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Secretary of State Hillary Rodham Clinton Remarks on an AIDS-Free Generation
National Institutes of Health, Bethesda Maryland
Thank you, Francis, for that introduction—and Tony for those inspiring opening remarks. It’s not easy to follow one of the top 20 federal employees of all time. Government Executive magazine got it right. That’s a richly deserved recognition, Tony.
It is an honor to be here with all of you today—in a room filled with some of America’s best scientists and most passionate advocates, true global health heroes, in an institution that is on the front lines of the fight against HIV/AIDS. I especially want to recognize Ambassador Eric Goosby, our Global AIDS Coordinator, and his predecessor, Mark Dybul; Lois Quam, the executive director of our Global Health Initiative; Tom Frieden from the Centers for Disease Control and Prevention; and UNAIDS Executive Director Michel Sidibe. Thank you all for your service and leadership.
I also want to acknowledge two people who could not be with us: First, USAID Administrator Raj Shah, who has had such a positive impact on our health and development work. And, second, I am delighted to announce our new Special Envoy for Global AIDS Awareness: Ellen DeGeneres. Ellen will bring her sharp wit and big heart—and her impressive TV audience and 8 million followers on Twitter—to raising awareness and support for this effort. I know we can look forward to many wonderful contributions from Ellen and her loyal fans.
The fight against AIDS began three decades ago. In June 1981, American scientists reported the first evidence of a mysterious new disease. It was killing young men by leaving them vulnerable to rare forms of pneumonia, cancer, and other health problems. At first, doctors knew virtually nothing about this disease. Today, 30 years later, we know a great deal.
We know, of course, about its horrific impact. AIDS has killed 30 million people around the world and 34 million people are living with HIV today. In sub-Saharan Africa—where 60 percent of the people with HIV are women and girls—it left a generation of children to grow up without mothers, fathers, or teachers. In some communities, the only growth industry was the funeral business.
Thirty years later, we also know a great deal about the virus itself. We understand how it is spread… how it constantly mutates in the body… how it hides from the immune system. And we have turned this knowledge to our advantage—developing ingenious ways to prevent its transmission, and dozens of drugs that keep millions of people alive. AIDS is still an incurable disease, but it no longer has to be a death sentence.
Finally, after thirty years, we know a great deal about ourselves. The worst plague of our lifetime brought out the best in humanity. Around the world, governments, businesses, faith communities, activists, and individuals from every walk of life have come together, giving their time and money—along with their heads and hearts—to fight AIDS.
Although the past thirty years have been a remarkable journey, we still have a long, hard road ahead of us. But today, thanks both to new knowledge and to new ways of applying it, we have the chance to give new lives and new futures not only to millions of people who are alive today, but also to an entire generation yet to be born. Today, I would like to talk about how we arrived at this historic moment and what the world can and must do to defeat AIDS.
From its earliest days, the fight against HIV/AIDS has been a global effort. But in the story of this fight, America’s name comes up again and again.
In the past few weeks, I’ve spoken about various aspects of American leadership, from creating economic opportunity to preserving peace and standing up for democracy. Our efforts in global health are another pillar of our leadership. They advance our national interests, making other countries more stable and the United States more secure. They’re an expression of our values—of who we are as a people. And they generate enormous goodwill.
At a time when people are raising questions about America’s role in the world, our leadership in global health reminds them who we are and what we do. We are the nation that has done more than any other country to save the lives of millions of people beyond our borders.
Our efforts begin with the American public: from people living with the disease, to researchers in academic medical centers, to individual donors, to businesses and foundations. Philanthropies like the Clinton Foundation, which has helped make treatment more affordable by supporting innovative ways to manufacture and purchase drugs, and the Bill & Melinda Gates Foundation, which has underwritten breakthrough research.
But no institution in the world has done more than the U.S. government. We have produced a track record of excellence in science. Researchers here at the NIH conducted pivotal research that identified HIV and proved that it causes AIDS. The first drug to treat AIDS was supported by the United States. Today we are making major investments in the search for a vaccine; for tools like microbicides, which give women the power to protect themselves; and for other lifesaving innovations.
