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[These reports do not necessarily reflect the views of the United Nations] CONTENT: 1 - AFRICA: Interview with Dr Jim Kim, director of WHO's HIV/AIDS department 2 - AFRICA: Interview with Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa 1 - AFRICA: Interview with Dr Jim Kim, director of WHO's HIV/AIDS department NAIROBI, 5 September (IRIN) - Dr Jim Kim, Director HIV/AIDS Department, WHOIn 2003 the World Health Organisation (WHO) joined UNAIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria to declare the lack of access to antiretroviral (ARV) drugs a global health emergency. In response, WHO and its partners launched the 'Treat 3 Million by 2005' (3 by 5) initiative. IRIN/PlusNews spoke to Dr Jim Kim, director of WHO's HIV/AIDS department. QUESTION: After the problems seen in Arusha with the Fund's next round and donors' apparent reluctance to increase their funding, what guarantees of sustainability can mass antiretroviral therapy (ART) have? Are we urging poor countries to take on life-or-death commitments that are dependent on erratic outside funding? ANSWER: Around the world, entire communities face social collapse because of the AIDS pandemic. The drive to provide treatment comes from affected countries and their leaders. WHO is working with ministries of health to provide technical assistance to help scale up treatment. Because treatment is for life, long-term funding is essential to ensure that an entire generation will not be lost to HIV/AIDS. Current resources are the result of extraordinary advocacy efforts by communities living with HIV, activists, NGOs, faith-based organisations, leadership from heads of state and multilateral organisations. There was nothing automatic about getting the funding we have, and there will be nothing automatic about sustaining it but, in my view, this is simply the task we are faced with if we are serious about tackling the worst pandemic mankind has faced for hundreds of years. Those of us who have the means to mobilise at a community, national and international level must do so to ensure appropriate resources. The Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria has been a remarkable instrument in galvanising global treatment and prevention of HIV/AIDS. Three years ago, the Global Fund was an idea: since then it has raised US $3 billion - two-thirds of which is dedicated to HIV/AIDS - and are successful in rolling that money out into effective prevention and treatment programmes. The United States President's Emergency Programme for AIDS Relief (PEPFAR) has committed $15 billion to AIDS relief globally and is also moving quickly. National governments have also increased funding for treatment - the British government recently doubled its international AIDS budget. New commitments from the World Bank, as well as the private sector and non-governmental, faith-based and community organisations, have also emerged. Six million people living with AIDS need ART now, and this number is growing. The '3 by 5' target aims to mobilise the world to treat half of those in need - three million by the end of 2005. Continued long-term national and international support is essential to continue to move towards reaching the target. We simply must recommit ourselves to doing whatever it takes to meet the challenges ahead. Q: To what extent has the recent controversy around generic companies withdrawing from the World Health Organisation's prequalification list threatened the survival of antiretroviral programmes? A: What we are talking about here is short-term pain for long-term gain; it is about improving the overall quality of medicines for all poor people, not just those living with HIV. As drugs are relisted over the next few months, in the medium to long term I think we will all conclude that the prequalification process will have had a positive affect on scaling up treatment. The Prequalification project, set up in 2001, is a service provided by WHO to facilitate access to medicines that meet unified standards of quality, safety and efficacy for HIV/AIDS, malaria and tuberculosis. Prequalification was originally intended to give United Nations procurement agencies, such as UNICEF, the choice of a range of quality medicines. Countries most in need of life-saving ARV and other drugs often do not have the regulatory capacity to ensure the safety and quality of medicines from different suppliers around the world. With time, the growing list of medicines that have been found to meet the set requirements has come to be seen as a useful tool for anyone purchasing medicines in bulk, including countries and other organisations. Companies wishing to have a product prequalified voluntarily submit a dossier to WHO, to allow qualified assessment teams to evaluate its quality, safety and efficacy. The manufacturer must also open its manufacturing sites to an inspection, comprised of regulatory experts from among 28 of the world's leading national regulatory agencies, including experts from Europe, Canada and Australia. Ranbaxy Laboratories Limited informed WHO in November that it was voluntarily withdrawing all its antiretrovirals (product dossiers under assessment and all prequalified products) from WHO prequalification. This action was taken after the company found discrepancies in the documentation relating to proof of the products' bioequivalence with originator medicines. The company has already presented WHO with a plan indicating proposed dates for the submission of new study reports for these products - the first study is expected to be completed by December 2004. Rather than threatening the survival of antiretroviral programmes, this withdrawal seeks to ensure the improvement of medicines. [Information on the practical implications of the withdrawal of the above-mentioned products from the list of prequalified products for treatment programmes can be accessed on the WHO prequalification project web site, where the list of alternative products prequalified by WHO may also be found. [http://mednet3.who.int/] Q: Isn't there a danger that the "positive living" aspect of HIV/AIDS treatment - better nutrition, for example - is being lost with all the focus on ART? A: WHO supports positive living - good nutrition, exercise, etc. - but none of those things alone have ever been shown to halt the progression of HIV disease. The only intervention that has ever been shown to have a proven impact on mortality is ARV therapy. However, there is no question that good nutrition, exercise and many other aspects of healthy life can have beneficial effects for everyone, especially those living with HIV and AIDS. Comprehensive programmes that integrate treatment and prevention, as well as the promotion of 'positive living', are essential. As access to treatment and prevention is increased within countries, health systems and infrastructures will be strengthened, which will have wide- reaching effects on improving public health services for everyone. As more people are brought onto treatment, People living with HIV/AIDS visiting health centres for their treatment checkups will have increased opportunities to consult with a health professional about their overall health. A focus on ART does not mean the neglect of other, essential areas of care for [people living with HIV/AIDS] PLWHA - rather, it enhances these other areas. Q: What do you think are the key components of a successful government rollout of ART? A: The most important component is strong political will and commitment to implementing a comprehensive approach to HIV that involves accelerating both treatment and prevention. Leaders have the responsibility to stand up to AIDS and take the fight forward. We have already seen great progress in terms of leadership: we now have nearly $ 20 billion pledged for integrated AIDS prevention and care, and more and more countries are committing to scaling up treatment and care. Partnerships and collaboration at country and international level between all stakeholders - national authorities, UN agencies, multilateral agencies, foundations, non-governmental, faith-based and community organisations, the private sector, labour unions and representatives of the community of people living with HIV/AIDS - are absolutely essential for successful rollout. Everybody has a role to play and all stakeholders need to work together, coordinating in line with the 'three ones' principals initiated by UNAIDS for one agreed HIV/AIDS action framework that provides the basis for coordinating the work of all partners; one national AIDS coordinating authority, with a broad-based multi-sector mandate; and one agreed country-level monitoring and evaluation system. WHO works closely with ministries of health and others partners in-country, to design national HIV/AIDS plans and to identify existing gaps. Prevention and treatment needs differ from region to region, as well as country to country. The kind of assistance Belarus needs might be quite different from the needs of Swaziland or the Philippines. But what countries are consistently asking for is technical assistance to turn funding into national AIDS plans, and to turn plans into real programmes for people living with and affected by HIV/AIDS. WHO is working with countries to provide this technical assistance, but much more collaboration is needed. Q: Beyond the rhetoric, are people living with HIV and AIDS really considered an asset in the response to HIV and AIDS, rather than the source of the problem? A: HIV is non-discriminatory and can hit anyone at any time and in any walk of life. Conversely, PLWHA are absolutely central to the fight against HIV/AIDS and, from the beginning, it has been AIDS activists who have pushed society towards deeper dialogue and swifter action in fighting AIDS. PLWHA live in the communities with the most need of prevention, treatment and care, and are best equipped to advocate for change. Never before have a group of people affected by a disease stood up so loudly and effectively to fight it. As ambassadors, PLWHA involved in the fight against HIV/AIDS can help defeat the epidemic like no one else. WHO is involving PLWHA at every level of the drive to reach the '3 by 5' target. In November 2004, WHO awarded a $1.5 million contract to the Tides Foundation-Collaborative Fund, a global consortium of people