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“This is the last speech I shall make at any of these international conferences in my role as United Nations Envoy. I’m glad, for obvious Canadian reasons, that it comes in Toronto. But I’m equally pleased because this has been a good conference, covering an extraordinary range of ground, and I therefore feel confident in asking you to join with me in giving force to the oft-repeated mantra: “Time To Deliver.”

Of what would that meaning consist? Allow me to set out a number of items.

Number 1: Abstinence-only programmes don’t work. Ideological rigidity almost never works when applied to the human condition. Moreover, it’s an antiquated throwback to the conditionality of yesteryear to tell any government how to allocate its money for prevention. That approach has a name: it’s called neo-colonialism.

Number 2: Harm reduction programmes do work. Needle exchange and methadone treatment save lives. More, it would be positively perverse to close the ‘Insite’ safe injection facility in Vancouver when it has been positively evaluated in a number of studies; in fact there should be several more such facilities in Canada and around the world. Russia, Central Asia, parts of India are all struggling with transmission through injecting drug use. To shut ‘Insite’ down is to invite HIV infection and death. One has to wonder about the minds of those who would so readily punish injecting drug users rather than understanding the problem for what it is: a matter of public health.

Number 3: Circumcision, as a preventive intervention, should not be subject to bureaucratic contemplation forever. We have enough information now to know that it is an intervention worth pursuing. What remains is a single-minded effort to get the word out, respect cultural sensitivities, and then for those who want to proceed, make certain that we have well-trained personnel to do the operating.

The men are lining up for the procedure in Swaziland. And when I was in the Zambian copper belt, just a couple of weeks ago, at an animated meeting with the District Commissioner, he indicated that he was a part of an ethnic group which was circumcised. I then revealed that I was circumcised, and there followed a joyous frenzy of male bonding amongst all the circumciseees. The fact of the matter is that even in the remotest parts of Africa there is now an awareness of the issue; it’s important to act on it.

Number 4: The growing excitement around a microbicide is entirely warranted. This is a preventive technology whose time has come. To be sure, there can be no flagging in the dogged quest for a vaccine, but it would appear that where preventive technologies are concerned, the microbicide is first in line. Now is the time to make certain, in advance, that when the discovery is made, it is instantly accessible and acceptable to the women of the world, wherever they may live.

Number 5: In the hierarchy of preventive measures, the Prevention of Mother To Child Transmission is very near the top. It is a bitter indictment that so few HIV-positive pregnant women have access to PMTCT. But that’s just the half of it. It is inexcusable that in Africa and other parts of the developing world we continue to use single-dose Nevirapine, rather than full triple therapy during pregnancy, as we do in western countries like Canada. This means that hundreds of thousands of babies continue to be born HIV-positive, rather than reducing the transmission rate virtually to zero. I ask: what kind of a world do we live in where the life of an African child or an Asian child is worth so much less than the life of a Canadian child?

Number 6: It is now accepted as unassailable truth that people in treatment need nutritious food supplements to maintain and tolerate their treatment. And yet, there is a growing clamour from People Living with AIDS that decent nutrition simply isn’t available, leaving them in a desperate predicament. The World Food Programme released a study at this conference calculating the cost of food supplementation at 66 cents a day for an entire family; what madness is it that denies the World Food Programme the necessary money?

Number 7: One of the issues that received an insufficient airing at this conference is sexual violence against women. Just a few months ago, I was visiting the local hospital in Thika, Kenya, which houses the one rape counseling centre in that part of the country. The rise in sexual violence has meant that there are over thirty reported cases every month, with multiples of that number never of course reported.

In April of this year there were forty-six reported cases. Twenty-two were under the age of eighteen; half of those were under the age of twelve. Horrific you say? Without question. But how would you characterize an emerging pattern of the sexual assault of women between the ages of sixty-five and eighty, the rapists confident that they can rape with impunity without fear of transmission?
Sexual violence is everywhere reported, from marital rape to rape as a war crime. The phenomenon is by no means singularly African; we live in a world community where the depravity of sexual violence has run amok. In Africa, however, the violence and the virus go together. And yet, we lack the laws, the jurisprudence, the enforcement that would give to women even a modicum of protection. If ever there was a cause to mobilize AIDS activists around the world, this is it.

Number 8: We urgently need a resolution of the vexing debate over testing and counseling. We made progress at this conference, but by no means definitive progress. It seems to me that the growing embrace of routine testing and counseling, with an opt-out provision to protect human rights, is the appropriate emerging consensus. Everyone should keep an eye on Lesotho where the Know Your Status campaign will, I believe, become the bench-mark, pro or con, for the continent and beyond.

Number 9: There is an ongoing epidemic of child sexual abuse. The dynamic of abuse of children is often different from that of the sexual abuse of women: what is common to both is the terrifying danger of transmission. Children require different interventions. Alas, we are nowhere near the articulation of a response. In this instance, as in every such instance, children are relegated to the scrapheap of society’s priorities, and have been so relegated throughout the twenty-five years of this pandemic.

