come down across the board, as you know, very, very dramatically, and some deals have been struck, and arrangements have been made, and contributions by a number of companies have been announced, and so I think there's a real possibility that the issue of price affordability is going to become less of an issue and the issues of availability and quantities, I hope, will become an issue that we need to be addressing and that the industry all across the board and all around the world will need to be addressing.

MR. GLASSMAN:  Other questions?

QUESTION:  Jack Calfee, AEI.

The answer that you just gave, would that apply to new drugs, new vaccines that have not yet been developed?  If a manufacturer were to develop an AIDS vaccine that's suitable for Africa or Asia, but not for the U.S., a different variant of HIV, would they expect you to buy that vaccine from generic producers or would they be able to sell--

AMBASSADOR TOBIAS:  I'm sorry?

QUESTION:  Would the developer expect you to buy their vaccine from generic producers or would you buy it from them?

AMBASSADOR TOBIAS:  Well, first of all, my ardent hope is there will be some to buy and that we can really make genuine progress in the vaccine area, but if that happens, it's not going to be an issue of where we can get it.  If we can get effective, safe products that are going to work, we're going to buy them.  And if there are choices to make, we will buy the effective, safe products that we can buy at the lowest costs at which we can buy them.

QUESTION:  That seems to take the profit out of developing a new vaccine.

AMBASSADOR TOBIAS:  Well, that's the other problem in this because we need to be very careful, and I know a lot of people, this isn't something that's specifically in my area of responsibility, but I know enough about the incentives here to just worry that 10 years from now we're all going to wake up and discover that we won the battle and lost the war because somehow we need to be taking a long-term look at this, also, to ensure that either  the private sector or combinations of the public and private sector or, in some fashion, that investments are getting made today in the research that will bring the products out tomorrow.  And the life cycle of all of this is so long that it may not be readily apparent if that stops happening, if people aren't paying attention until it's too late.

There are a number of companies that are very committed to this.  NIH and others are very committed, but it is an issue that we need to be worrying about over the long term.

QUESTION:  If you promise to buy from the manufacturer--

AMBASSADOR TOBIAS:  I probably have given you your limit.

QUESTION:  Okay.  Thank you.

MR. GLASSMAN:  We'll take one more question over here.

QUESTION:  Jim Driscoll, with National AIDS Treatment Advocacy Project.

Are you considering expanding the number of PEPFAR countries from 15 to include countries to Eastern Europe and Asia?

AMBASSADOR TOBIAS:  Well, let me define what I believe the PEPFAR countries are because I believe the PEPFAR countries are the world.  The president did not name me the 14-country AIDS coordinator.  The president named me the United States Global AIDS Coordinator.  In the PEPFAR program--the President's Emergency Plan for AIDS Relief--I would divide into three geographic groupings.

There are 14 focus countries for which there's been a considerable amount of new money appropriated by the Congress to address those countries.  Those countries are in Africa and the Caribbean, and they account for, just in those 14 countries, 50 percent or so of the total AIDS infections in the world.

There's a second category of countries for which about $5 billion is earmarked over this 5-year period that represents 75 countries, where the United States government today is engaged in some kind of bilateral programming.

And then there is the rest of the world.  Now, there are things we can do in the rest of the world--and are--to make a difference, without necessarily spending a lot of money.  For example, there are places where we are working with the host government, at their request, to help them develop a strategy, to help them develop a plan, and to help them attract other sources of donors who can help, but getting strong political leadership to step up is an important starting point.

The Congress has mandated, in the appropriations legislation that was just passed, that the administration select a 15th focus country, and the criteria is that the 15th focus country must be somewhere in the world other than the Caribbean or Africa.  So there will be a 15th country that we will add to this category, but we're going to pay a lot of attention to the total of the 75 countries where we have bilateral programs because some of those represent the emerging, huge problems of tomorrow and, in some cases, tomorrow is upon us.

By the same token, if we get so spread out and so thin on this, we'll be 10,000 miles wide and an inch deep, and maybe we'll feel good, but we won't make the impact that I think we can make if we stay focused on the things that we decide to focus on.  But we've got to figure out how we're really going to make an impact on all of this, and that's our intent.

MR. GLASSMAN:  Thank you, again, Ambassador.

[Applause.]

MR. GLASSMAN:  Could the panelists come up.  We're not going to take a break, but will everyone who is--I think there are a lot of people over here, and you can see on the screen there, but you can actually see the live action if you move up to this table that says it's reserved is now no longer reserved.  So people in the back move up, and you'll get a better view.  Also, we don't like having an empty table to talk to.  So please come over.  Good.  Thanks for moving up, everyone--more comfortable.  Everyone comfortable?

Let me introduce the panelists.  I'll introduce them in alphabetical order, but they're going in slightly different order.

Roger Bate is--because they're in alphabetical order around here--Roger Bate is a visiting fellow at the American Enterprise Institute, and before that he was director of the International Policy Network, from 2001 to 2003, and director of the Environmental Unit of the Institute of Economic Affairs.   He is the author of several books.  He concentrates on water policy in developing countries, diseases in developing countries, especially AIDS and malaria.  He's the author of malaria and the DDT story, and I'm very happy to say he's a regular contributor to Tech Central Station.

Next to him is Nick Eberstadt, who holds the Henry Wendt Chair in Political Economy at AEI.  For many years, he served as a member of the Harvard Center for Population Development Studies, and he is currently a member of the visiting committee for the Harvard School of Public Health.  He has written many books, including, "Poverty in China," "Foreign Aid and the American Purpose," and most recently, with Sally Satel, "Health and the Income Inequality Hypothesis."

David Gordon is the director of the Office of Transnational Issues at the Central Intelligence Agency.  He joined the CIA in May 1998, when he was appointed national intelligence officer for economic and global issues on the National Intelligence Council.  He is also an adjunct professor at the School of Foreign Service at Georgetown.

Marwyn Samuels is the co-founder and chairman of the U.S.-China AIDS Foundation, a not-for-profit foundation dedicated to the prevention of HIV and sexually transmitted diseases in China, through programs of public awareness, education and training.

And Jeffrey Sturchio is vice president for External Affairs and Human Health in Europe, the Middle East and Africa at Merck and Company.  He has been deeply involved in Merck's participation in the accelerating access initiative and industry- UNAIDS partnership to help improve HIV/AIDS care and treatment in the developing world.  He's also a member of the private-sector delegation on the board of the Global Fund to fight AIDS, tuberculosis and malaria.

Each of the panelists will speak for about 10 minutes or so, and then we will have questions from the floor.  First, David Gordon; second, Roger Bate; third, Nick Eberstadt; fourth, Marwyn Samuels; and, fifth, Jeffrey Sturchio.

David Gordon?

