President Bush's AIDS Initiative

Real Audio of Briefing

MODERATOR: Apart from Iraq, the subject in the President's January 28th State of the Union address that probably attracted the most national and international attention was his emergency plan for AIDS relief.

This plan is a 5-year, $15 billion initiative to turn the tide in combating the global HIV/AIDS pandemic, and this commitment of resources will help the most afflicted countries in Africa and the Caribbean to wage and win the war against HIV/AIDS, extending and saving lives.

Well, here this morning to brief and discuss with us this very important initiative and this very important issue is, I must say, a very high-powered team: I am surrounded by doctors this morning.

Immediately to my left is Dr. Joseph O'Neill, Director of the White House Office of National AIDS Policy. To his left and in the middle is Dr. Anthony Fauci, the Director of the National Institute of Allergy and Infectious Disease at the National Institutes of Health.

And then to his left is Dr. Jandayi Frazer, the Senior Director for African Affairs at the National Security Council.

Dr. O'Neill will have a brief opening statement to make, and then after that, they will be glad to take your questions, asking you as usual to please use the microphones, and identify yourself and your organization. Dr. O'Neill.

DR. O'NEILL: Thank you. Thank you for being here. From the first discussions that we have had with President Bush on the issue of AIDS and global AIDS, it was made very clear to me the President's unwavering and deeply felt conviction that the United States has to take the lead, and is taking the lead, on fighting this global HIV epidemic.

I think his compassion and his commitment to this were manifested in the most dramatic way possible in his announcement in the State of the Union address. The program that he announced is a program that, while based on compassion, is also based on a very strong clinical model.

And it is the focus of this program on providing treatment that is also ground-breaking for us. So I want to thank you for being here. I don't know if Tony or Jandayi have anything that you want to add, or we can just take questions.

DR. FAUCI: I think we can just jump right into the questions, and we can give you some of the details through questions of the program, and how it evolved, and what it is, and where we are going with it. So it will depend on your questions. That's fine.

MODERATOR: All right. We will take the lady in the back.

MS. HATHAWAY: Sue Hathaway, South African Broadcasting. I have two questions. The first is where did this turnaround come from? I would say that in the past that Republicans especially have not been real open-minded about sending money and spending a lot of money on AIDS, and there has been a significant change on that part with the announcement of this program.

How did that come about? And the second question is on culture and imposing the American conservative agenda in face of the vastly different cultures in Africa?

DR. O'NEILL: Well, let me point out to you that prior to this announcement that President Bush in the first -- well, prior to this announcement, President Bush oversaw an 82 percent increase in foreign assistance to HIV/AIDS care over what he was handed when he took office.

So the first point that I would want to make is that from day one in office, this was a high priority for President Bush. So there is really no turnaround in his policy.

This is a magnification of an existing commitment. We very much understand as well that programs, no matter where they are conceived, need to be implemented locally. So in our vision, we will be working very closely with communities in the affected countries, with providers in the countries, and with people living with HIV/AIDS in these countries, to develop the kind of programs that achieve the goals of the program, which is to get people into care and make anti-retrovirals available to them, but to do that in a way that fits with local mores and standards.

MODERATOR: Charlie.

DR. FRAZER: Could I just add one thing historically about that. A lot of people ask that question as if this was something that just happened on that night. Some of you may recall historically that right from the beginning of this administration that the President had been very interested.

In fact, several of the cabinet members, including Colin Powell, Tommy Thompson, Paul O'Neill, and others have visited Africa, and when Governor Thompson, the Secretary of HHS, came back from a trip that I made with him, we briefed the President regarding the importance of mother-child transmission prevention.

And when the President initiated that $550 million program last year, (a), it was a ground breaking program, but (b) he emphasized to us all that he felt that we needed to do more, but we needed to do more with a program that was feasible and accountable, because he felt that as much as he passionately felt that he wanted to do as much as we possibly can, he wanted to make sure that it was a program that would succeed, and that would get good results.

And on the basis of that, he asked his staff, the people in the White House, to help people like myself and Joe, to go and figure out a feasible program.

