2010 International AIDS Conference

July 19, 2010
Prepared Remarks by Bill Gates, Co-chair and Trustee

Thank you, Vuyiseka, for that kind introduction.

I also want to thank President Clinton for the inspiring message he delivered this morning.

It’s an honor to speak with all of you today. As you saw in the video, the world has made amazing progress in the fight against HIV. Yet we also have to recognize that these are tough times for all of us who are passionate about this cause. Economic turbulence has driven up government deficits, and some countries have responded by freezing or even reducing their investments in global health.

This is a challenge we all face. But it does not need to define our time. I am here today because, when it comes to the fight against AIDS, I am still an optimist.

The past 10 years are a time of remarkable progress. Today more than 5 million people are receiving antiretroviral treatment, up from fewer than half a million just six years ago. Since 2001, the rate of new HIV infections has fallen 17 percent.

Those of you in this room helped make this progress possible. The scientists made progress on new tools to fight the disease. The community workers and clinicians drove prevention campaigns. The advocates argued for more funding – and the world responded by adding money for this cause faster than any other health problem in history. The Global Fund has been a fantastic vehicle for making sure this funding helps the people who have the greatest need.

All of you came together to overcome huge obstacles. Two decades ago, the skeptics said: “We can’t make drugs to treat a virus.” But you persisted – and now they can. Then the skeptics said: “We can make the drugs, but we can’t make them cheap enough.” But you kept pushing – and now they do. Then the skeptics said: “We can make the drugs cheaply, but we don’t know whether people will stick to the regimen.” But you insisted – and now they know.

Today the skeptics look at the struggling economy and say: “We can’t beat AIDS unless we can treat more people. And we can’t treat more people without more money. So if we don’t raise more money for treatment, we’ll lose the fight against AIDS. It’s hopeless.”

The skeptics have a point. This is a tough economic environment. Right now there isn’t enough money to simply treat our way out of this epidemic. If we keep spending our resources in exactly the same way we do today, we will fall further behind in our ability to treat everyone.

That’s why I want to make the case today that, even as we advocate for more funding, we can do more to get the most benefit from each dollar of funding and every ounce of effort.

If you push for a new focus on efficiency – in treatment and prevention – and also push to create new prevention tools, we can drive down the number of new infections dramatically and start writing the story of the end of AIDS.

Scaling up existing tools

Male circumcision

Our first task is to scale up the prevention efforts that are cheap, effective, and easy to apply. Some of these – especially male circumcision and preventing mother-to-child transmission – are so cheap, and so effective, that in endemic countries it is more expensive not to pursue them.

In a single month last year, 36,000 men in Kenya were circumcised, at a total cost to the government of $1.4 million. If these men had not been circumcised, and eventually became infected with HIV at the prevailing rate for uncircumcised males in Kenya, treating them would have cost the government nearly 10 times as much.

That’s an astonishing financial return – but it’s not just saving money; it’s saving lives.

I have to admit: When it comes to circumcision, I used to be one of the skeptics. I thought: “Sure, it reduces transmission by nearly 60 percent. But there’s no way that large numbers of men will sign up for it.”

I’m glad to say: I was wrong.

Wherever there are clinics available, men are volunteering to be circumcised in far greater numbers than I ever expected. I would like to show you a short video about one of them, a young man from Swaziland.

Last December, I went to South Africa to see for myself how enthusiastically men are embracing circumcision. I visited a clinic in the township of Orange Farm that serves more than 750 men every month. I met a few of them, and they were all thrilled about getting circumcised. The ones who had already undergone the procedure said it made it easier for them to use a condom.

I also met a surgeon – a tireless young woman named Josephine Otchere-Darko. She told me she had performed 67 circumcisions that day. I asked her, “When do you stop?” She said: “When we are done.”