Alongside our research and development work, the United States has led a global effort to bring these advances to bear in saving lives. When my husband was president, he appointed America’s first AIDS czar and more than tripled U.S. investments in preventing and treating AIDS worldwide. And in 2003, with strong bipartisan support from Congress, President Bush made the momentous decision to launch the President’s Emergency Plan for AIDS Relief, or PEPFAR.
At the time, only 50,000 people in sub-Saharan Africa were receiving the anti-retroviral drugs that would keep them alive. Now more than 5 million do, along with more than a million people in other regions. And the vast majority receive drugs financed by either PEPFAR or the Global Fund to Fight AIDS, Tuberculosis, and Malaria—which the United States helped create.
And PEPFAR is having an impact far beyond AIDS. It has expanded on the World Health Organization’s efforts to treat and prevent tuberculosis, which is the leading cause of death among people with AIDS. PEPFAR has also helped build new facilities throughout our partner countries that see patients not just for HIV/AIDS but for malaria, for immunizations, and much more. To staff these clinics, we helped train a new cadre of professional health workers, who are making their countries more self-sufficient. In some countries, the same trucks that deliver AIDS medicine now also deliver bed nets to prevent malaria. For all these reasons, PEPFAR is one of the platforms upon which the Obama Administration built our Global Health Initiative, which supports one-stop clinics offering an array of health services while driving down costs, driving up impact, and saving more lives.
I say all of this because I want the American people to understand the irreplaceable role the United States has played in the fight against HIV/AIDS—and the need to keep going.
To be sure, we have done it in an ever-expanding partnership with other governments, multilateral institutions, implementing organizations, the private sector, and civil-society groups—especially those led by people living with the virus. But the world couldn’t have come this far without us, and it won’t defeat AIDS without us.
What’s more, our efforts have helped set the stage for the historic opportunity the world has today: to change the course of this pandemic and usher in an AIDS-free generation.
By an AIDS-free generation, I mean one where, first, virtually no children are born with the virus; second, as these children become teenagers and adults, they are at far lower risk of becoming infected than they would be today, thanks to a wide range of prevention tools; and third, if they do acquire HIV, they have access to treatment that helps prevent them from developing AIDS and passing the virus on to others.
HIV may be with us well into the future. But the disease that it causes need not be.
This is an ambitious goal, and I recognize that I am not the first person to envision it. But creating an AIDS-free generation has never been a policy priority for the United States government—until today.
This goal would have been unimaginable just a few years ago. Yet it is possible, because of scientific advances largely funded by the United States and new practices put in place by this administration and our many partners around the world. While the finish line is not yet in sight, we know we can get there, because we know the route we need to take.
It requires all of us to put a variety of scientifically proven prevention tools to work in concert with each other. Just as doctors talk about combination treatment—prescribing more than one drug at a time—we all must step up our use of combination prevention.
America’s combination-prevention strategy focuses on a set of interventions that have been proven most effective: ending mother-to-child transmission, expanding voluntary medical male circumcision, and scaling up treatment for people living with HIV/AIDS.
Of course, interventions like these can’t be successful in isolation. They work best when combined with condoms, counseling and testing, and other effective interventions. They rely on strong systems and personnel, including trained community health workers. And they depend on institutional and social changes like ending stigma; reducing discrimination against women and girls; stopping gender-based violence and exploitation, which continue to put women and girls at higher risk of HIV infection; and repealing laws that make people criminals simply because of their sexual orientation.
Even as we recognize all these crucial elements, today I want to focus on three key interventions that can make it possible to achieve an AIDS-free generation.
First, preventing mother-to-child transmission. Today, 1 in 7 new infections occurs when a mother passes the virus to her child. We can get that number to virtually zero, while saving mothers’ lives too.
In June, I visited the Buguruni Health Center in Tanzania. There I met a woman living with HIV who had recently given birth to a baby boy. She had been coming to the clinic throughout her pregnancy for medication and information—because she wanted her boy to get a healthy start in life, and most especially, she wanted him to be born HIV-free. When we met, she had just received the best news she could hope for: Her son did not have the virus. And thanks to the treatment she was getting there, she would live to see him grow up.