And that is the reason why we put a lot of work into going to Africa, and going to the Caribbean, and speaking with our colleagues, to look at what works in a developing nation, because one of the problems you have is that when you parachute a program that is a Western program, you are taking the first step towards failure, because there is really no -- not only no guarantee, but it is unlikely to work.

And that is why we embrace the kinds of things like Peter McGhenye's (phonetic) network model, which was working quite well in Uganda.

So this goes back, you know, literally years. This is not just an evolution that happened overnight before the President's address. This is a manifestation of a commitment that had been going on right from the very beginning.

DR. FRAZER: I would just add to that to drive home the point that the President's first announcement in the Rose Garden on HIV/AIDS was the first contribution to the global fund.

And so when you ask what Republicans have done historically, I would remind you that Republicans have been in the Oval Office since 2001 and have demonstrated a commitment from the outset.

Prior to that, it was Democrats in the Oval Office who first were addressing the funding level for the pandemic. And so from the beginning of the Republicans coming into the White House, there has been a tremendous commitment towards this problem.

DR. O'NEILL: And to think about just AIDS in general, and then we will move on to the next question, I would remind you that the largest -- and we are here to talk about global programs -- but the largest domestic care and service program in the United States, which is the Ryan White Care Act, which now runs at about $2 billion a year to provide care for people domestically in the United States, was signed into law by President Bush 41.

So there has been a long history of close involvement of the Republicans on this issue of AIDS, both domestically and globally.

MODERATOR: Okay. Charlie up front here.

MR. COBB: Yes, Charlie Cobb with All-Africa.com. Fifteen billion dollars is a fair amount of money for AIDS, but why funnel it through what really seems to me to amount to a separate bureaucracy, a new bureaucracy, instead of the Global AIDS Fund, which is only getting what, $200 million in Fiscal '04, and I guess has a billion dollar commitment from this Administration, even though they say they need something like $10 billion?

Isn't this a bit cumbersome, constructing really a brand new bureaucracy for a global AIDS fight when you have got the fund?

DR. O'NEILL: Well, a couple of points to your question. First of all, remember Dr. Fauci making the point that this is a very focused program on achieving a strong clinical treatment result in a focused part of the world.

And Dr. Fauci mentioned that the President was very concerned that we would be able to identify results from this program, and that we stay focused on treatment, and that we stay sharply focused on being able to be accountable for these funds.

It is clear to us that the way to do that and to achieve those goals is through a bilateral effort. We are not constructing a new bureaucracy, but we are certainly going to take advantage of this program to refine our existing bureaucracies so that we become more responsive.

The other point that I would mention is that in the President's announcement of this that he also announced an additional one billion dollars of new money donation to the global fund over 5 years.

And just last week it was announced that Secretary Tommy Thompson has now become Chairman of the Board of the global fund. So there should be no question in anybody's mind about the U.S. Government's commitment to the global fund.

But in this announcement, this particular new program is focused on achieving a specific goal in a specific region, and in order to do that, it needs to be done through bilateral mechanisms.

MODERATOR: A very quick follow-up.

MR. COBB: I hear what you are saying, in terms of what you want to do, the institutional you. You think that a bilateral approach is the best approach. Am I right on that, and would you elaborate some more about that approach, since there seems to be a global consensus of a multilateral approach?

DR. O'NEILL: Well, again, I would remind you that the U.S. Government make the first contribution to actually found the global fund, and continues to be the largest contributor to the global fund, and strongly supports the global fund.

So it is not that we -- it is definitely true that we believe that multilateral approaches are effective. but the global fund was never intended to be the sole mechanism by which the U.S. Government achieves our goals strategically for HIV/AIDS care.

DR. FRAZER: And I would just add to that as well. Part of the effectiveness of the global fund is to leverage multilateral dollars. The United States is the largest contributor, the first contributor, and in a second round of pledges, we are out front.

We were encouraging other countries also to contribute to the global fund, and then that will really demonstrate its effectiveness as a mechanism for raising funding globally.

We put our money in the global fund to leverage others and to encourage other donors to do so as well. And so they need to pledge for the second round as we have.

MODERATOR: Okay. The gentleman on the right there.

MR. JARREAU: Patrick Jarreau, Le Monde. I would like to know where are the great masses of the use of this $15 billion, and secondly, will it come with any ideological limitations? I mean, you know, advocating abstinence rather than condoms, and things like that?