Number 10: It is impossible to talk about children without talking about orphans. And it is impossible to understand how, in the year 2006, we still continue to fail to implement policies to address the torrent, the deluge of orphan children. Countries have programmes of action; they languish unfunded. One of the most chilling pieces of statistical data is the finding that only three to five per cent of orphans receive any intervention of any kind from the state.

The monumental numbers of orphans, so many of them now adults because the pandemic has gone on for so long, pose a bracing, almost insuperable challenge for the countries which they inhabit. I appeal to everyone to recognize that we’re walking on the knife’s edge of an unsolvable human catastrophe. Inevitably we’re preoccupied with the here and now, but the cumulative impact of these orphan kids, their levels of trauma, their overwhelming personal needs, their intense collective vulnerability strikes at the heart of the human dynamic, creating a sociological rearrangement of human relationships. And we’re doing so little about it; our response is microscopic. We are inviting the whirlwind, and we will not be able to cope.

Number 11: It is impossible to talk about orphans without talking about grandmothers. Who would ever have imagined it would come to this? In Africa, the grandmothers are the unsung heroes of the continent: these extraordinary, resilient, courageous women, fighting through the inconsolable grief of the loss of their own adult children, becoming parents again in their fifties and sixties and seventies and eighties. I attended a grandmother’s gathering last weekend on the eve of the conference: the grandmothers were magnificent, but they’re all struggling with the same anguished nightmare: what happens to my grandchildren when I die?

We need major social welfare programmes that will recognize these essential caregivers’ contributions to society as legitimate and difficult labour, and offer the guarantee of sustainable incomes to the grandmothers of Africa: from food to school fees to income generation, the answers must be found. It’s another test for the delegates to this conference.

Number 12: In the midst of everything else, we must continue to roll out treatment. I am worried by the new figures. There were one million, three hundred thousand people in treatment at the end of 2005. Six months later, there are one million, six hundred and fifty thousand in treatment. The additional three hundred and fifty thousand seems a very modest increment. Treatment is keeping people alive; treatment is bringing hope; treatment is stimulating prevention; treatment is meshing more and more frequently with community-based care; we cannot let the process slow.

Number 13: And while I’m on the issue of treatment, I am bound to raise South Africa. South Africa is the unkindest cut of all. It is the only country in Africa, amongst all the countries I have traversed in the last five years, whose government is still obtuse, dilatory and negligent about rolling out treatment. It is the only country in Africa whose government continues to propound theories more worthy of a lunatic fringe than of a concerned and compassionate state. Between six and eight hundred people a day die of AIDS in South Africa. The government has a lot to atone for. I’m of the opinion that they can never achieve redemption.

There are those who will say I have no right, as a United Nations official, to say such things of a member state. I was appointed as Envoy on AIDS in Africa. I see my job as advocating for those who are living with the virus, those who are dying of the virus … all of those, in and out of civil society, who are fighting the good fight to achieve social justice. It is not my job to be silenced by a government when I know that what it is doing is wrong, immoral, indefensible.

Number 14: Unbeknownst to many, we are on the cusp of a huge financial crisis in response to the pandemic. I think we have been lulled into a damaging false security by the fact that we jumped from roughly $300 million a year from all sources in the late 1990’s, to $8.3 billion in 2005. And indeed it sounds impressive. But we need $15 billion this year, and $18 billion next year, and $22 billion in 2008. Any straight line projection will take us to $30 billion in 2010 … the moment of universal access to treatment, prevention and care.

We’re billions and billions short of those targets. If these circumstances continue, universal access is doomed. All governments, as they continue to expand their treatment and prevention initiatives, are spooked by worries of financial sustainability. They’re right to be spooked.

The financial promises made at the G8 Summit in Gleneagles one year ago, are already unraveling. We will never accumulate the extra $25 billion for Africa by 2010 as was committed.

PEPFAR has not yet announced its extension beyond 2008; when it does (as it surely will), the annual contribution, given the other demands on the US Treasury, will probably remain at $3 billion a year. That large amount was a very significant percentage of the total expenditure on AIDS back in 2003/2004. But as a percentage of what is needed for global AIDS programmes in 2008 — $22 billion — $3 billion seems pretty paltry from the world’s superpower.

The Global Fund to Fight AIDS, Tuberculosis and Malaria is still half a billion short this year and more than a billion short next year. At the moment, there is no obvious way to close the shortfall. It is almost inconceivable that the extravagant promises of Gleneagles are revealed as so fatuous that the Global Fund is now compromised. No one is asking for any more than that which was promised. But the Pavlovian betrayal of the South has already begun.

Everything in the battle against AIDS is put at risk by the behaviour of the G8. Yesterday, Dr. Julio Montaner characterized that behaviour as genocide. I remember back in 2001, in an op-ed for the Globe and Mail, I used the phrase mass murder. It’s hard, in the face of the annihilating human toll, not to be driven to linguistic extremes. This issue of resources makes or breaks the response to the pandemic. It is imperative that the delegates here assembled never let the G8 countries off the hook.
Number 15: I want to say a strong word about human capacity.

