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Diplomacy in Action

International Efforts in Fighting AIDS and a Preview of the XIX International AIDS Conference (AIDS 2012)

Chris Collins, Vice President and Director of Public Policy at amfAR, the Foundation for AIDS Research; and Member, Conference Coordinating Committee for XIX International AIDS Conference (AIDS 2012)
Washington, DC
November 30, 2011

 2:15 P.M., EST


MODERATOR: Thank you, everyone, for coming to the Foreign Press Center today. We appreciate it. Joining us today is Chris Collins. He is vice president and director of public policy at amfAR, the Foundation for AIDS Research. But he also has another very important role, and that is as a member of the Conference Coordinating Committee for the 19th International AIDS Conference – that is, AIDS 2012 – which will be taking place this summer, this coming summer, in Washington, D.C. for the first time.

So I’d like to remind you that this briefing is on the record, and we will have questions after the initial remarks from Mr. Collins, and at that time, if you could just please state your name and organization.

Mr. Collins.

MR. COLLINS: Good afternoon, and it’s great to join you this afternoon. My name is Chris Collins. I head up the policy office for amfAR, the Foundation for AIDS Research. The policy office is based in D.C., here, and we do a lot of work analyzing policy issues, communicating with the public and the media, and also doing direct advocacy with members of Congress and also with the Administration. We work on both domestic and global issues in the HIV/AIDS response, so I’d be happy to talk about both those areas with you if you’d like.

I’ve been asked to talk a little bit about some global issues and then talk a little bit about the conference, but it sounds like most of this session is really about questions. So I guess what I would say on global is just to reiterate what we’ve been hearing. We are at the pivot point. We’re at a point of tremendous opportunity in the response to the global epidemic. Our investments in science have really paid off in terms of giving us the tools to begin to end the worst epidemic of our time. Doing that is within our grasp, but it’s going to take resources, and it’s going to take more strategic use of resources than in the past.

We just heard in the last – I guess last week we got the new UNAIDS report with the latest epidemiology of HIV. And that what report shows is basically a flattening of HIV incidents, a decrease of incidents or new infections among children, and a decrease in mortality. You’re seeing those changes in the global epidemic largely because of the track record of success we’ve had in getting services to people. And that includes prevention of mother-to-child transmission programs, which are beginning to scale up and reach more people. That’s why the child infections are going down. Mortality is falling, of course, because of the tremendously successful scale-up of ARV or antiretroviral access around the world. And you’re seeing a flattening of incidents in part, I think, because we’ve been doing more things that we know work in prevention, like male circumcision, but also we seem to be seeing an impact of greater treatment delivery and the impact that has on prevention. And I’ll say more about that in a minute.

This moment of tremendous opportunity in the epidemic comes right up against some of the biggest fiscal challenges we’ve seen in a long time, both in the United States and, as you know, in many countries around the world. As you probably heard, last – just last week, the Global Fund announced that it’s not going to be asking for proposals for Round 11 at this time because of lack of funding. This is really a devastating – devastating news coming from the Global Fund, which has been one of the core multilateral efforts in terms of getting life-saving services to people. The fact that they’re not able to issue their call for proposals on time because of lack of funding is a terrible sign, and it suggests that we’re at risk of squandering the enormous opportunity that we have in front of us right now.

The challenges fiscally, of course, aren’t just with the Global Fund. Here in the United States, Congress is trying hard to find ways to reduce the U.S. deficit. In the immediate term, that means trying to make decisions about the federal FY12, Fiscal Year 2012, budget, which has not been set yet. The Senate has proposed numbers for programs like PEPFAR, our bilateral AIDS program, and the Global Fund that are about flat funding, but over in the House the proposal for FY12 is to cut global health funding in total by 9 percent. So we’re talking about devastating impacts on people all around the world and a real squandering of opportunity if we see the kind of cuts that the House is proposing. So we’re very hopeful that the President and leaders in the Senate will push hard to maintain the Senate number without any cuts when they make their final conference report on the FY12 numbers.

And it is also true that other countries are investing less in the global response to AIDS. It’s really a terrible tragedy. At a time when science is showing the way out in terms of addressing this scourge, we see countries deciding it’s time to move on. And the Kaiser Family Foundation and UNAIDS recently came out with a report showing the global investment in the response to AIDS is now beginning to fall.