MR. GORDON:  Thanks very much, Jim.  It's a great pleasure to be here today.  I want to talk about the outlook for the evolution of the HIV/AIDS pandemic, in particular, some additional comments to the most recent paper done by the intelligence community which was produced just before the book--

[Tape change: T-1A to T-1B.]

MR. GORDON:  --classified.  After being briefed with our president and Secretary Thompson, they asked us to produce a declassified version.  It's on the next wave of HIV/AIDS and talks about the spread of the pandemic into five populace countries: Nigeria, Ethiopia, in Africa, and then Russia, India and China.

This study was the latest in nearly 20 years of studies that we've done on HIV/AIDS at the CIA, and I want to particularly thank my colleague, Nick Eberstadt, whose engagement with us has benefitted us very greatly in understanding these issues.

In our paper, we argued that the number of people infected with HIV/AIDS threatened to grow significantly by the end of this decade and that a significant portion of that increase would be driven by the spread of the disease in those five populace countries.

Indeed, we estimated that the number of people with HIV/AIDS in those countries might grow from around 14 to 21 or 23 million as of 2002--the numbers are very dicey here--to as many as 50 million or more by the end of this decade, far surpassing the numbers of AIDS-infected people expected in Central and Southern Africa, the current geographic focal point of the disease.

So the main hypothesis was that AIDS was going to spread dramatically from its geographic base in Central and Southern Africa to other parts of Africa, including the two most populace countries in Africa--Nigeria and Ethiopia--and indeed to the Eurasian land mass, including significantly in Russia, China and India.

So a year-and-a-half on, where are we?  Where do we see things going?  I think that the analysis has basically held up pretty well.  I think we are in the early stages of looking at this.  As a warning issue, which is how we saw our paper, I think the central message has clearly gotten a lot of resonance.  A year-and-a-half ago, I think this was a fairly novel argument that so soon we would have this dramatic geographic spread of the concentration of the disease.  I think, increasingly, analysts and governments in those affected countries, and in the international AIDS community are accepting that there is a very large problem there and that the problem is getting worse.

Let me caveat this a little bit.  As some of you know, some of the latest HIV estimates from UNAIDS are somewhat lower than previously announced.  That's a good news story, basically, where you have the demographic and health survey in Kenya, in particular, which is a very sophisticated survey, has come in with a number that's around 20- or 30-percent, I believe, lower than our prior estimates.

That's basically a good news story.  It doesn't suggest that AIDS is really diminishing.  It was so large a challenge that it's not going to come down in the hierarchy of challenges faced by the most affected countries in sub-Saharan Africa, certainly, but I think any news is good news here.

There's some suggestion in the data that prevalence in Ethiopia may be somewhat lower than previously estimated, although that's probably more an estimation error, rather than a decline in actual numbers.  And the reported numbers in Russia  in the last two years has also declined, and it's unclear what's going on here.  Some believe that the percentage of intravenous drug users infected may be reaching a saturation point, and the new infections in the general population, hitherto low-risk groups, may not yet be detected.

That said, I think the main story holds, that as we look out towards the end of this decade, the looming growth of the pandemic will be substantially in these five large-population countries.

Let me go through a little bit about where things are going, in terms of leadership and response, in each of the countries.  I think there have been some surprises here.  Certainly, in China, senior Chinese leaders have responded faster than we expected.  The Chinese president has publicly acknowledged the AIDS challenge facing the country.  He met an infected person on television recently, and that has moved very, very, very dramatically.

I think that the AIDS issue is going to be a fascinating window into the larger issue of change in China, social change, political change in China.  And whether or not--clearly, I think there's a recognition of the problem--whether China will be able to grapple with this will depend upon whether it will allow the openness and accountability that has so far been so dramatically lacking in their political system.  So I think that the AIDS issue in China will offer both important lessons in its own right, but also be a window on a larger process of change in the most populace country in the world.

In Russia, on the other hand, the government reaction was even slower than we anticipated.  President Putin hardly ever mentions HIV/AIDS.  He's been satisfied to leave the issue basically in the hands of a deputy health minister, and not much is happening in Russia, in terms of establishing this as any kind of a national priority.

India's reaction has been mixed.  We got a lot of criticism to our projections.  Even Bill Gates' offer of $200 million to contribute to fighting AIDS in India was criticized by senior Indian government officials as hyping up the threat.  Yet, at the same time, if you look at what's happening on the ground in India, there's been a very significant ramping-up of AIDS programs.  And the good news about India is, of all of the five large population countries, it's the best positioned in terms of health infrastructure to make an effective response to the disease, and there is some good evidence that that may be happening.

Nigeria is a complicated issue as is almost everything in Nigeria.  President Obasanjo has spoken up more frequently about HIV/AIDS.  There is a civil society movement taking hold in Nigeria.  I'm troubled, I'm troubled by the difficulty Nigeria is having facing other health challenges and, in particular, for political reasons, this summer the Nigerian government suspended the oral polio vaccination program in the Northern states of Kano, Kaduna, and Zamfara, which I think raises some very, very serious doubts about the government's ability to make progress on what will be a much more significant challenge with addressing HIV/AIDS.  Eradicating polio is a relatively simple process, when compared to HIV/AIDS.  So Nigeria, hard to say.

Ethiopia, I think we also see a substantially more active role by the government.  President Meles has clearly increased the level of effort that he devotes to speaking about HIV/AIDS.  In October, the government inaugurated a pharmaceutical plant to produce antiretroviral medications and announced a plan to provide free medication to low-income AIDS sufferers.  They have also substantially increased the numbers of sentinel surveillance sites.  So I think it's a pretty good story from Ethiopia.

Of course, the major difference between the situation now and the summer of 2002, as Ambassador Tobias highlighted, is that the international response in that time period has really been much, much stronger than expected, especially by the United States government, but also by the private foundations, the Global Fund and beginning, and hopefully increasing, in other key bilateral donor countries.

The risk here--and there is a risk--is that the more that outside groups do and give, the greater the risk that some countries will not take leadership, and ownership, and provide their own resources and support.  This is historically been an issue in foreign aid.   Nick has talked about this in his writings--the ownership challenge.  And I think particularly for these large countries, the fact of the matter is that, in large countries--India, China, Russia--that absent domestic commitment, resources and leadership, that the international community, in and of itself, will not be able to make a major impact on what happens to the future of the pandemic.

Let me talk a little bit about some of the trends that we are looking at.  The first are security transitions.  The good news is that there are a number of peace transitions occurring in sub-Saharan Africa after long periods of war.  The downside to that is, as we highlighted was true for the case of Ethiopia, there is a risk that, in the process of demobilization, both soldiers and prostitutes who had been following the soldiers, where infection rates tend to be high, take that into other areas of the country, into the rural areas, the villages in particular.