Right intervention for the right population

Male circumcision is an amazing advance in prevention. If we had a vaccine that was as effective, we would do everything in our power to deliver it to every person who could benefit from it. And it is reaching many men – but not nearly enough of them. In the four years since we learned about its benefits, only 150,000 men in sub-Saharan Africa have been circumcised – out of 41 million who need it. That’s inexcusable. Countries need to make this a priority in their policies and in their funding. We have to do a far better job of scaling up interventions that are proven to work, as soon as they are proven to work.

We have seen similar gaps with other prevention efforts, including counseling sex workers and offering drug treatment and needle exchanges for drug users.

There are many reasons for these failures. For instance, more aid from donor countries needs to reach the people it’s intended to help.

But there is one reason that especially deserves our attention: Many prevention efforts are not targeting the communities where transmission is the highest.

According to the Know Your Epidemic report published this year by UNAIDS, 10 percent of HIV infections in Kenya are due to sex between men. In some coastal regions, it could be as high as 20 percent. Yet most districts in Kenya have no prevention programs for these men.

In Russia, the epidemic is concentrated among injecting drug users. In areas where they received clean needles, testing, and other services, the infection rate rose 15 percent over five years. Where they didn’t, it skyrocketed 105 percent. Clearly, these services work. Yet Russia has gutted them – cut the budget to zero – and shifted the money into programs for the general population.

Why? The problem is not a lack of data. UNAIDS can help any endemic country analyze information to understand which populations are at the greatest risk.

The problem is that many countries are not using this data to make their funding decisions. Instead, politicians are making them based on fear and stigma. They don’t want to associate themselves with people who engage in behavior that makes them uncomfortable.

As President Clinton said this morning, every dollar wasted puts a life at risk. If you’re afraid to match your prevention efforts to the right populations, then you’re wasting money – and that costs lives.

Treatment as prevention

There is one other prevention technique where greater efficiency will make a big impact: antiretroviral (ARV) treatment.

We now know that putting people on ARVs makes them far less likely to pass the virus on to others. Treatment is prevention. But this raises a crucial question: How can we get the most prevention benefit from the treatment we’re providing? When you have a higher CD4 count and your viral load is low, you feel healthy and are more sexually active. As your CD4 count drops, your viral load spikes, and you become less active, but you may be more infectious. When should you start treatment?

A recent study involving seven African countries found an intriguing answer: People with CD4 counts below 200 were six times more likely than healthier people to transmit the virus. This was true even after accounting for the fact that they were less sexually active. So whether your goal is to maximize the preventive benefits of treatment or to save as many lives as possible, you should focus first on treating everyone with a CD4 count below 200.

This gives us vital information for the fight against HIV. It helps us see where our treatment efforts can be targeted so they make the biggest impact for prevention.

At the same time, we have to face a harsh truth: Because of the virus’s long latency period, expanding our prevention efforts won’t drive down the number of deaths for a decade or more. Even as we act now to prevent future infections, the only way to save more lives immediately is to expand the number of people receiving treatment.

Unfortunately, the current high cost of treatment means we cannot treat everyone who needs it.

If you have AIDS, and you go to a health clinic, you should never have to hear someone say: “I’m sorry. You can’t have the drugs that would save your life. We don’t have the money.”

When funding is limited, there are two ways to stop turning people away and start expanding treatment: You can reduce the cost of the drugs; or you can reduce the cost of delivering them to patients.

The cheapest first-line drugs now cost less than $100 per year. We need to keep working to reduce the cost of these and other treatment drugs, especially the more effective regimes that contain tenofovir. But unfortunately, none of the drugs are likely to get a lot cheaper in the next few years.

That leaves one option for expanding treatment now: driving down the cost of delivery.

We are seeing exciting evidence that this is possible. In 2006, PEPFAR studied a number of its sites in Botswana and reported delivery costs of nearly $1,000 per patient per year. Two years later, the cost was down to $245. In Nigeria, it dropped from $2,000 to $280 – a reduction of nearly 90 percent.

