No Time to Lose: A Life in Pursuit of Deadly Viruses (36 page)

We worked very hard, in an exceptional joint effort with WHO, where Jonathan Mann’s old right arm Daniel Tarantola led the effort with Ben Plumley and my chief of staff, Julia Cleves. In mid-2000, our negotiations with the drug companies finally began to bear fruit. Five companies (Boehringer Ingelheim, Bristol-Myers Squibb, Hofman-La Roche, GlaxoWellcome, and Merck) agreed to quite significant cuts in the price of HIV drugs for regions severely affected by the AIDS epidemic. We launched the Accelerating Access Initiative in May 2000, not alone as in 1997 with the Drug Access Initiative, but this time with WHO, UNICEF, the UN Population Fund UNFPA, and the World Bank. It was a paradigm shift, although the drugs, even priced at $1200 per patient per year—a 90 percent reduction from the price asked in Europe—remained excessively expensive for most developing countries.

The deal got major media coverage worldwide, and the expectations were so high it was frightening. Our big gap remained the absence of a funding mechanism: even with the price discounted, someone still had to pay. My bet was that with drastically reduced prices, we could now convince donors to pay for treatment. I learned once more that no good deed remains unpunished. At the World Health Assembly in Geneva, the same month of May 2000, the African ministers of health, led by the always confrontational South African Minister Manto Tshabalala-Msimang, rejected the initiative and objected that we had not consulted them—as if we could have negotiated price reductions with 45 ministers in the room. We clearly had a major communication challenge on our hands. I was double-gutted when Bernard Pécoul of Médecins Sans Frontières compared the project to “an elephant giving birth to a mouse.”

The immediate impact was disappointing. In the absence of international funding the uptake was poor. Senegal, and then Uganda and Rwanda were the first countries to use the mechanism. Access to treatment improved very rapidly in Senegal, but the country did not have as many people in need of treatment as the other two. We had made a mistake in accepting that the final price negotiations had to happen country by country, as industry wanted to keep control over the sensitive cost structure of their drugs. I sent battle-scarred staff members such as Julian Fleet, Jos Perriens (who had worked with me in Kinshasa), and Badara Sam to assist interested countries, and we shared very informally all the confidential price information we could get, so that people negotiating in country X would know what country Y was paying, a major asset in bargaining.

The European Commission then moved in with its own initiative, driven by Lieve Fransen, the Belgian epidemiologist who had worked with me in Kenya and Antwerp. We worked with them toward a very unusual round table in September 2000, which brought the Big Pharma CEOs together in a room with Yusuf Hamied and other generics manufacturers. Generics were no longer taboo. I was amazed that the chair of the European Commission, Romani Prodi, was present throughout this unprecedented half-day meeting; he was accompanied by several of his commissioners, including Pascal Lamy, a remarkable representative of French Cartesian thinking and one of the sharpest brains I have met, who later became head of the World Trade Organization. All companies present agreed to the call for differential pricing, asking only for better predictability of demand for their drugs in order to plan production, guarantees against re-exportation of the cheaper drugs into high-income markets, and price protection in high-income countries. If European countries were to ask for the same price reductions as developing countries, then clearly the whole deal would collapse.

Despite all these meetings, I also continued to travel across the world to mobilize support and money. Still too few patients in Africa had access to treatment. We set up a system with WHO and Médecins Sans Frontières to monitor the price of antiretroviral drugs globally. It was a very worthwhile, but also very frustrating, exercise: in general there is not much openness about prices from either side of the transaction. We constantly had to intervene. For example, in December 2000, Glaxo attempted to block access to generic drugs in Ghana, even though the price of CIPLA’s generic was only slightly lower than Glaxo’s medication: $1.74 per day versus $2. In some low- and middle-income countries, in particular in Central America, the Middle East and Eastern Europe, prices for HIV drugs were even higher than in the United States often because of the middlemen. Thus in Uganda we found that in 2001 a drug called Sequinavir cost 17 percent more than in the United States. And there was still the pending lawsuit by pharmaceutical companies against the government of South Africa’s imports of generics. As long as that was not resolved, we could not be confident that they were committed to affordable treatment in developing countries.

Kofi Annan started pushing the companies to accept a settlement with the South African government, as he believed this was a global obstacle. Some pharma CEOs also understood that the court case was doing more damage to their reputation than any benefit it could ever hope to gain them. Jean-Pierre Garnier, the new CEO of the now-merged GlaxoSmithKline, broke ranks with other companies, and in February 2001 the pharmaceutical industry withdrew its complaint. It was a major victory for both the South African government and for the AIDS movement. The Treatment Action Campaign was jubilant. And the power relations in health care shifted slightly.