living with HIV/AIDS, and treatment activists, to help prepare PLWHA for ART. In implementing the million-dollar grant, the Tides Foundation-Collaborative Fund is supporting more than 30 networks of PLWHA around the world in treatment preparedness activities, including treatment literacy projects and civil society advocacy initiatives. The future of health belongs as much in the hands of those affected as those who care for them. People living with HIV/AIDS must be involved in all aspects of HIV/AIDS programmes and at all levels of decision-making and activity. December 2004[ENDS] 2 - AFRICA: Interview with Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa NAIROBI, 1 December (IRIN) - Stephen Lewis UN Special Envoy for HIV/AIDS in Africa. Credit: IRIN Stephen Lewis is the UN Special Envoy for HIV/AIDS in Africa, and has been a key campaigner for urgent and robust international action to meet the challenge of the pandemic. He spoke to IRIN/PlusNews about his optimism over the '3 by 5' initiative. QUESTION: After the problems seen in Arusha with the Global Fund's next round and donors' apparent reluctance to increase their funding, what guarantees of sustainability can mass antiretroviral (ARV) treatment have? ANSWER: My own feeling is that it will be impossible for the western world to turn off the financial tap once the treatment is underway. The treatment will be abridged by the amount of money available, but I think however many people are put into treatment, that treatment will be sustained. I do not foresee a situation where the resources will suddenly be cut off in the middle of the treatment. I also feel confident that we're going to turn a significant financial corner in 2005; that there's something really important happening, which isn't fully understood yet, and that's that the United Kingdom is taking over the AIDS agenda. The UK has the chairpersonship of the G8 next year, and of the European Union. They've already said they're going to host the Global Fund meeting in September, and they've asked for a major meeting in March to bring together all the major players. [Chancellor of the Exchequer] Gordon Brown is pursuing relentlessly [industrialised countries], moving them to the 0.7 percent of GDP target for ODA [Overseas Development Aid]. The way in which the United Kingdom is taking on this agenda finally gives leadership to what has been the most difficult problem on the planet: the leadership simply has not been there before. So, I have a cautious optimism that we're about to see a significant jump in resources. And I'm one of those people who still believe that it is possible to achieve the WHO's [World Health Organisation] target of three million people in treatment by 2005. I genuinely believe it's still within reach, and that the momentum is picking up at country level. I don't want to pretend it's going to be easy, though - it's going to be very tough. Q: Are we urging poor countries to take on life-or-death commitments that are dependent on erratic outside funding? A: In a sense we are. Let's take Lesotho, for example: they want to have 28,000 people on treatment by 2005, and this is without question one of the poorest countries on the face of the earth; a country that lacks capacity and has one of the highest prevalence rates in the world. Nevertheless, the government is so determined to save its people that I feel nothing will stop them, and if Global Fund money suddenly dried up, they'd be on the hook, but I don't believe their treatment programme would fall apart - because every one of these countries understands they are in a life-or-death struggle. Personally, I don't believe they'll be faced by abandonment but, if that terrible prospect happened, they would somehow sustain treatment. Q: To what extent has the recent controversy around some generic companies withdrawing from the World Health Organisation's prequalification list threatened the survival of ARV programmes? A: I don't think it's threatened it one whit. I think what is important is to recognise that what the WHO was doing was being fiercely protective of quality assurance. I think the significant thing that's happened is not that the drugs were de-listed because they're of lesser quality, but because some of the bioequivalence work done by others was shoddy. What I think is really important is the fact that two of [generic drug manufacturer] CIPLA's drugs have been reinstated after they were given appropriate bioequivalency studies. In early 2005 I think you'll see additional drugs reinstated and new drugs put on the list. The WHO's 3 by 5 programme and its prequalification process, and the support they've given for generics, are among the most dramatic and visionary interventions of any made by the UN since this began. Q: Isn't there a danger that the positive living aspect of HIV/AIDS treatment is being lost with all the focus on ART? A: There is inevitably the argument being put that prevention is being sidelined by this obsession with treatment, and that nutrition is being diminished somewhat, and that the various opportunistic infections are being inadequately attended to, and that the simple truth of positive living is