DR. FAUCI: The prevention program was adopted straight from the 12 points of prevention from the WHO, and also published through U.N. AIDS and others, and the 12 points of prevention are comprehensive. They involve everything from education, behavioral modification, treatment of sexually transmitted diseases, abstinence programs, mother-to-child transmission prevention, and condom distribution.

So if you look at the WHO's 12 points of prevention, this is what this was modeled on, and the totality of the picture is about 51 or 52 percent in the use of anti-retroviral drugs to treat about one-third, 33 percent, in prevention; and about 15 percent in care.

MODERATOR: Okay. To the lady up front here.

MS. TREVOR: I was just wondering. You broke down those numbers --

MODERATOR: Could you identify yourself.

MS. TREVOR I'm sorry, Rebecca Trevor, from Research Europe. You just broke down those numbers, and I was wondering if research fits in at all with that?

DR. FAUCI: Research money is not going to be part of this, and in fact perhaps exclusively, research money is put in through the National Institutes of Health and the CBC, and is not included in this. This is money that is for prevention, treatment, and care.

There may be important questions that our Sub-saharan, and African, and Caribbean colleagues might want us to help them with answering in a research setting, at which point we will then utilize our research infrastructure, and we have a number of infrastructure components already existing on the part of -- when you are talking about research, fundamentally the National Institutes of Health.

We have our HIV prevention trials networks, vaccine trials networks, comprehensive international programs on research on AIDS. All of those are in place and separately funded.

Were our African or Caribbean colleagues to ask us to say that we are going to be doing these treatment, and prevention, and care programs, but there are some questions we need to ask and answer. We would be ready and willing to engage in collaborative arrangements with them. But that would not cut into the $15 billion that are being proposed for this program.

DR. O'NEILL: And I think when you think about the U.S. Government's contribution to the global fight against HIV and AIDS, you also have to add into that the tremendous investment that we make in finding a vaccine and finding a cure, which is ultimately what we need to have.

MODERATOR: The gentleman on the right.

MR. BEATTIE: Hi. It is Alan Beattie here from the Financial Times. I have another question about the way that the aid is delivered. As I understand it, some of the experience of these sort of vertical disease-specific interventions in the past has not been entirely helpful in terms of cutting across existing public health systems, and pulling key people out of positions, and also kind of creating a bureaucracy which only lasts as long as the individual bits of money attach to it.

I hear what you say about Uganda, but Uganda is a kind of special case, and most of the countries don't have anything like the capacity to deliver things like this on the ground.

Are you not worried that you are going to replicate the problems that have been had in programs before?

DR. FAUCI: Actually, the design of the program was specifically to address the concern that you are expressing. If you take a Western model and superimpose it on a country, then even though the country -- it looks like they are going to readily accept it, generally you run into a number of problems.

What we did when we looked at the Uganda model, and you are right, Uganda is a bit more advanced in this particular area than many, but not all, of the other countries.

But what we also did, and Peter McGhenye and his colleagues in Uganda were very helpful in this, that when you go around to many of the other countries, although they do not have the high-tech health care infrastructure, there is some semblance of a low-tech network model that is not identical to Uganda, but it can be, we think, readily adaptable to that, starting with a central medical center, and then going progressively out with lower and lower technology to primary, secondary, and tertiary satellite clinics or health care facilities.

Now, some countries have the bare rudiments of that, and in those countries we would expect that they would be applying or asking for help with those resources to enhance those infrastructure capabilities so that they will be able to implement a model that actually is an African model, and works for Africa.

We then went to the Caribbean and looked at the program in Haiti that is run, for example, by Professor Jean Pape, with help from Paul Farmer at Harvard, and we found that in fact they were also much to the amazement of many people, they were successfully implementing a modification of the program.

So the critical issue is that no one feels that one size fits all countries; that would be naive, inappropriate, and doomed to failure. But the broad philosophy of utilizing the kinds of infrastructures that either already exist, as rudimentary as they may be, and are amenable to being enhanced by resources, because wherever we went, we found that people said, you know, we feel that we can do it.

The only thing that we really need is that we need resources to be able to treat people, because many of them, they can't afford the drugs, and in fact even in Uganda, the only people who are getting treated now are people who can themselves afford the drugs.