That’s why tomorrow is so critically important. President Obama is going to be speaking tomorrow at 10:00 a.m. in Washington, D.C. at an event sponsored by the ONE Campaign. And we very much hope that the President will be announcing specific action steps to follow up on what Secretary Clinton talked about earlier this month, November 8th, when she said that the goal of an AIDS-free generation is now a policy priority for the United States. It was a terrific speech, and she identified several of the interventions that we know for sure work and that need to be brought to scale to achieve that vision of an AIDS-free generation. And now we hope to hear from the President tomorrow specifically how we will put that into practice by scaling what we know works, by making choices.

Because of the new science showing us things that clearly work and the fiscal pressure, those both add together into an era of tough choices. That’s what we’re heading into now. If we’re going to take advantage of the opportunity at hand, we’re going to need to be making choices about investment in things that can get the job done. And so that is part of the challenge, I think, for policy makers going forward.

One thing just to mention about the PEPFAR program, again, which is our bilateral program here in the United States, it has been terrifically successful. It’s saved millions of lives. It continues to scale up and become much more efficient. As Secretary Clinton announced on November 8th, actually the PEPFAR costs for treating somebody with ARVs for one year fell 24 percent just in the last year to about $335 per person. That’s the PEPFAR cost. This is terrific news. It means we really can scale up treatment and do it in an affordable way.

But the other thing to know about PEPFAR, and I think for journalists covering global health, is that PEPFAR is one of the most robust platforms we have for building out and delivering other health services to people around the world. It is the foundation, I would say, for President Obama’s Global Health Initiative. It can be a real platform for reaching more people with HIV and family planning and other sorts of services they need.

I know you’ve already talked – thank you very much for the coffee. I may start talking more quickly now in a minute. I know you’ve talked a bit about the science – scientific results on treatment as prevention, the HPTN 052 trial that we heard about in May. That’s very exciting, and there’s another aspect to that too – and I think Marjorie actually mentioned it – that in the United States we’re seeing payoff there too. It is – yes, it is hard to reach everybody who needs treatment with the treatment they need. On the other hand, we’re seeing some environments where we’ve expanded healthcare access, like San Francisco and the state of Massachusetts; we’ve expanded healthcare access, we’ve ramped up the number of people benefitting from treatment. We brought what’s called the community viral load down in those communities, and we think we’re beginning to see a real impact on incidence, that the HIV infection rate is falling in those places where more people are getting treatment. So treatment isn’t going to do all – isn’t alone going to bring incidence down, but I think what we’re finding is that it’s going to be key to our prevention goals.

It’s also interesting – you may want to look at the UNAIDS report that came out last week. They identify four countries in which they think we’re seeing the prevention impact of treatment. The UNAIDS report says that what we’ve seen as a pattern over time in the epidemic is that there’s a spike in the epidemic curve, and then it falls, as most epidemic curves do, and then it reaches a plateau. What UNAIDS is suggesting is that to get that plateau to dip again it may take treatment then, wider delivery of treatment to bend that plateau down again.

Also interesting to know that the federal – the Centers for Disease Control of the United States has made estimates of the knock-on effects of delivering treatment to people around the world. CDC, Dr. John Blandford at CDC – he’s a health economist there – recently estimated that for every 1,000 patient-years of ARV treatment – or in other words, for every 1,000 people treated for HIV in a year – 228 HIV patients avert death because they’re getting treatment, but in addition, 449 children don’t become orphans; 61 sexual transmissions of HIV are avoided, and 26 transmissions vertically, between mother and child, are avoided. So we’re really seeing from our own government documentation about the tremendous impact of treatment, and we’re seeing it in our own country and I think it sounds like around the world.

Now, last but not least, a word about the conference. I am on – I’m honored to be on the Conference Coordinating Committee, and I think it’s really significant that the conference is coming to Washington, D.C. this year. It’s significant for a couple reasons. One is that’s possible because the United States has reformed its law. We used to ban immigration by people living with HIV, a terribly discriminatory practice that was ended a couple of years ago with the leadership of President Obama and other leaders in Congress. But also because we are at this pivot point of incredible scientific and program opportunity mixed with the challenge for funding, it’s important to be having this conference in Washington, D.C., where so much of the global response to HIV is financed and where lawmakers are looking for where they can make cuts.