Some of these savings come from minimizing personnel costs. As a site sees more patients, the staff needs less training. Some tasks can be shifted from doctors to nurses, or from nurses to assistants.

Some clinics also cut costs by simplifying their testing regimes. They may run fewer CD4 counts or check less often for toxicity.

To drive down the cost of delivering treatment, we need to do both: minimize personnel costs and simplify the testing regimes. But the best practices aren’t being measured or shared. Is there a more-expensive drug that actually saves money, because it requires less monitoring or can be delivered by lower-paid staff? We don’t know. We need to identify the most efficient models and then make sure every clinic follows them.

If we could limit the delivery and administrative costs to no more than twice the cost of the drugs themselves, then the total cost of treatment would be about $300 per patient per year. For the same amount of money we spend today, we could treat more than twice as many people.

ARV treatment and male circumcision are two powerful, proven tools for prevention, and we should scale them up as quickly as possible.

Another set of interventions – those designed to persuade people to change risky behavior – have had success in certain regions with certain populations. For instance, our foundation supports efforts in India to encourage sex workers and their clients to use condoms, and the results have been impressive. Now, as we scale up various methods of behavior change in Africa, we need to measure their impact so we know which ones make the biggest difference.

The payoff of scaling up existing tools could be huge. If we identify the most effective prevention efforts, and then expand access to them, we can prevent millions of deaths.

This is good news – but it is not good enough. Even if we did everything possible with the tools we have today, the most optimistic predictions suggest that they would only reduce new infections by half. Millions of people would continue to transmit the virus, and we would never have enough money to treat everyone who needed it.

Developing new tools

Fortunately, there is no reason to assume that in the future we will be limited to fighting HIV with the tools we have today. We can do better. Innovations in basic science, diagnostics, computer modeling, and our understanding of the virus itself will make it possible to create new weapons for the fight against AIDS, prevent even more infections, and save even more lives.

Let me describe some of the work that I’m especially excited about.

ARV-based prevention

One promising area is ARV-based prevention: pills, injections, and gels that contain the drugs now used for treatment.

Four years ago, when Melinda and I spoke at the International AIDS Conference in Toronto, we called ARV-based microbicides “the next big advance in the fight against HIV.” The early trial results of gels that did not contain ARV ingredients failed. But we are still very optimistic about the long-term potential of microbicides and other forms of ARV-based prevention.

The new generation of microbicides currently being tested is more likely to succeed because they contain ARVs. The results from the first of these trials, CAPRISA, will be announced tomorrow.

Researchers are also building on important lessons from the early microbicide trials. They now understand that we need a wide range of products, because people have a wide range of needs. For instance, some women can’t or won’t use a gel every day. So researchers are studying long-acting products that can be delivered by vaginal rings that stay in place for a month or more. Efficacy trials on one ring are scheduled to begin next year. If it works, it could help overcome some of the adherence problems we’ve seen in early microbicide trials.

Another promising area of research is pre-exposure prophylaxis, or PrEP – a daily pill or a long-lasting injection. This would put the power of prevention into the hands of women who can’t use microbicides, and people at high risk, such as injecting drug users and men who have sex with men. Later this year, researchers in London will begin a new study of the oral treatment drug rilpivirine, to see if it can be used as a long-lasting injection for PrEP.

When we get results from these studies, we should be ready to act right away. But right now, we’re not ready. Suppose we got positive results on an ARV-based prevention tool today. Between gaining regulatory approvals, raising money, training the staff, and other activities, using the normal approach would likely take at least six years to scale it up. That is unacceptable. When there are positive results, we need to be ready to launch a large community trial almost immediately. We made this mistake with male circumcision. I hope we won’t make it again with ARV-based prevention.

Vaccines

Effective ARV-based prevention would be a big advance, but the ultimate prevention tool would be a vaccine.

For years, some questioned whether it was even possible to prevent acquisition of HIV with a vaccine. The results from the trial in Thailand last year gave us the answer: It is possible. We’ve never had this kind of evidence before.

