International AIDS Conference
Durban, South Africa
July 20, 2016
Good afternoon, and thank you for that kind introduction. Returning to South Africa is always a great pleasure – and I'm honored to be here today.
Coming back is also a reminder of my first trip in 1997, when I visited Soweto.
I was focused then on helping to close the digital divide, knowing that computers could help people achieve some important things.
But I also realized that I was missing a larger point. There I was donating computers, when this country – and much of this continent - was in the grip of a public health catastrophe that couldn't be solved by a PC.
In 1997, three million South Africans were living with HIV, with 2,000 more newly infected every day. And of the 30 million people living with HIV worldwide, more than two-thirds were in sub-Saharan Africa.
My visit to Soweto was a reality check.
And I start with this story because I think it's important for all of us involved in this fight against AIDS to recognize that the magnitude of our task remains substantial.
The reality today is that while the UNAIDS goals are laudable, the challenge to reach them is formidable.
There's no question that the world has made remarkable progress in the fight against HIV.
When this community last met in Durban, just a few thousand people in Africa were receiving treatment – now that number is more than 12 million.
New annual HIV infections have fallen by more than a third.
And back then, the cost of effective HIV drugs was about $10,000 a year, compared with under $100 today.
It is a tribute to those of you in this room – and many others - that this progress was possible.
But we can't let that success cause us to lose focus.
It won't be enough to just keep doing what we're already doing. It won't even be enough to expand our efforts with the tools currently available.
If we are to have any hope of achieving our audacious goals, then we will have to find new and better ways to dramatically accelerate progress.
Here is the reality facing us today:
The rate of decline in new HIV infections among adults is stagnating.
After an initial surge in the decade after the first Durban conference, new infections have dropped only 4.5 per cent since 2010.
And of the nearly 2 million people newly-infected each year, almost 1.4 million are here in sub-Saharan Africa – with women and girls infected at two-and-a-half times the rate of men.
There are gaps in treatment.
Almost half of those living with HIV are undiagnosed; millions who are, are not being treated; and millions more getting treatment aren't achieving sustained viral suppression.
There are even greater gaps when it comes to prevention.
People don't have access to or use condoms consistently; take-up of voluntary medical male circumcision is insufficient; and introduction of oral PrEP is not happening fast enough at the scale needed, and there are challenges to overcome in terms of the required regular, daily use.
At the same time, funding is flat lining.
Add to all this, the fact that we are chronically under-prepared for the looming challenge of the "demographic bulge," and the need to up our game becomes urgent.
The largest generation in history is entering the age when they are most at risk from HIV.
Here's what that means in sub-Saharan Africa.
In 1990, there were 94 million people between the ages of 15 and 24. Today that number has more than doubled. And by 2030, there will be more than 280 million young people in this part of the world.
So that highly vulnerable age group will be around three times as populous in 2030 as it was back in 1990.
It means, in effect, that with stagnating incidence rates, if we are only doing as well as we have been doing, there will be lots more people aged 15-24 living with HIV.
Indeed, modeling suggests that all the gains made in sub-Saharan Africa could be reversed.
Even by fully achieving the 90-90-90 treatment goals, the impact on incidence by 2030 will be modest at best.
As UNAIDS rightly acknowledges, only meeting highly ambitious prevention targets will have the kind of impact we need.
So we convene here at a pivotal moment.
To start writing the story of the end of AIDS, new interventions and new ways of thinking about treatment and prevention are essential.
First, delivery of treatment needs to be more effective and more efficient – starting with finding innovative ways to reach and treat the 16 million people worldwide who do not know they are living with HIV.
We need more creative and effective ideas to make testing and treatment both more accessible and more acceptable.
This includes initiatives like self-testing, simplified community care models, and longer-lasting supplies of treatment drugs to cut down the number of visits people have to make to the clinic.
Every single person living with HIV should be encouraged to seek treatment; enabled to reach viral suppression; and empowered to sustain it. And we know those benefits don't end with the individual, since treatment also lowers the risk one has of passing the virus to partners and loved ones.
But the truth is: We're not going to treat our way out of this epidemic.