Our argument, of course, is that HIV is not the place where you make those cuts. If this were a business, and the business were ending the AIDS epidemic, this is the time you would invest; this is the time you’d get strategic. But it is not the time you would de-vest. The theme of the conference is “Turning the Tide,” and I think it’s a really great title. I think it sort of gives – it sort of resonates with that idea that we’re at a turning point, that we have in our grasp the ability to begin to end this terrible epidemic, and that we really are – lawmakers in Washington, D.C. and around the world and the public – are faced with a moment of decision now. I think that that’s what this conference really is about.

I hope that what the conference becomes is a time where we let the world know that we have the ability to begin to end this epidemic, and then within the conference discuss what specific policy and financing and program changes we may need to make in order to reach that goal.

I also hope that the conference will be an opportunity to shine a light on successes, because there’s many. The United States is one success. As you may have heard – I didn’t hear all of the last presentation, but we now have, thanks to President Obama, a national HIV/AIDS strategy, which has made the response to HIV much more coordinated, strategic, and I think, effective. But we’ve also seen successes around the world in places like South Africa, which is really taking hold of its own domestic epidemic, falling incidence in several places where they’ve been able to scale up comprehensive services.

So it’s a very exciting time, and I’m very glad that you’re engaged in covering it.

MODERATOR: Chris, thank you very much. I’ll give you a chance to have a couple of sips of coffee now. And as you probably know, this is the second part of a two-part program we have for World AIDS Day, which is tomorrow. The first part was on the domestic perspective of AIDS and treatment and initiatives. That was carried by our Foreign Press Center in New York, and they’re joining us now via DVC for this portion, which is on the international perspective on treating AIDS.

So with that, I will open it up to questions on the floor, and hoping there are some. So please give your name and your news organization, if you have any.


Chris, maybe you want to talk a little bit more about the conference itself. I think that’s something that we really haven’t looked into all that much. This is news just coming out now. We’re still – what? – six or seven months away from the conference here in Washington? This is the first time it’s being held in the United States, which in itself is important. What about that? Is that – is there a special meaning to that, that it’s being held in the United States this time?

MR. COLLINS: Well, I think there is. The conference was here a long time ago, back in the ’90s, I guess. And then, because of this law in the United States prohibiting immigration by people living with HIV, it just really wasn’t possible, of course, to hold it here anymore. It was an embarrassment and a violation of human rights that we had that policy. And again, it took real leadership in Congress and with the President to change that. And I’m very glad to see that’s happened. It’s made it possible for it to be here.

As I said, I think it is very significant that the conference be in D.C. now, at a time when Dr. Tony Fauci, who heads the National Institute of Allergy and Infectious Disease at the National Institutes of Health in the United States, is saying that we are now in the position to control and, ultimately, to begin to end this epidemic with the tools we have in hand. Now is the time to bring that message and that opportunity to policymakers in a very real way in Washington, which the United States has been, really, the global leader in terms of financing the response to AIDS. I think that, given what we’re seeing in terms of falloff of funding elsewhere in the world, we’re going to continue to need the United States to be the global leader on this issue. So I think it’s very important what happens at this conference, what the messages are, that we reach a bipartisan group of lawmakers and their constituents with a pretty clear message about the opportunity at hand.

One way to say that is we either invest now and do what we know works, or we’re going to be spending money on this epidemic for decades and decades to come. If we invest now and get more strategic, a new analysis in The Lancet, actually from June of this year, suggests that we can begin to bend all the curves if we get strategic in our allocation and put a little bit more in, if affected countries put in a little bit more money to this effort and other emerging economies put a little bit more in along with rich countries, and that’s invested strategically, modeling now shows that we can bend the incidence curve down, mortality can fall, and really, within four or five years, you begin to see the cost curve fall. That’s not something we’ve ever been able to say before in the response to AIDS, that we could see a light at the end of the tunnel where the resource needs start to decrease.

But it’s not going to happen if we just do status quo. If we cut back our funding, let incidents get out of control again, this is an epidemic that’s going to be with us for generations. Conversely, if we do what we know works and keep the investment going, beginning to end this epidemic can be the legacy of this generation, and it can be the legacy of this conference.

MODERATOR: You make an interesting point, because as we see more money and more publicity behind AIDS, I think we’re seeing differences across the globe – for example, on how countries are acknowledging the problem, how they’re treating the problem.

I know we have a number of broadcasters from Asia here. Is there something you could say about how Asia, as a whole, is looking – or individual countries, for that matter, is looking at the AIDS – the situation with AIDS?