Researchers are now studying the Thai samples to look for a correlate of protection. If they found one, it would be a major breakthrough, because it would help us select the most promising candidates for future trials.

There are other exciting developments. In the past year, both the NIH Vaccine Research Center and the International AIDS Vaccine Initiative have isolated very potent antibodies that can neutralize almost every strain of the virus. This is the first step in making a vaccine that can stimulate the body to produce these antibodies.

These are promising ideas. But right now, it takes much too long to turn ideas into products. So far, only three vaccine concepts have undergone clinical efficacy testing. The first was in 2003. The most recent was the Thai trial, in 2009.

In that span of time, nearly 17 million people were infected with HIV.

That’s why we need to speed up the development process for all new tools, without compromising safety or the potential to get products licensed. Researchers can help by designing trials that require fewer participants, involve earlier reviews of the data, and target the populations with the highest incidence. At the same time, the agencies that regulate trials can be more receptive to these ideas, and pharmaceutical companies can do more to allow direct comparisons of their products.

Seeing the Impact

Vaccines, new diagnostics, and ARV-based prevention are some of the new tools I’m excited about. Of course, it’s impossible to know which of these might break through. But if we got just a few of them, the impact would be phenomenal.

To understand the impact, our foundation worked with researchers at Imperial College in London. They ran computer models for two parts of Africa where the epidemic looks very different. In both cases, we found that new tools could lead to dramatic results.

Rural Zimbabwe

The first is rural Zimbabwe, where the epidemic is generalized across a large part of the population. We’ll start with the status quo – what could happen if we don’t do any more than we do today.

Now I’ll add a line to show what could happen if we scale up some existing interventions that work in a generalized epidemic – such as male circumcision, ARV treatment, and preventing mother-to-child transmission. As you can see, annual new infections could be reduced by 38 percent in 2031.

Now let’s look at some new tools. First I’ll add ARV-based PrEP and microbicides. These could bring annual new infections down by a total of 53 percent.

If we also got a partially effective vaccine and delivered it to most of the population, it could cut annual new infections by 90 percent.

These figures suggest that we could stop nearly 400,000 infections between now and 2031, just in rural Zimbabwe. That would be fantastic. But the way we fight a generalized epidemic is very different from the way we fight one that’s concentrated in a particular population. The epidemic is different, so you need to apply the tools in different ways.

This raises a question: Can we make as much progress in places where the epidemic is concentrated?

Urban Benin

To find out, let’s look at urban Benin, where the epidemic is concentrated among sex workers and their clients.

Again I’ll start with what could happen if we don’t do anything new.

Next I’ll add a few existing tools that are targeted for this population, such as promoting condoms among sex workers. Scaling these up could cut annual new infections by 46 percent in 2031.

Now let’s see what happens if we add PrEP and microbicides delivered to most sex workers in the area. That could cut annual new transmissions by a total of 64 percent.

Finally, let’s add a partially effective vaccine that’s delivered to about half of the population. That could reduce annual new infections by 90 percent, averting nearly 66,000 new infections between now and 2031.

These findings make me very optimistic. In both countries, whether the epidemic is concentrated or generalized, current and new tools together could cut annual new infections by 90 percent in 20 years. Other countries might need different interventions to achieve such dramatic results. But these numbers show us what’s possible.

Conclusion

If the numbers fell this far in the hardest-hit countries, it would change the face of AIDS. New cases would plummet. Every person who is sick could be treated. The control of HIV would stand alongside the eradication of smallpox as one of the great public health victories in history.

This is the opportunity we have. We are at a turning point. We can keep doing things the old way, and keep getting the same result. Or we can change. We can push ourselves to make the most of every dollar of funding and every ounce of effort: to identify the most effective ways to save lives, and to share what we learn as widely as possible.

If we do that, we will have matched our compassion with the growing capacities of science, and we will start to write the story of the end of AIDS.

Thank you.