And there are many people who are lined up that if there were just the drugs available, they would be able to be plugged into that program. So that is the reason why we feel that it is really an in-country model that can be flexible and adaptable.

MODERATOR: The person in the middle.

MS. WOLVESON: Elaine Wolveson, GAWH.org. We are very concerned with the fact that 55 to 60 percent of the people with AIDS are women in Africa, and many of the structures do not take into account equitable for women in Africa. Have you developed any protocols or are they in the working stage where women's needs in Africa will be addressed with regard to HIV and treatment?

DR. O'NEILL: Obviously the care and prevention for women is critically important. The first move that was made in the direction of this program was in fact the Material Child Transmission Initiative, and we were very clear when we talked about it that it was -- that it was not just intended to just care for women at the time of birth, but to also provide ongoing care for women, as it would be called MCTC Plus.

So at the very core of this was an approach that was directed out of recognition of these tremendous needs. So all I can tell you is that it has been very much in the forefront of our minds in designing this program, and we look forward to working with people who are concerned about these particular issues to make sure that we get it right.

MODERATOR: The lady up front here.

MS. GLASS: Pamela Glass, from a paper in Mauritius. I was just wondering how this program might be able to benefit countries in the Africa region like Mauritius that do not now have an AIDS problem, but are worried about it, and would like to expand their prevention programs for preventing a crisis in the future. Thanks.

DR. O'NEILL: I think there are several -- that is a question that could probably take up several days of conferencing to talk about, but I will mention a few things that come to mind.

First of all, drawing global attention to the fact that treatment is possible, and that treatment is a priority, is tremendously important for delivering prevention messages, and making people aware that this is actually out there.

If people have hope -- and the President was very clear on this when he has spoken about this -- but that if people have hope, they will get tested and they will come in for treatment if treatment is available.

I think the second point is that this program is going to build a tremendous amount of training materials, infrastructure, a huge focus on the whole issue in Africa that can't help but benefit other countries that are not part of the 14.

And also I remind you that this is not taking money away from the existing over one billion dollar investment that this Administration is making in global AIDS that covers 50 or 51 other countries.

But it is taking a very strong leadership, and making a very clear statement to the world, that HIV is here, that we have to do something about it, that treatment is possible, and that we are calling on other developed countries of the world to join us in this, and to work with us to make sure that people all around the world have the options that we intend the people in these 14 countries to have.

DR. FRAZER: I would just add particularly on Mauritius that the African Growth and Opportunity Act, the AGOA Forum that was just held during January, the First Lady launched an initiative with a girl's secondary school that is part of the President's broader Africa education initiative, which has an HIV/AIDS component in it for prevention education.

MODERATOR: The gentleman in the back.

MR. FULTZ: Mark Fox, BBC News. I would be interested to hear Mr. O'Neill's reaction to the criticisms from Global AIDS Alliance that you have only given around half of what they feel is the fair share for the United States given its GDP to donate to the global fund.

And also today that suggesting that there was some pressure coming from the White House on the Senators to cut the funding even further with the bill that is in the Foreign Relations Committee, and is apparently stalled.

DR. O'NEILL: One of the -- it is Dr. O'Neill, first of all -- and I think that it is sort of interesting that it seems that every silver lining has to have a cloud, and some people will look very, very hard to find that cloud.

We have made again the first contribution to the global fund, and are by far and away the largest contributors to the global fund. The President announced in his State of the Union address an additional one billion dollar donation to the global fund.

We are very proud of that, and we intend to continue working both multilaterally, as well as bilaterally, to fight this scourge of HIV and AIDS. We expect criticism, and we are used to it, but it is not going to dissuade us from doing what we think is the right thing to do, and what we think is the right way to do it.

MODERATOR: Okay. The lady up front here.

MS. ANTOA (phonetic): Sarantuya Tsedevsuren, a TV reporter from Mongolia. Mr. O'Neill, can I interest you in the cooperation and policy of the Office of the National AIDS policy with Asian countries?