That's what we saw in Ethiopia in the 1990s.  Early evidence from Angola suggested that process may be going on there.  There is a risk of that in the Sudan, in Liberia, and elsewhere.  So the dangers for HIV/AIDS posed by peace processes, obviously, the answer isn't stop making peace, but it is to identify the need to address HIV/AIDS issues as an important transition issue in conflict resolution.

Socioeconomic transitions elsewhere in the world.  Clearly, in China, while the initial spread of the disease was related to blood donation practices and to drug use and drug trafficking in the regions down near the Southeast Asia border, changes in culture and sexual norms are very, very important.

The entire Asia-Pacific region traditionally has had the lowest rate of sexually transmitted diseases of any region in the world.  And a generation ago, premarital sex was almost unheard of in China, while today it's a constant reality in China's cities, with booming populations that are scheduled to increase dramatically.

Similar forces are likely to be responsible for the increase in HIV in Indonesia, as well.  Russia, I think that in Russia, the rest of the former Soviet Union, a lot of these countries have been going through economic upheaval, major structural changes.  These have left literally millions of people unsure about their income streams, unsure about their belief systems.  Many have found solace in drugs.  Others have turned to prostitution, both of which have been very heavily correlated with the spread of HIV/AIDS.

As we look out, as we in the intelligence community look out, we're shifting our focus from warning about what could happen with HIV/AIDS to looking at the impact of the disease and the effectiveness of the response.  And I must say that we are having, it's a very challenging time to look at the social, political, economic and military impact of HIV/AIDS.  Many of us--myself included--have been warning for years about the potential disruptive impact of HIV/AIDS across a wide spectrum of issues, but actually measuring this impact has been a large challenge for us.

On economics, I think a lot of studies show a significant economic impact at the individual level, the household level, the community level.  A growing body of work is helping to illustrate the costs of HIV/AIDS for businesses.  But it's been very difficult to assess the macroeconomic impact and where that may be heading.

For the military, a lot of us have been warning about high HIV prevalence rates in African militaries.  It would seem to be clear that this poses a major challenge for military manpower and military readiness, but again it's very hard to forecast the specifics of what that means.

If HIV/AIDS undermines military manpower capabilities in Africa, does that mean that some peacekeeping missions could be left wanting, leaving the door open for continued violence and instability, or is there a possibility that weakened militaries will be less likely to participate in regional wars as  a result of HIV/AIDS?  It's really very hard to derive very, very firm answers for this.

I've gone on beyond my time.  I just wanted to give some flavor of where we see things going and what we're doing.  Any of you who are interested in looking at "The Next Wave" paper can just go on the CIA website, scroll to the National Intelligence Council, and find the piece there.  I think you'll find it interesting.

MR. GLASSMAN:  Thank you, David.  Let me ask you a quick national security issue.  When we were in Africa, we were told that one of the worries is orphans.

MR. GORDON:  Yes.

MR. GLASSMAN:  That there are 14 million orphans or prospective orphans, and that they would become kind of the "shock troops" of armies that could be very disruptive.

MR. GORDON:  Jim, I didn't read my talking points here.  I was over my time.  I left out the orphans talking point.   You caught me.  Clearly, clearly, orphans are a substantial problem.  I think, again, the pressure put on communities as a result of this has been enormous.  I think we do have evidence, in places like Nairobi, that street crime has been increased partially as a result of this.

This is an enormous social challenge, and I think it is certainly a question--there's no question in my mind that the social impact of HIV/AIDS is a major national security challenge for the most affected countries in Africa.

MR. GLASSMAN:  Thank you, David.

Roger Bate?

MR. BATE:  Good morning, ladies and gentlemen, and thank you very much, Jim.

While prevention remains the main method for controlling the spread of HIV/AIDS, I'm going to confine my remarks this morning to treatment and, in particular, Africa.  And I'll probably look at two aspects in particular: the incentive for future drug research and the competence of the multilateral agencies charged with purchasing drugs for Africa.

Poverty remains defines most of the diseases in Africa.  This is a picture of malaria transmission on the left.  The darkest areas are annual transmission every month, and the pinker areas are just one to six months.  They correlate pretty much perfectly with the lighter areas on the right side, which are GDP figures for Africa.  The darker areas on the right show greater wealth.

AIDS is slightly different in that, as the next chart shows, the pinker areas and the orange areas are the situations where AIDS is the most severe, but on the whole, poverty still drives this disease because, without education about methods of prevention, without hospitals with electricity, trained medical staff, appropriate devices, diagnostic techniques, et cetera, a complex and virulent disease like AIDS has a far easier time in a poor country than in a rich one.

The fact that AIDS affects wealthier people, though, is the main reason we actually have drugs to combat the disease.  There are drugs to combat diseases like malaria, and yellow fever, and dengue fever, but there are very few of them compared to the number of drugs which have been developed for AIDS, and that's primarily because AIDS affects people or has affected people significantly in the West.

The average health budget in African countries is about $10 per person per year, as opposed to $3,000 per person per year in the United States.  Botswana and South Africa, as you can see on the bottom of the map in the South, are significantly higher than that.  They're in the $150 to $200 range, but still very, very low.

Since 1987, the Food and Drug Administration has approved 80 drugs to combat HIV and the opportunistic infections that thrive in its presence.  According to one study, each antiretroviral drug has reduced the number of U.S. deaths from AIDS by about 6,000, lowering from a high of about 50,000 deaths a year in 1995, down to less than 20,000 last year.

Most of the drugs are patented to West, and mainly American, drug companies, and there has been considerable legitimate widespread price discrimination across the planet, so that the prices charged in this country are considerably higher than elsewhere.  But given how expensive HIV antiretroviral and other opportunistic infection drugs are, it's not just those in the poorest countries that are affected or unable to purchase them, and we are seeing, if you look in Africa, you see this massive discontinuity between the dotted line right at the bottom, which is deaths in the United States, as opposed to sub-Saharan Africa, which has, as you can see, exponentially increased.

This has led to what is a widespread, but paradoxical, view of the pharmaceutical industry.  They provide lifesaving medicines, but then they price them out of the reach of all but the richest.  I think that this cartoon nicely demonstrates how people see big pharma.  The men and women in white coats developing fabulous AIDS drugs, and next door you have the besuited, bespectacled lawyers working for these countries who are in charge of the "mass murder" section, making sure that patents are enforced and people don't get the drugs.

Patents and prices do have a part to play, especially in countries outside of Africa.  I'm not talking about countries outside of Africa today, but we can discuss that if there any questions.  But as was ably demonstrated in an article in the 2001 Journal of the American Medical Association, patent protection is a minor reason for lack of treatment in Africa.

In fact, as you can see from this map, if you look at South Africa at the bottom, of the 15 antiretroviral drugs available in 2001, 13 of them were patented in South Africa, 8 in Zimbabwe, and in every single other country, it is less than half.  The modal number here is 1 or 2.  Namibia, Angola, Ethiopia, Eritrea, Libya, Algeria, Cape Verde, Guinea-Bissau, Mozambique, Mauritius had none patented at all.