So second, we need a stronger and more rigorous approach to primary prevention to help people protect themselves and others from infection.
We need to get much more out of existing prevention methods, and there are some good practices to draw on.
Backed by social marketing initiatives and increased availability, South Africa and Zimbabwe saw increases in condom use.
Kenya and South Africa have started systematically rolling out oral PrEP programs, beginning with people at high risk.
And Kenya has shown how a country with a well-organized program that includes sufficient funding, data analysis, and myth-busting campaigns, can achieve its targets for voluntary medical male circumcision.
Male circumcision is an amazing advance; the single most powerful one-time intervention there is.
But the new target calls for 27 million additional voluntary circumcisions by 2020. And to date, only about 12 million men and boys have been able to access one.
Scaling up male circumcision, making it – and keeping it – a routine health intervention must be a priority. But current funding is insufficient and monitoring of take-up inadequate.
The payoff from expanding the use and efficiency of existing prevention tools is potentially huge.
But even if we did everything possible with what we have today, it won't be anywhere near enough to help us achieve the ultimate goal of ending AIDS as a public health threat.
In the end, if we are going to get to where we want to get, we must develop and deliver new prevention techniques that people want and will use.
There are promising advances in the R&D pipeline, such as anti-retrovirals that stay in the bloodstream for long periods of time, or a reasonably effective vaccine.
It will take time before anything truly revolutionary is available, perhaps 5-10 years on an optimistic view.
But this research has to be funded aggressively, it has to be funded sustainably – and, most important of all, it has to be funded now.
The dramatic growth in funding that we saw from 2000 has slowed. And there are no guarantees of increases as the world's attention is drawn to other economic, political, and social challenges.
So we need to keep making the case not only for maintaining R&D funding, but for why we also need more of it. Then we need to make sure that it gets properly allocated.
We urgently need to turn ideas into products more quickly. Because every day that passes, another 5,500 lives are changed forever.
But whatever new solutions we come up with, each one must include effective campaigns to counter the stigma and discrimination that continue to undermine our efforts to beat this epidemic.
So the third thing we need to do, is gain a deeper understanding of the social and cultural dynamics around this disease.
Every place has a unique epidemic; so every place must have a unique response.
There is no one-size-fits-all solution.
That's why prevention efforts that engage with specific at-risk communities and address their distinct circumstances - like the Avahan project for sex workers in India - have proven more effective than broad prevention campaigns.
But those programs are hard to design, and hard to execute on.
We need better information about what motivates people to access and use prevention tools.
And we need more knowledge about the barriers that inhibit take-up.
Do the tools fit with their daily routines? Are people and their partners comfortable using them? Are they too expensive? Are they readily and consistently available?
Knowledge gaps are greatest when it comes to women and girls.
We simply don't have good enough data about what directly and indirectly increases their HIV risk: poverty, gender inequality, forced and early marriage, sexual violence, lack of education.
As Melinda said recently, there is either no data, and even where data exists, it often ignores women and girls entirely or it misrepresents their unique circumstances.
PEPFAR'S "DREAMS" project, and complementary initiatives by the Global Fund, should help us learn more about the distinctive needs and wants of adolescent girls and young women.
Having good information is one thing. It then has to inform a good response. In particular, for young women, sex workers, men who have sex with men, and people who use drugs.
Because unless we start to dramatically reduce new infections across all key populations, we face potentially catastrophic consequences.
Without huge efficiencies in treatment and prevention; new prevention tools; more funding – both domestic and international, including a fully-replenished Global Fund; and a greater curiosity about people's lives, then it hangs in the balance whether the next generation actually ends up with more HIV than any previous one.
We have a choice about that.
We can keep doing the same things, the same way, and run the serious risk of a resurgent epidemic.
Or we can push ourselves to discover, develop, and deliver more effective treatment and prevention methods and strategies.
If we do that, we will have matched our compassion with our capabilities and given millions of our fellow human beings the chance to lead the full, productive lives they deserve.
And only if we do that, will we turn the promise of an AIDS-free world from a slogan into a reality.