DR. O'NEILL: Absolutely. This government, and this Administration, is interested in this issue all over the world. And make no mistake about it, the fact that we are focusing on these countries means that we are focusing where 50 percent of AIDS is in the world right now. And we are very aware, and our institutions have done much of the leading research that have demonstrated the fact that we have emerging HIV epidemics in many other parts of the world, including dramatically in parts of Asia.

We are absolutely committed to working with you, and we are absolutely committed to continuing our support of the global fund, which makes money available for other parts of the world, as well as our other bilateral $1 billion annual contributions for our bilateral activities, which cover 50 or 51 countries, which would certainly include many countries in your region of the world.

MODERATOR: The lady up front here.

MS. ELLIS: Susan Ellis, Washington File. Dr. Fauci, will you talk a little bit more about the Haiti situation. You said that Dr. Jean Pape --

DR. FAUCI: P-A-P-E, Jean W. Pape.

MS. ELLIS: Will you talk a little more --

DR. FAUCI: Yes. I mean, there is an organization in Haiti that Dr. Pape has been working fundamentally in the research arena, and then realizing very clearly that you cannot conduct research as we all know now in this country without addressing the very compelling issues and problems of prevention and care.
So he has with his colleagues, and he is not alone, but he is the one that we deal with who is very well known in Haiti, together with a person named Dr. Paul Farmer, from the Harvard School of Public Health. Dr. Farmer has initiated years ago the direct observation of therapy short-course, what we call Dots for Tuberculosis, and successfully translated that model to going out into the bush and getting anti-HIV drugs to individuals in the rural areas of Haiti.

So in a country where it looked like, because there was a somewhat inadequate health care delivery system, that you actually couldn't treat people with HIV, which is very often the misperception that has stalled a lot of the efforts of trying to get individuals who are HIV infected to be treated.

And as Dr. O'Neill said, it is important to put together on the same scale treatment and prevention, because in this country, before we had anti-retroviral drugs at all, it was very difficult to get people in to get the message of prevention to them, because you didn't have anything to offer them. But we found out that as soon as you have prevention, if you got people to talk about HIV, and to determine if they were infected, that they knew that if they turned out to be infected that you would have something to offer them. So there was a great incentive to come in and get involved in these programs. We found that is the same situation that they are seeing in Haiti, and that they have been quite successful with minimal resources -- the same sort of thing that we have seen now in Uganda, and there are programs in Kenya that are starting to get off the ground now. We see the same sort of thing in a variety of other countries.

So we feel that by linking those three -- and that is the reason why those three are inexplicably linked in the program -- that there will be a double and triple-barrel benefit. You get people into care and you treat people, and hopefully you would spread the prevention method.

MODERATOR: Okay. The lady on the left there, followed by the lady in the middle.

MS. ZIEGLER: Julie Ziegler with Bloomberg News. I am wondering what role you might see the private sector playing, if any, in implementing the President's proposal. Specifically, would there be any companies that might be awarded contracts as a result of this, or just --

DR. FAUCI: This gets back to the question that the gentleman asked also about infrastructure. There are NGOs, and there are a number of private organizations, and some governments are heavily involved and others are not, and in the countries that the governments are not, there may be NGOs that are heavily involved, and there are some in which there are both. Private organizations, we all feel, and not just we, the United States, but people, anyone -- European countries, and in-country people who have experience -- realize that you have to have private organizations. You have to have NGOs involved, people and organizations that have been there on the ground and know how the systems work.

So the purpose of this, whether money comes from the bilateral agreement, or even money that comes from the global fund, we feel that there is going to be a good deal of similarity of how you get translation into programs, protocols, treatment programs, into the in-country area, is by embracing many private organizations. We feel that NGOs are going to play a major role in not only bilateral programs, but in the global fund program.

MODERATOR: The lady in the middle.

MS. ZIEGLER: I was asking more about private companies, and more like drug makers, and others, like the U.S. private sector, rather than NGOs.

DR. FAUCI: Well, I mean, of course drugs have to come from groups that either manufacture or retail drugs. If you take a look at some of the programs that are being successfully run, Uganda is one of them. There are drugs that come from companies, for example, and I just mention this as an example, Sipla was a company, and as you know an Indian company, that is making generic drugs available. There is a Thai company that is making triple drugs available for a reasonable price. And in fact many of those countries are interacting with those companies to get the drugs that they need. So they are obviously going to be an important part of the whole program.