So, as I said, pricing is an issue, and it's more of a component in other countries, but in Africa, it is a lack of political will, lack of infrastructure, lack of medical facilities, et cetera, is the reason why drugs aren't getting to people.

But the impact of the concern about prices, the downward pressure on pricing, although certainly welcome because it means more people are being treated and the onward going threats of compulsory licensing, patent attenuation in countries like Argentina, Brazil and also threats from South Africa have certainly reduced the incentives for continued HIV research in the private sector.

Couple these threats with the reducing number of cases in the wealthy countries--those people who can afford to buy the drugs--and you see a significant reduction in incentive.  Now, most of those reductions have come from improved prevention in the United States and Europe and also previous medical breakthroughs.  It's, therefore, as I would argue, not surprising there's been a drop-off in research effort.

This chart is drawn from data from the drug industry association, PhRMA, and it looks at HIV and opportunistic infections.  The pink line shows AIDS medicines and vaccines in development, the yellow line shows the number of companies that are working on those medicines and vaccines, and the blue line shows those medicines which have been approved by the Food and Drug Administration.

The first thing that needs to be said is this is an extremely healthy picture.  The fact that there are so many drugs out there, and the fact there are so many countries interested is very good news, but there is undoubtedly a drop-off in research effort.

Now, I have been criticized, when I put this chart up before, for the experts have explained to me that there should be volatility in the pink line because, as we learn more about the disease, we learn more about the compounds, you would expect to see some drugs just dropping off, people saying we're not going to take these any further.  We're going to look and see what is going to work or we're more likely to know what will work in clinical trials.  Therefore, you would expect some volatility there.

What I would argue is more worrying is the yellow line.  The yellow line shows, in the last six years, a 27-percent reduction in the number of companies working in ALVs and opportunistic infections related to AIDS.  It's not the players like Merck, who--and no doubt we'll hear from Jeffrey Sturchio in a minute--that are doing less research.  In fact, they're probably spending even more money than they have in the past.  It's at the margins, it's the biotech companies, it's the start-ups, it's the smaller firms that are quietly walking away from doing AIDS research.

Put yourself in their shoes.  Ask yourself this question: If you're the head of a small biotech company or, more importantly, it's venture capital backers, where would you invest your money?  High-potential research?  Erectile dysfunction?  Cancer?  Baldness?  These are areas where you are likely be able to recoup money.  Why would you spend any money on AIDS research?  Your scientists might end up winning a Nobel Prize if you develop a vaccine.  But as the venture capital backer of this firm, do you really want to spend money on a disease that, although it's unbelievably important, possible the worst pandemic ever, are you going to be able to recoup costs or even make a profit?

The reason why new drug development is so important, as has been already mentioned so far today, is because of the problem of drug resistance.  Like the ever-mobile, but ultimately static red queen in "Alice in Wonderland," it's basically we need to run to stand still.  New breakthroughs are absolutely essential.  The fewer companies working on drugs and vaccines, the greater likelihood that resistant strains of diseases will take hold.

In the West, we're seeing increasing amounts of methicillin-resistant staphylococcus aureus; in numerous hospitals, we're seeing resistant TB; and in many parts of the world, we're seeing resistant malaria to numerous antimalarials, and it probably will happen with AIDS, and it undoubtedly is in some instances.

So, for the last part of my talk, I want to talk about drug resistance in the policy sphere and discuss some of the latest concerns about U.S. funding of AIDS treatment.  But before I get there, because I'm sure there are not that many people in this room who have actually been exposed to drug resistance, I have got here a record book of a patient in a clinic in Lusaka--or it's about 30 miles of Lusaka--in Zambia, and I'm just going to take you through this very quickly.

On the 11th of June, a patient comes in, a gentleman comes in complaining of symptoms which look like they're malaria.  The doctor diagnoses malaria.  He prescribes Fansidar, which is the brand name of sulfadoxine-pyrimethamine, which is a widely used antimalarial.  The patient is treated, he goes home, and everything is okay.  But two-and--a-half months later, on the 30th of August, the patient is back.  It's a new case of malaria, and Fansidar is once again prescribed.

Unfortunately, 11 days later, he's back again.  He's still got malaria.  It's almost certainly the same type of malaria, the same case of malaria, and the doctor once again realizes it is malaria, but prescribes Fansidar again.

Now, you might wonder why the doctor is prescribing a drug that has not worked.  Often, the instance or the reason is because he has got nothing else to give the patient, and it might work again, it might not.  This kind of thing happens every day, thousands of times every day in Africa.  It happens in other parts of the world, too, but in Africa it's the worst.

What it means is that the doctor, the patient, the clinical staff, everybody in that hospital is wasting their time.  Worse than that, this patient is still ill.  And given the region he's from, he almost certainly works in the farming sector, which means his family is probably going hungry while he's suffering from this disease.  And as far as I know, this patient survived.  If it had been a child, the odds are that he would survive, even as a kid, but could have died.

So why did the doctor prescribe Fansidar?  Well the main reason is that he probably didn't have access to the next round of drugs, what are known as ACTs or A-C-Ts, the Artemisinin Combination Therapies, and these drugs are available.  They are widely--well, not widely, but they are sold in the West, and they are available in many African countries.

To try and overcome this kind of problem, where drugs are available, but they're not being sold in or they're not being applied for treatment in developing countries, in particular, in Africa, it was one of the motivations for setting up the Global Fund for AIDS, tuberculosis and malaria.  So we're looking at this as an example of where perhaps the Global Fund should have been providing this clinic or this country with more drugs.  Of course, picking one example would be unfair.

However, recent allegations in the Lancet, which is the leading British medical journal, there were allegations made that the World Health Organization and the Global Fund were falling down on the job in malaria treatment.  The authors of the paper claimed that this was medical malpractice since the alternative drugs existed, that they are not that expensive, that they should be used, and therefore the policy is, in fact, killing children in Africa.

And they also point out that the World Health Organization and the Global Fund approve of these in their written documents, approve of these drugs and are trying to promote them.  Yet, as can be seen from this next slide, there is considerable failure from the existing drugs.  I just gave you a one-person example of where Fansidar, an SP, is failing.

This graphic or this chart, given to me by the lead author of that Lancet paper--Amir Attaran--shows the massive failure, parasitological and clinical failure, of chloroquine, in particular, in Ethiopia, Kenya, Senegal and Uganda.  The failure of SP is not so high, but clinical failure with SP happens much faster than it does with chloroquine, from most of the evidence.  So these are countries which are switching to SP as a first-line treatment, and we will undoubtedly see massive problems there, too.

Worth bearing in mind that Ethiopia, Kenya and Uganda are three of the 12 African countries that the United States has targeted for help from the Global Fund, and here we see the Global Fund and other agencies supplying drugs where failure rates are extremely high.