being diminished because of the obsession with ARVs - I understand that. But my own feeling is that once we get treatment significantly underway, everything else will be given it's due. It was inevitable, as you have 25 million people in Africa fighting for survival, that the treatment process would preoccupy us. But it will calm down and, as it does, the focus on positive living and nutrition - all these things - will reassert their place again. I don't really think they're being lost, but I think the debate and the loud discourse about treatment inevitably takes the centre of attention. [Meanwhile] the health sector must benefit from what's happening, otherwise it makes no sense - it must include the building of capacity: they won't be able to sustain the treatment unless they have greater capacity. In many ways capacity is an even greater hurdle than the flow of resources. Treatment must not displace all the other priorities in the health system. We have to recognise ARVs are the centrepiece of the struggle at the moment, but the treatment of AIDS must be seen as a way to strengthen capacity and infrastructure. Q: What do you think are the key components of a successful government rollout of ART? A: Number one: there must be a voluntary testing and counselling culture developed in the country - testing must become central to the response and very careful and sophisticated counselling techniques must be developed and honoured and implemented. Number two, I think, is the constant and steady and reliable flow of drugs - those drugs must never be interrupted. Overall, it would be preferable to have the fixed-dose combination generic as the first line of response. It may be that the brand-name products will one day come up with a fixed-dose combination of their own but, at the moment, we need a continuous flow of the fixed-dose combination drugs. Number three: we need the facilities and the capacity to sustain the treatment, and that means an adequate number of health professionals, which means an emergency training intervention - you don't always need a doctor or even a nurse, but you do need people who are carefully trained in the minimum requirements. We can't continue to lose health professionals from these high-prevalence countries - western countries have to come up with an agreement whereby we won't be poaching health workers from these countries; they have to be paid an adequate salary and given benefits, so that they'll be induced to stay in their countries. The fourth component is to make sure that you have a network of community health workers, who can follow the people who have AIDS back into their communities and make sure the regimens are adhered to, and that resistance or side effects are dealt with - the most recent UNAIDS report showed that 90 percent of the care is being done at a community level. I'm probably missing many things, but for me those four points are key. There's another ingredient people don't talk about enough, and that's food; I'm not merely talking nutrition; I'm talking survival - enough food not to be starving and perpetually hungry; so hungry it robs your immune system of its ability to fight the virus. The problem of food in so many of the southern African countries is desperately acute. Again, you have a UN agency which is showing an astonishing resolve and response, and that's the WFP [World Food Programme]. What they're doing at a country level - you just have to see it to believe it. They've completely enlarged their focus, so they're not only responding to natural disasters, they're responding to the human predicament of AIDS. Q: Beyond the rhetoric, are people living with AIDS really considered an asset in the response to HIV and AIDS, rather than the source of the problem? A: I think the rhetoric is largely illusory - I don't trust the rhetoric. When I travel I don't see it being translated into genuine respect for people living with AIDS, and recognition of what they can contribute. A lot of it is extremely pro-forma and offensive, and it's used as a way of fobbing off the issue. I think it varies from country to country but, in most cases I've encountered, the government considers the people living with AIDS, who are leading the fight against prevention, as more of a nuisance than real contributors. They just simply don't get enough of a hearing, because it's not yet understood that they can contribute because they are the experts - they know everything about the virus. They should be meeting with ministries of health on a daily basis and talking to all the other sectors, including education and agriculture, and they should be demonstrating to governments - whether it's through the workplace or community programmes - how you overcome stigma. They should be integrated completely into public policy at every level and in every sector, and they are not. I never see due respect for the very knowledgeable and important community of people living with AIDS. I'm constantly reminding communities and governments that it's not just respect that's needed, it's also a recognition that you can't afford to lose this body of knowledge. 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