What has clearly emerged as the most difficult of issues, almost everywhere, certainly in Africa, is the loss of human capacity. In country after country, the response to the pandemic is sabotaged by the paucity of doctors, nurses, clinicians and community health workers … the shortages are overwhelming. Everyone is struggling. Most of the shortage stems from death and illness; some stems from brain-drain and poaching. But whatever the source, we have a problem of staggering dimensions.

The capacity crisis illumines, more than anything else, what is needed. There are solutions: investment in the public sector and in extensive ongoing training can begin to fill the gap. But again it needs the donor community to uphold its responsibilities. And most important, the key to recovery lies at country level. The key to subduing the entire pandemic lies at country level.

What has to happen, I think, is that we place a temporary moratorium on the endless, self-indulgent proliferation of meetings, seminars, roundtables, discussion groups, task forces ad nauseam, plus the production of reports, documents, monographs, statistical data ad repetition, and concentrate every energy at country level.

At the opening of this conference, Peter Piot talked of the next twenty-five years. He’s right to do so. He indicated it would be a long and difficult haul; he’s right again. But if the next twenty-five years are to take advantage of the guarded optimism of this conference; if the next twenty-five years are to overcome the lethargy and inertia of the last twenty-five years; if the next twenty-five years are to link, inseparably, poverty and disease and the Millennium Development Goals, then it has to happen, in-country, on the ground, organized and orchestrated by the countries themselves.

And the agencies on the ground, whether multilateral, bilateral or civil society, must be held accountable. That’s what’s been missing. That’s the job of the delegates to this conference: holding people and organizations accountable. And that includes everything from the pharmaceutical companies that have been so intractable about prices of second-line drugs to bilateral trade agreements designed to deny access to generic drugs.

Number 16: This 16th International AIDS Conference, beyond any preceding conference, has given voice to youth. But it’s still a limited and marginalized voice, reflecting the hostile ambiguity of the adult world. The figures are brutal and stark: fully fifty per cent of new infections between the ages of fifteen and twenty-four. And yet who can deny the appalling absence of programmes for, and engagement of, young people in the fight against the pandemic. The situation cries out for redress … and it must be redressed well beyond smarmy tokenism.

Finally, in my view, as delegates doubtless know, the most vexing and intolerable dimension of the pandemic is what is happening to women. It’s the one area of HIV/AIDS which leaves me feeling most helpless and most enraged. Gender inequality is driving the pandemic, and we will never subdue the gruesome force of AIDS until the rights of women become paramount in the struggle.

Last Monday morning, at the women’s march, the signs read “Women’s Rights are Human Rights”. That was the slogan that captured the Vienna International Conference on Human Rights in 1993. It was the slogan repeated at the Cairo Conference on Population in 1994, and yet again at Beijing in 1995. It’s never been made real, and so long as men control the levers and bastions of power, it never will be real.

Whether it’s the apparatus of the United Nations, including the agencies, or the endless numbers of High-Level panels, or auspicious studies of human development like the Blair Commission on Africa, the demeaning diminution of women is everywhere evident. And those examples are but proxies for the wider world, particularly the developing world, where freedom from sexual violence, the right to sexual autonomy, to sexual and reproductive health, social and economic independence, and even the whiff of gender equality are barely approximated.

It’s a ghastly, deadly business, this untrammeled oppression of women in so many countries on the planet.

My closest colleagues and I have come to the conclusion that one of the ways to diminish the impact of the AIDS virus is by creating a powerful international agency for women, funded and staffed to the teeth. There must be voice and advocacy and operational capacity on the ground for fifty-two per cent of the world’s population. There is a UN reform panel at the moment, contemplating the creation of a new entity, provided they have the courage to confront the warped and abysmal gender architecture of the United Nations. If they find the courage, I deeply believe that we could begin to still the carnage.
And what works for AIDS can work everywhere.

I challenge you, my fellow delegates, to enter the fray against gender inequality. There is no more honourable and productive calling. There is nothing of greater import in this world. All roads lead from women to social change, and that includes subduing the pandemic.

For my own part, when I leave my post of Envoy at the end of the year, I have asked that my successor be an African, but most important, an African woman. ”

(August 18, 2006)

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Stephen Lewis is the UN Secretary-General’s Special Envoy for HIV/AIDS in Africa, a post he has held since June 2001. He is a Commissioner for the World Health Organization’s Commission on the Social Determinants of Health, and a Senior Advisor to the Mailman School of Public Health at Columbia University in New York. Mr. Lewis is also Director of the Stephen Lewis Foundation, which is dedicated to easing the pain of HIV/AIDS in Africa. He has received many accolades including 22 honorary degrees, a Companion of the Order of Canada, Maclean’s Magazine 2003 “Canadian of the Year,” and in April 2005, was listed as one of the “100 most influential people in the world” by TIME magazine. Recently, he was the 2005 CBC Massey Lecturer, the first of which was held at UBC last year.