Some of the Lancet authors, notably Dr. Attaran, have demanded that no more U.S. funds should go to the Global Fund until they sort this kind of problem out.  And given that perhaps a billion dollars will be going to the Global Fund for combatting AIDS, this is rather a serious allegation and concern.

Of course, the World Health Organization and Global Fund have responded.  They say that they are rolling out the alternatives to these drugs, the ACTs, as fast as possible, and that eventually these will come on-line as first-line treatments throughout Africa, but they say it will take 5 to 15 years.  So who is right?  Is the World Health Organization and the Global Fund right or the 13 leading malaria experts who wrote this Lancet paper?  Well, as often as you would expect, the truth is somewhere in the middle.

Changing drug policies in poor countries can be very difficult and time consuming.  Workers may have to be retrained.  It takes time to restock drugs, and materials have to be printed explaining how new dosing regimes can work, but will this really take 5 years, let alone 15 years?

At this clinic that I just mentioned, you have nurses here who are looking at various tablets, and they are contemplating the change in regime which is being considered in this clinic.  Fansidar, which is one of the SPs that I was mentioning, was being used and was failing.  The drug above, Coartem, is one of the artemisinin-based drugs, and they are contemplating a switch.

Now, this isn't particularly sophisticated.  This is in a nice, glossy handout that all of the nurses can walk away, but it's something that can be put on the board.  So is it really going to take five years?  For example, in this location it took a couple of months.

However, the countries themselves, the WHO had several defenses.  The countries themselves may be reluctant to change drug policy.  Existing bureaucrats like existing systems.  They are used to them.

And I say this with some, although I'm a regular critic of the World Health Organization, I think that it's tough, when you're operating in numerous countries, to actually get the countries themselves to want to change policy.  But then the failure, if you like, the perhaps understandable failure of changing the drug regimes on malaria stand in stark contrast to the claims made by the World Health Organization that they are going to treat three million Africans with AIDS drugs in the next five years.

Remember that dispensing AIDS drugs is a hell of a lot harder job than it is dispensing drugs for malaria.  Malaria is a simple blood test.  You can know pretty quickly whether someone has got malaria.  There aren't that many drugs you can prescribe.  You only need to give a few pills and, maximum, it will last for a week.

AIDS, the tests are much more complicated.  As we heard from Ambassador Tobias, you have to look a the CD counts.  You are supposed to be changing the dosing.  There are lots of problems when you're doing it.  It's not that it can't be done, but it's far more complex.

So, as far as I'm concerned, the multilateral health agencies can't have it both ways.  It can't be impossible to roll out easy-to-use malaria drugs in under five years, but possible to treat millions of AIDS patients over the same period.

So I think that what we are seeing is a, when it comes to the allegation against the World Health Organization, I think medical malpractice is possibly too harsh a charge, but there certainly seems to be a level of dropping of the ball, lack of interest in malaria, and there seems to be no doubt that Secretary Thompson, Ambassador Tobias, the rest of the Bush administration should take a close look at how the Global Fund is actually spending the money on drugs and perhaps withhold funds.  I'm not competent to judge whether they should do that.

But we should also accept--and I don't mean to be pessimistic when I say this--I mean we should inject some realism here, that treating millions of African AIDS victims in the next few years is extremely unrealistic.  Earlier this week, South Africa announced yet a further delay or potential delay in treating 53,000, the people that they wanted to treat, I believe, by the beginning of May.  Remember, South Africa is the most sophisticated country in Africa.  Although there's been a lack of political will in the past to bring out ALVs, perhaps there seems to be some change of heart.

At the moment, perhaps 75- to 100,000 Africans are being treated with ARVs.  Do we really believe that that's going to be possible to ratchet it up to 3 million in the next 4 or 5 nears?  I don't think so.  But failure to hit that target should not be seen as failure.  The lure of U.S. taxpayer dollars should not drive overpromising.  It's going to be hard enough to maintain donor funding, donor interest.  Failure inevitably sets in.

Ultimately, rolling out drugs too quickly without the requisite infrastructure development will lead to greater drug resistance and real failure.  I do hope that the administration keeps its eye on the ball when it comes to the Global Fund and its own agency, the U.S. Agency for International Development, is doing with the funding that it's giving it.  Because if it doesn't do that, and doesn't help to provide incentive for new drug development and incentives for the private sector who have developed most of the antiretrovirals and most of the drugs for opportunistic infection, succeeding with treatment in Africa is going to be an impossibility.

Thank you.

MR. GLASSMAN:  Thank you, Roger.

Just to be clear, the failure of I think it was, the SPs that you were talking about, that was specifically because of resistance that was developed?

MR. BATE:  Yes, the resistance in that of Zambia is running at about 60 percent, so it's just that the strain of malaria, probably that the strain of malaria the patient had the second time was slightly different than the first time, which is why Fansidar, the SP, wasn't working.  But that kind of problem occurs all over Africa.

MR. GLASSMAN:  Do you think it's reasonable to say that that kind of problem is going to be a big one when it comes to AIDS drugs?

MR. BATE:  Well, that's why there are triple combination therapies, because of--HIV is a remarkable virus.  It can mutate rapidly.  I think in one trial that they had with one drug, they started to see resistance within one month, which is pretty scary.  So I think that it's almost inevitable.

MR. GLASSMAN:  Nick Eberstadt?

MR. EBERSTADT:  Thank you, Jim.  It's a pleasure to share this platform with all my friends here, but I want to tip my hat, in particular, at David Gordon for the work that he has done within the U.S. government in informing our decisionmakers about the national security implications of infectious diseases, including HIV, but other ones.  There are a lot of reasons that the United States is in the forefront of the international struggle against HIV, and one of the reasons is that our decisionmakers have been better informed than decisionmakers in other countries.  So, David, a salute.

A few years ago I wrote a book called, "The Tyranny of Numbers," and what I thought I would discuss with you very briefly this morning is enunciation of "The Tyranny of Numbers," specifically the implications, the numerical implications for ART treatment in low-income areas.

Does anybody happen to know or does anybody happen to have a guess at how much people in the United States spend on medical and health services for household pets in a given year?

[Laughter.]

MR. EBERSTADT:  Don't guess.  Around $40 billion a year.

Does anybody have a guess, if we leave South Africa out of the sub-Saharan tableaux, on how much is spent publicly on medical and health services for the 600-plus million people in this large area?  If we do it on an exchange-rate basis, it's probably around $4 billion a year.

This is a reality, a very cruel one, but it frames the scope of the possible with respect to health strategies for the area, and it bears on health strategies for other parts of the low-income world.  The point that I'm going to share with you very briefly is that the cost-benefit calculus for antiretroviral therapies for poor people is extraordinarily unforgiving.  It is extraordinarily unforgiving.