MR. COLLINS: Well, I think there are plenty of success stories in Asia. Thailand is always held up as an early example, where the prime minister really took ownership of the challenge, convened leaders in the government and the private sector, and took some very evidence-based, decisive moves to bring that epidemic under control in his country. It’s a great model.

I think that everywhere in the world, but I would also include Asia, something we’ve got to place increasing attention to is addressing the HIV-related needs of most at-risk populations, or marginalized groups. Those include gay men and other men who have sex with men, injection drug users, and sex workers. These populations, in just about every country, have higher rates of infection than the general population. In fact, even in heavily affected countries, gay men and other men who have sex with men are 19 times more likely to be living with HIV than people in the general population. And yet the response in terms of getting prevention and treatment programs to gay men and other MSM has really been deplorable for many, many years. In every program, in just about every program you can name, there’s been a willful ignorance of the problem. The EPI surveys don’t even ask if people are gay or men who have sex with men, so in many countries, we don’t even know how big the problem is. And then when – even when we know, there’s gross underinvestment relative to the role of gay people and sex workers and IDUs in the epidemic.

There are a lot of reasons for that. Policy makers don’t like to put money towards marginalized groups. It’s not politically expedient. People are willing to look the other way many times. People in those groups are scared to come forward for services. But it’s a cycle of dysfunction we simply have to break if we’re going to get a handle on the epidemic in Asia and around the world. So now is the time – I mean, part of being more strategic is putting your money where the challenge is most acute. And in many countries, that is among injection drug users, gay men, and other men who have sex with men, and sex workers. We’re going to have to confront the political challenges, the social challenges, the fiscal challenges in terms of providing resources necessary to grapple with that challenge.

In Asia and elsewhere, sometimes that’s going to mean a real full-court press to make existing health structures more safe and approachable for people in those marginalized groups – healthcare worker sensitization, policies to make sure that nondiscrimination practices are in place. So we need to change healthcare systems to make them work for marginalized populations, people who are most affected. But in some cases, also, we’re going to find that governments are unwilling to do that or aren’t capable of doing it, or that even if they are, targeted services are more appropriate. So we’re going to continue to need to fund nongovernment organizations who can provide very targeted services to particular marginalized groups and environments in which they feel safe.

So I think in Asia, where the MSM and IDU epidemic is a big part of the picture, as well as the sex worker epidemic, that is one of the real challenges going forward, is confronting the underinvestment in the response in those areas. I think as you probably know, there’s also a real concern about drug prices going forward and some of the free trade agreements that are now being negotiated. I’m not an expert in that area so I’m not going to say a lot more about it, but I will say that if free trade agreements are negotiated between the United States and other countries that make it more difficult to get generic products to people who are in desperate need of AIDS drugs, well, you’re going to see a lot of backtracking in all this progress.

MODERATOR: And finally, what we were talking about in many of the issues you touched on is cultural sensitivity. I mean, I think that’s one thing that you really have to be aware of, as you approach this particular issue, is cultural sensitivity. We can talk about politics, we can talk about money and all of that, but all of that is pretty much, I think, under the umbrella of cultural sensitivity.

MR. COLLINS: It’s – absolutely, cultural sensitivity is a huge issue here, and it’s also changing the law, and it’s allocating the money. There are a lot of things involved in getting it right in terms of reaching marginalized populations. Absolutely, cultural sensitivity is part of it.

I really want to call out and acknowledge the tremendous leadership of Secretary Hillary Clinton on this issue. This is someone, a global leader, who has really understood the connection between human rights and health. The rights of women, the rights of marginalized groups are essential if we’re really going to get advanced health status for those populations. I have been very impressed with what the Secretary has done in terms of advancing the rights of women around the world, how she’s spoken out, and I would also say that about marginalized groups, including gay men and men who have sex with men.

The Secretary has been a real leader, and I think the U.S. State Department has also done quite a bit to let other countries know that criminalizing gay sexual behavior isn’t going to help them do – make any advancement in terms of responding to HIV or other health concerns. So I’ve been impressed by the holistic approach that this Administration and the Secretary has taken. I think that kind of leadership from the donor countries and from all the donors is going to be essential, as is the leadership of civil society in all of those countries.

MODERATOR: Okay. We’ll open it up – open up the floor to questions one more time, see if there are any. Any questions? Going once, twice.

Okay. Well, Chris, thank you very, very much. I think there’s an interview to be done after this, but we appreciate you stopping by today.

MR. COLLINS: Thanks very much. I appreciate it.