This is what American leadership and shared responsibility can accomplish for all mothers and children. The world already has the necessary tools and knowledge; last year alone, PEPFAR helped prevent 114,000 babies from being born with HIV.
Now we have a way forward too: PEPFAR and UNAIDS have brought together key partners to launch a global plan for eliminating new infections among children by 2015. And we continue to integrate prevention and treatment efforts with broader health programs, which not only prevents HIV infections, but also keeps children healthy and helps mothers give birth safely.
In addition to preventing mother-to-child transmission, an effective combination-prevention strategy has to include voluntary medical male circumcision. In the past few years, research has proven that this low-cost procedure reduces the risk of female-to-male transmission by more than 60 percent—and the benefit is life-long.
Since 2007, some 1,000,000 men around the world have been circumcised for HIV prevention. Three fourths of these procedures have been funded by PEPFAR. In Kenya and Tanzania alone, during special campaigns, clinicians perform more than 35,000 circumcisions a month.
In the fight against AIDS, the ideal intervention is one that prevents people from being infected in the first place. The methods I’ve just described are two of the most cost-effective interventions we have, and we’re scaling them up. But even once people do become HIV-positive, we can still make it far less likely that they’ll transmit the virus to others—by treating them with anti-retroviral drugs. This is the third element of combination prevention that I want to discuss today.
Thanks to U.S. government-funded research published just a few months ago, we now know that if you treat a person living with HIV effectively, you reduce the risk of transmission to a partner by 96 percent.
Of course, not everyone takes the medication exactly as directed, and so some people may not get the maximum level of protection. Even so, this new finding will have a profound impact on the fight against AIDS. For years, some have feared that scaling up treatment would detract from prevention efforts.
Now we know beyond a doubt: If we take a comprehensive view of our approach to the pandemic, treatment doesn’t take away from prevention. It adds to it. So let’s end the old debate over treatment versus prevention and embrace treatment as prevention.
There’s no question that scaling up treatment is expensive. But thanks to lower costs of drugs, bulk purchasing, and simple changes like shipping medication by ground instead of air, we and our partners are reducing the cost of treatment. In 2004, the cost to PEPFAR for providing ARVs and services to one patient averaged nearly $1,100 a year; today, it’s $335 and falling. Continuing to drive down these costs is a challenge for all of us—from donors and developing countries to institutions like the Global Fund.
Treating HIV-positive people before they become ill also has indirect economic benefits. It allows them to work, support their families, and contribute to their communities; and it averts social costs, such as caring for orphans whose parents die of AIDS-related illnesses. A study published just last month weighed the costs and benefits and found that—quote—“the economic benefits of treatment will substantially offset, and likely exceed, program costs within 10 years of investment.” In other words, treating people will not only save lives—it will generate considerable economic returns too.
Now, some people have concerns about treatment as prevention. They argue that many people transmit the virus to others shortly after they have acquired it themselves, but before they have begun treatment.
This is a legitimate concern, and we are studying ways to identify people sooner after transmission and help them avoid spreading the virus further. But to make a big dent in this pandemic, we don’t need to be able to identify and treat everyone as soon as they’re HIV-positive. In places where the pandemic is well established, as it is in most of sub-Saharan Africa, most transmissions come not from people who are newly infected, but from people with longstanding HIV infections who need treatment now or soon will.
We already have the tests we need to identify these people. If they receive and maintain their treatment, their health will improve dramatically, and they will be far less likely to transmit the virus to their partners.
Let me be clear: None of the interventions I’ve described can create an AIDS-free generation by itself. But used in combination with each other and with other powerful prevention methods, they present an extraordinary opportunity. Right now, more people are becoming infected every year than are starting treatment. We can reverse this trend. Mathematical models show that scaling up combination prevention to realistic levels in high-prevalence countries would drive down the worldwide rate of new infections by at least 40 to 60 percent. That’s on top of the 25 percent drop we’ve already seen in the past decade.