Let's just go through this as a back-of-the-envelope exercise for a moment.  You can do your own calculations.  You can change the assumptions.  It is trying to show you the sorts of parameters that we're dealing with here.

Often it is said that the median incubation period between HIV infection and onset of AIDS is 9 years, about 9 years, maybe 10, 11, 9.  As a benchmark, we can also say that without ART treatments, life expectancy after the onset of AIDS we can figure is about 2 years.  There are different numbers that are given for the next one.  The period for which life can be extended, median period of life extended through ART treatments.  I'll use the number 3.  You may see other numbers given, but let's say 3 years of life extension.

Let's say we can get all of the medicines that we need, on a generic basis or from Super Cipla or wherever, and let's say that we can get those medicines for ART treatment for about $300 per person per year, which is a rather optimistic estimate, I would say.  And let's say that, in addition, we have about $150 a year of health care services, personnel services, that are used in administering these.  And finally, since money costs, let's put a discount rate on this whole project--in poor countries, discount rates tend to be higher--let's say 10 percent.

If you go through the numbers I've just given  you, you will find that the cost per year, life extended through ART, works out to about $2,500 a year.

Now, let's say that Bill and Melinda come into our scenario here, and they buy all of the medicine for us and give it to us for free, but we still have to pay for health care service costs, for some minimal health care service costs.  We go back to the calculator, and what do we get?  We get there a cost per year of life extended about $750 per year.

Now, what do these numbers mean?  Let me compare these numbers to some alternative health care interventions that could be done.  Let's say, malaria.  Roger knows much more about malaria than I do, but as I scan through the literature, I see that some estimates have been made for the cost of averting what the World Health Organization now calls a DALY, a disability adjusted life year.  Forget the jargon.  You don't need the jargon.  You need to know the cost or the estimated cost.  Around $10 to $15 per year of life.

How about tuberculosis interventions--a DOTS treatment?  Again, if one looks at the estimates that have been developed for low-income areas, about $5 per year of life per DALY.  And of course the estimates for increased life from clean water interventions or from vaccinations would be much less than that.

Now, none of the calculations I offered you for ART are sacred.  They're all "back of the envelope."  You can change any of those numbers: the discount rate, you can change the estimate about life extension a little bit, you can change the cost estimates a little bit.  But none of those changes will get the cost per year of life extended anywhere near, anywhere near, not within an order of magnitude, of those other interventions that I have just described for you.  And this is the ethical and practical problem that we face with ART interventions at the moment in Third World, low-income, poverty settings.

The bottom line I think is we have to say that this is an unacceptable reality.  We have to change this reality.  The only way we can change this reality is by altering the realm of the possible, and, in turn, the only way we can alter this realm of the possible is through medical breakthroughs.  Those will depend upon research, those will depend upon innovation, and those will depend upon offering us, at some point, I hope in the not-too-distant future, better hope of a prospect for a vaccine or other sort of new medical innovations.

Thank you.

MR. GLASSMAN:  Thank you very much, Nick.

In the interests of moving along, I won't ask yo a question.

Mawyn?

MR. SAMUELS:  I thank the AEI for inviting me to participate in today's forum, and all the more so, as some of you may know, today is--at least in China yesterday--it was the Chinese Lantern Festival, which, in China, is the official end of the 15-year new year celebrations.  But actually, in pre-modern China, it was the equivalent of our Valentine's Day, which I suppose is not exactly the most proficious day on which to be talking about HIV and STDs, but in any case--for that matter, in view of the apparent origins of HIV, it's also appropriate that this is the Year of the Monkey, so perhaps it is, after all, a good time to be talking about AIDS in China.

As I start, I should note, by way of an introductory caveat, that the U.S.-China AIDS Foundation comes to the issue of AIDS in China from a slightly different perspective than many AIDS scholars, researchers and activists.  We do so because our entry points on this issue come via two different routes:  On the one hand, since 1985, in organizing training programs for government officials at the national level in China, and on the other, and perhaps more directly, since 1993, as practitioners, business people in the media and entertainment industry have joined.

Both of these undoubtedly color our own views as to, at least on two issues regarding the battle against HIV/AIDS in China, namely, the issues of public awareness and training.  And given the time constraints today, as much as I'd like to go on forever about both of these issues, I'll try to focus my attentions on the issue of public awareness and prevention.

In doing so, let me first begin by trying to put at least a little bit of quantitative flesh around the issue of HIV/AIDS in China.  I certainly won't try to compete either with Nick's comments just a moment ago or with his articles on the issue of the volume or the rates of HIV in China.

As many of you well know, estimates vary.  They range anywhere from 850,000 to 3 million, and in at least one or two cases, some people talk about 6 million HIV-infected individuals in China, but as we also I think all know, there is now a kind of political compromise which says that there are 1 million cases of HIV-infected individuals in China today.

The failure to gain a more precise estimate is due to a lot of factors, most of which are already well-known, such as inadequate monitoring and testing infrastructures and a host of social factors, including the stigma associated with HIV, and equally associated with STDs and the so-called high-risk population.

Nevertheless, let me hit you with two numbers--two sets of numbers--that are reasonably accurate and, more importantly, the convergence of which greatly underscore the scope of the problem in China.

As the relationship between HIV transmission and STD proliferation is well-known, I'll use one of these figures.

By China's own CDC official estimates of only about a month ago or less than a month ago, there are, on average, today, 4 million new STD cases per year in China.  Now, if we only take the typical STD-to-HIV ratio among commercial sex workers in China, as kind of a rough statistical model, this constitutes a potentially 10 percent or 400,000 new cases per year via this single mode of transmission.

Now, why is that significant?  A second number may help underscore and define the significance of the first number.  Of China's approximately 5.5 million professional medical personnel trained in Western medicine, less than one-tenth of 1 percent have had any professional training whatsoever in STD prevention and treatment and far fewer have had any exposure at all to training in HIV/AIDS prevention or treatment.

Moreover, of those M.D.s who have been trained in either STD prevention and treatment or HIV, about 60 percent are actually research scientists and not practitioners.  To put this in a somewhat more dramatic perspective for our discussion today, by current estimates, there are about 2,000 doctors trained to deal with 4 million new STD patients a year or about 2,000 new patients per doctor per year.

In the case of HIV/AIDS, the ratio today is literally absurd.  That is to say, the ratio would work out to be about 12,500 patients per doctor today, and with a conservative 400,000 new patients per year, if no new AIDS specialists are added, we're talking about--

[Tape change: T-1B to T-2A.]

MR. SAMUELS:  And we can blame a lot of factors here for this, including the health care system itself and in particular the commercialization of the health care system in China over the last decade--something, by the way, which the China CDC is recently doing in public, criticizing the health care system of their own country.