DR. O'NEILL: And as I stated, in implementing this program, we very much would welcome interest from the private sector to work with us. Many private corporations have extremely well developed delivery systems in Africa, for example. We would love to be able to work with them in areas where those are needed. So we are very much in a mind frame about bringing as many types of partners into this fight. We can't do it alone. We need the best that America has to offer, but I also have to say that we need the best that the world has to offer here, and we would really welcome seeing other developed and wealthy countries join us in this really important effort.

MODERATOR: The lady in the middle there, please.

MS. ASHATI: Nora Ashati, Cox Newspapers. The President quoted some figures in his State of the Union, something like 4 million people needing immediate drug treatment in Africa, and 3 million children infected. And then there is the plan, and it is detailed, and it says that there is 2 million who are going to receive the anti-retroviral. How do you determine which 2 million? Which 2 million are going to get those?

DR. FAUCI: Those are all vetted out through WHO, and through publications, through individuals who work with U.N. AIDS. Generally, you feel that in a country in which there is a target population of X-number of people who are HIV infected, WHO and U.N. AIDS feel that you will reach them by programs that they have experience. You would reach about 50 percent of those individuals, and of the people that you reach who are HIV infected, the general types of surveillance that have gone on would indicate that about 20 percent of those people would be at the stage of infection, where they would require immediate treatment.

So all of these are derived numbers that we didn't just pick out. We really very heavily relied on the numbers that were coming out from WHO for the individual countries. The number of infected people, and the projection of the rate of the epidemic, the number of people who might be infected. Those numbers -- we didn't want to recreate the wheel on this. We wanted to go with what was established by our international colleagues.

MODERATOR: Okay. The last questions, and let's take the lady and the gentleman right here.

MS. PATRICK: Hi, Kelly Patrick, the Globe and Mail. In the release you mentioned that the $1 billion that is being committed to the global AIDS fund is going to be contingent on the funds performance. Can you tell me specifically how you are going to judge the fund's performance when deciding on whether or not to extend the rest of the billion that you promised?

DR. O'NEILL: No, the $1 billion is committed to the global fund. We are open to and we want the fund to succeed. Remember that we made the first contribution to the fund. The kinds of things that we -- and I think we feel very good about the signs that we are seeing from the fund -- but the most important point that I want to make is looking at this initiative that we are talking about here today, it is a focused initiative in a focused part of the world to do specific things, and we feel that the way to do that and accomplish that goal is through this bilateral effort.

DR. FRAZER: Let me just add to that. We obviously think that the global fund is working effectively, but in out years, one is going to need to look, to see what results on the ground are actually occurring. So, in the global fund there is a mechanism for accountability, in terms of results on the ground. That is the measure, the criteria, the most important. In addition, as I said earlier, part of the idea of putting the money in a global fund was to get other donors to join us, and so we very much will watch to see that. The fund was never intended to be a hundred percent U.S. financed mechanism. It was intended to get others internationally to join us. So in the second round of pledging, it is going to be extremely important for other donors to also step up and contribute. The President did with this billion dollar announcement, and what we are looking for is for the other donor countries to also contribute in the second round of pledging.

MR. TAZI: Good morning. My name is Phillip Tazi, and I am with the African Correspondence Association. I just got back from Cameroon, where I spent a month talking to young people across the country, and I was quite struck by some of the things that they were able to share with me regarding the attitude towards HIV/AIDS. But as an African immigrant living here in the United States, I wanted to ask many of us feel frustrated because we can reach out to foundations here in the U.S., but we really don't have the results as to get most of the material that we collect here and send it back to the continent. Is there somewhere where we could go to get a list of foundations that would supply more materials and also have the shipping? Over the years I have spent plenty of money shipping boxes of supplies, and I just thought that someone might be able to share information about it.

DR. FRAZER: I will be glad to talk to you off-line and give you some ideas about where we can go. There are a lot of foundations in this country and around the world who are very interested in the issue of global HIV and AIDS, and interested in Africa. We talked to many of them in our office, and we would be happy to help solve some of those problems that you just articulated.

MODERATOR: Thank you very much, doctors. Thank you, ladies and gentlemen.