But this also sort of begs the question, in my view, at least.  There are really only two near-term, relatively near-term solutions that one can discuss reasonably about this.  First of these is a sustained, and I mean really sustained national and regional prevention campaign and effort, on the one hand; and secondly, a large retooling of older and the training of new medical personnel, public health administrators, so-called VCTs, and information managers throughout China.

To be sure, this is easier said than done, and it costs a lot of money.  It so happens that we have more direct experience with the public awareness front than others.  I'll focus most of my attention on this issue today.  But this is not to underestimate the extraordinary importance of what I would call executive education training for medical personnel and others.  Indeed, we ourselves are in partnership with the China National Training Center for STD control in order to provide such training, and if time permits, I'll happily address some of this later in greater detail.

As to the issue of public awareness and prevention, although much has been said and continues to be repeated often about the villainous troglodytes in the corridors of power in China, I'll make a statement which may be a bit controversial but accords with something which Mr. Gordon just said, essentially that the legal and political constraints to broad public awareness about HIV in China, whatever they were in the past, are no longer the core issue in China.  In fact, they've been eroding rapidly over the past two years.

The first major television specials on HIV prevention to be broadcast nationwide at prime time on a Saturday night occurred on December 1, 2001, on CCTV, Channel 1.  This two-hour-long variety program reached some 200 million households, featured the first interview of an AIDS victim on national television, and included many celebrities from China, Taiwan, Hong Kong, and Singapore.  It also happens to be that it was our first endeavor, in fact, in the HIV prevention effort as co-designers and co-sponsors along with five government ministries; that is, the ministries of culture, education, propaganda, and health, of course, and the state administration of radio, film, and television.  They were all the official sponsors, along with ourselves.

For a time, this event opened up a veritable floodgate for local and regional media outlets to deal quite openly, if often somewhat erroneously, with the issue of HIV/AIDS.  However, as Peter Piot later noted, this program literally brought AIDS out of the closet in China.

To be sure, there were constraints at the time and there continue to be some constraints.  At that time, for example, we could not openly discuss or promote condoms.  Hence, we, along with the health authorities in China, resorted to various euphemisms, like the slogan, "HIV: a man's disease" or "a man's responsibility."  We also used a giant elongated yellow balloon with a happy face as a surrogate condom.  Happily, the prohibition no longer prevails and, for that matter, the yellow balloon, now with clear references to condoms, often accompanies government-sponsored public awareness efforts in China.

Naturally, as you're all aware, the political and legal constraints to broad media public awareness also sharply declined in the wake of the SARS crisis, and most recently, as Mr. Gordon has mentioned, when Premier Wen Jiabao visited Ditang Hospital and this was broadcast throughout China on television and in the newspaper.

I'll come back to this issue in a moment, but let me turn to another dimension of the issue of public awareness that really conditions everything in this field.  Almost anyone familiar with China understands that scale effect is both an advantage to and a constraint on the management of anything in China.  Similarly, and related to scale effect, regional diversity remains an important variable in China's social, cultural, economic, and even political reality.  And even this--and this is true even as the country is fast creating a more integrated system in economy.

While this has many ramifications in all fields, in the case of HIV prevention it has also a significant impact.  It does so in several ways.  Most obviously, while HIV exists in virtually every province in China, it also clusters in places like Yunnan, Sichuan, Xinjiang, and Hunan.  Now, this also means that local provincial authorities have varied considerably in terms of their attitudes and policies towards HIV.  Some, like those in Yunnan, have been fairly progressive.  Others, like those in Hunan, has been notoriously backwards.

However, by the same token, HIV also diffuses in China along both traditional and modern transport routes, affecting nearby and distant regions.  For example, I'm not sure if it's well-known here, but a new cluster of HIV has now emerged in Lhasa.  And it's easily attributable to the drug and sexual trade moving up from Yunnan and Sichuan provinces.

Equally important, of course, regional diversity figures prominently in defining markets and in shaping what messages can be sold in one place or another, thereby affecting the effectiveness of public awareness campaigns.  For example, about a year before we, how to say, embedded ourselves in the HIV public awareness effort in China, we conducted a commercial survey of music markets in urban contexts in China, mainly in Beijing and Shanghai.  Much contrary to our own expectations--even those of us who have spent years in China still have stereotypes running around in the back of our heads--much contrary to our own expectations, we found that Beijing, not Shanghai, is the center for music experimentation and innovation in China.  The notion that Shanghai is the kind of gateway for all innovative Western culture in China is, simply stated, not true.  Shanghai is a hotbed, to be sure, of romanticism and soft pop, including canto-pop, in the music world, but that's about it.  Put differently for those of you who are hip to these things, Jimi Hendrix is hip in Beijing and barely known in Shanghai.  Or, if you like, the new Cyndi Lauper would do very well in Shanghai but would flop in Beijing.

[Laughter.]

MR. SAMUELS:  And if you don't know what that means, I suggest you talk to your local teenager.

Suffice it to say here that the reality on the ground in China is a function of many, many, many factors, of course, but one key factor is defining what messages will sell and how they are packaged.  This brings me to one key point regarding the constraints in public awareness campaigns in China.  Much hand-wringing in the press to the contrary notwithstanding, especially over here, the law and public policy are entirely less constraining on this issue now than three other interlocking factors.  Number one, money.  Number two, market segment or definition.  And three, attention span.

Perhaps ironically, reform in the media industry, just as in other sectors, including health care, has in fact exacerbated the issue of public awareness because today there's no such thing as a free lunch in China.  This means at least two things: buying time or space on China's now entirely commercial and increasingly expensive media outlets; and two, filling that time or space with content that will attract and hold the attention of the audience, or market, against a flood of competition.  Much of which, by the way, that competition, much of which carries messages quite contrary to our HIV prevention goals.  Watch any Chinese TV channel for more than a half an hour or visit any street corner magazine vendor, and you'll see what I mean.  Put simply, pop culture of a sort defined by the Britney Spears generation has arrived with a vengeance in China.

So this being the case, amidst the cost and the competition, what strategies can one use to get the message across and, even if you did get the message out there, who the heck is listening anyway?

I sense that the time is getting much shorter.  I'll just outline a few points here.

First, I don't know how much people here are knowledgeable about the media industry in China, but I'll just draw out a few numbers.  Television as a media for public awareness presents many difficulties in China, and not merely because of any kind of consensus issues, but rather because the market strategies are much different than in the USA.  Why?  There are about 353 television stations, versus about 1600 in the USA.  To be sure, about 89 percent of all households in China have at least one TV set.  However, the average number of channels per city is 69, and the average number of channels per household is 16.  In effect, there's a fair amount of choice.

More importantly, and the most critical factor perhaps, at least in my view, is that viewing time is highly limited.  That is to say, for example, in key urban markets, the average teenager viewing time on weekdays is an astounding 1.2 hours a day, and on weekends escalates to an extraordinary 1.6 hours a day.  This, by the way, versus the standard average in the United States of 7 hours a day, whether weekend or weekday.  Adult viewing time in the same markets is about an hour and a half longer than the average teenager.

There's a simple lesson here.  Getting anyone's attention by a television is highly competitive, difficult to say the least.  One other component might make this even sharper.  If you're tired of ads on television here, well, in the USA only about 23 percent of all advertising generated by all media, about 23 percent of all advertising revenue is generated by television.  Even if one uses whatever models one likes to calculate the huge differential in advertising costs between China and the United States, it is nonetheless notable that in China 68 percent of all ad revenue is generated by television.  That means there's one heck of a lot of ads on Chinese television.

MR. GLASSMAN:  Marwyn, can you wrap it up?

MR. SAMUELS:  Okay, I'll do it quickly.

So there's a serious problem about television.  The only two ways in which TV can be effective in China on this is, in our view, two.  One is through a standard soap-opera format, which is very popular in China, which is usually a 20-segment soap opera.  And then secondly, by creating special networks.  And we in fact are now just, have just licensed a new health network on Chinese television.

But at the same time, due to the acquisition and production costs and to audience attention, television probably is not the most effective -- in China, and Marshall McLuhan was right, radio is a hotter medium for this.  So we, too, have been multi-tasking radio and television, linking them thing.  For example, we've purchased an hour's worth of time on one radio station and are purchasing another hour on the station that all truck drivers, bus drivers, taxi drivers, and every other driver uses in Eastern China.

I'll just conclude this real quick by saying that there are, of course, many organizations--foreign like ourselves, and domestic--now engaged in the effort in public awareness in China.  I should perhaps underscore one point, however, and that is namely the tremendous growth in increasing legitimacy of HIV, STD-involved NGOs in China, a phenomenon which is not altogether different from other single interest group development in China, and particularly environmental protection groups that have emerged in recent years.  In my opinion, this single interest group constitutes the core of a nascent civil society in China.

And insofar as we're also here interested in the social and political transformative character of Chinese polity, the one good piece of news emerging from the HIV crisis in China is that not only is the government of China unable to contain the phenomenon of participatory interest group development, but also has begun to discern its own self-interest in encouraging this phenomenon in some sectors, like the HIV sector.

This is not to say that democracy is just over the horizon, but it is to say that government and politics in China is becoming responsive to popular demand, and public awareness is also the precursor to informed public opinion.  If that sounds a bit too optimistic, then, to borrow a phrase from Li Pung, let me just say that, like SARS, the HIV/AIDS and STD epidemic in China is its own form of peaceful evolution.  That is to say, even if it comes at a huge price in the cost of lives, it is transforming the society indirectly.

Thank you.

MR. GLASSMAN:  Thank you.

Jeffrey Sturchio, and then we'll have questions from the floor.

MR. STURCHIO:  Thanks, Jim.

I'm sure many of you are wondering what can I add to this after you've heard from Ambassador Tobias and the other speakers.  I will try to just focus on two new elements of the discussion that haven't been focused on so far.   You've already heard a very interesting review of the status and likely future trends of the epidemic in various parts of the world, and also I thought that Ambassador Tobias made an interesting contrast between the despair that that would lead you to, just focusing on the problems that we face, and the hope that's there in some of the new interventions that are available and some of the new resources that are coming into the fight against HIV and AIDS.  So I'll come back to that point, but let me just focus on two things in my brief remarks:

First, what's the role of a company like mine--Merck and Company, which is one of the largest research-based pharmaceutical companies in the world--in responding to this global health challenge?  And, secondly, how can public-private partnerships really help make a difference?

So, first, what role can a company like Merck play in the fight against the epidemic?  Our primary role is to do what we do best, which is to discover and develop breakthrough medicines and vaccines that represent true advances in patient care.  Our research laboratories initiated an HIV research program more than 15 years ago and have discovered already two major antiretroviral medicines--Crixivan and Stocrin--which play an important role in antiretroviral therapy.

Our HIV vaccine research program is the largest and most intensive in the company's history, and a promising vaccine candidate is now in early human trials in 18 cities around the world.

We're also committed to making our medicines accessible to as many people as possible. Nearly three years ago we implemented an HIV pricing policy that makes Crixivan and Stocrin available at prices at which we don't profit in the poorest countries and those hardest hit by the epidemic.  We also offer significant discounts to more than 50 additional medium human development index countries.

Today, more than 120,000 people in 63 developing countries are being treated with combination therapy using our HIV medicines.  Clearly, there are still many more people who are untreated and require treatment.  There's clearly more work to do, but this is a firm step in the right direction.

And Merck is committed to public-private partnerships to help address the need to scale up the response to the AIDS epidemic.  One example of the power of those kinds of partnerships is available in the experience we have in dealing with the river blindness epidemic in parts of Africa, and Yemen, and Latin America, where since 1987 we have donated more than 280 million treatments for river blindness, a medicine called Mectizan.  And working together with a broad coalition of international agencies, governments, NGOs, and others, we've actually made real steps towards eliminating river blindness as a public health problem.

So that shows the power of these kinds of partnerships, but how can they help more broadly in HIV and AIDS?  I think these partnerships can play a critical role--and are playing a critical role--in the developing world by drawing on the resources and expertise of all stakeholders to help build the systems and infrastructure to ensure more equitable access to health care.

A good example in the HIV and AIDS arena is the work we've been doing with the government of Botswana and the Bill and Melinda Gates Foundation to help Botswana strengthen its comprehensive response to the epidemic.

Earlier, Roger and I think Jim mentioned in his introductory remarks that among the countries in Africa, Swaziland, for instance, now has something like two and five adults who are HIV-positive.  That's also true in Botswana.  And until recently, it was the country that was arguably the hardest hit in the world.  The purpose of this partnership between Merck, and the Gates Foundation and the government, it's very much a country-led partnership, but it's to develop a multisectoral, comprehensive approach across the entire spectrum of prevention, care support and treatment.

The Gates Foundation and the Merck Company Foundation have each dedicated $50 million to the partnership, and Merck is also donating our antiretroviral medicines to Botswana.  The program overall is making strong early strides, and the progress is clear, for instance, in the HIV treatment program in Botswana, where now more than 17,000 patients are enrolled in the program, and it's now the largest, to our knowledge, the largest government-sponsored treatment program no the continent, and this covers nearly one-third of those in Botswana, who are aware of their HIV status and who need treatment now.

So this partnership reflects the critical elements for success against history's worst epidemic.  It includes strong political leadership which can't be underestimated, a comprehensive and coordinated approach across the entire spectrum of care, investment in health care infrastructure and the training of health providers--that's a point that we just heard about in China.  Similarly, in Botswana there's a real shortage of trained health care providers--international assistance, and the continued investment and involvement of pharmaceutical companies like Merck, together with other stakeholders in the private sector and civil society, not least those people living with HIV themselves.

Botswana is still, in ma