For me it was one box to tick off, one headache less, and more time to devote to AIDS advocacy. The climate in the pharmaceutical industry was changing at various levels. Later that year, Professor Rolf Krebs, chairman of German Boehringer Ingelheim, told me he had canceled corporate donations to the arts and to culture, and had moved it all to AIDS. Then in January 2001, India’s CIPLA generic pharmaceutical company announced that it would sell a generic first-line antiretroviral treatment for $350 a year per patient, a dramatic cut in price. Yusuf Hamied was becoming a major player, even if his prices did also greatly vary from country to country, depending on their market and negotiation power—thus Combivir cost between $95 and $195 depending on the country. After that big move, the market did its own work, forcing the price down. By February 2001, a year of treatment cost around $400 in Uganda, and by July around $300: less than $1 a day. More than ever, the real gap was the funding gap.

International legal obstacles and uncertainties in terms of patent rights began to weaken. In 2001, at their conference in Doha, Qatar, the member states of the World Trade Organization agreed on the right of poor countries to issue “compulsory licenses” to override pharmaceutical patents in public health emergencies such as AIDS. This gave poor countries the legal right to produce low-cost generic drugs, provided they compensated the patent holder. In 2003 low-income countries lacking manufacturing capacity received an additional waiver to import generics from abroad. We were very involved in these breakthroughs through our American human rights lawyer Julian Fleet, whose legendary patience got him through the often Byzantine discussions—I could not have done it. His main task was to provide up-to-date technical information to delegations from developing countries, who didn’t have the expertise in their administrations.

But the United States, Europe, and Japan tried afterward to circumvent these favorable multilateral agreements by imposing bilateral free-trade accords, which often extended patents beyond what was agreed internationally, in negotiations that did not involve public health officials and where the developing country understandably concentrated on its main export industries rather than pharmaceutical imports. Our impact on those negotiations was very limited, and I am concerned that in the future, progress made in access to affordable treatment may be jeopardized by these bilateral treaties.

From then on, there was progress on many fronts. In 2002 antiretroviral drugs were finally accepted on WHO’s essential drugs list—a prerequisite for some countries to use them in the public sector. The Clinton Foundation ingeniously shaved off costs throughout the production process of antiretrovirals, announcing further price reductions with generic producers, and then on pediatric formulations as well. Fixed-dose combinations of three drugs in one pill were launched on the market by Indian generic manufacturers, improving drastically both quality of life and treatment adherence: from 10 to 15 pills a day, patients could now take just 2.

Yet most donors remained very reluctant to fund lifelong HIV treatment in developing countries. In October, I was invited to meet all main aid donors in the Netherlands, which was reconsidering its position, for a discussion on HIV treatment. They were still using the same arguments, and the Canadian International Development Agency even distributed a strategy document on AIDS that hardly mentioned treatment at all. Some of the discussions were almost completely detached from reality: some really believed that we had a choice between HIV prevention and treatment, in countries where every day hundreds of people were dying from AIDS—over 8000 every day worldwide in 2002. However, over a drink, most aid officials told me they felt personally very uncomfortable about their country’s official positions and asked for help to change them. So I went on a tour of Europe, Canada, and Japan to meet with ministers of international development, to garner support for HIV treatment. With the notable exception of the United Kingdom, most were open to breaking the taboo of funding chronic treatment in developing countries.

The real breakthrough came only when the Global Fund to Fight AIDS, Tuberculosis and Malaria was launched in 2002. It accelerated dramatically when, in January 2003, President Bush asked Congress to approve an Emergency Plan for AIDS Relief, with a goal of offering 2 million people antiretroviral therapy. These were game-changers.

Today the cost of antiretroviral treatment has fallen from $14,000 to less than $100 per person per year. In 2000, fewer than 200,000 people in the developing world were on antiretroviral treatment—most of them in Brazil; in 2011, there were about 7 million. In 2000, barely 0.1 percent of African people with AIDS received treatment; today it is about 40 percent.

Mortality from AIDS has declined dramatically in just about every country. By any measure this is spectacular progress, unparalleled in international development. It’s not a perfect situation: half of all people with HIV are still without access to treatment; as a result, in 2010, 1.8 million died who could have been saved. But the world’s commitment to universal access to antiretroviral treatments has been the most sweeping international commitment to global public health in the modern era. It changed the way the pharmaceutical industry is doing business: today, when a new antiretroviral treatment is launched, it comes immediately with lower prices for developing countries, instead of a tiered pricing system coming delayed and reluctantly, under pressure. An economist would say that with AIDS, new medicines, still under patent, are no longer considered just private goods for wealthy individuals or countries, but have become “merit” goods available to everyone.

What is clear is that AIDS changed the landscape for health in the developing world. My own contribution was only one among many, but very often each step of progress happened under the UNAIDS platform. The question that haunts me until today is whether we could have done it earlier, faster.

CHAPTER 21

A War Chest for AIDS

W
E NOW HAD
political leadership, more or less affordable drugs, and programs on the ground—but still no real money. On April 26, 2001, in Abuja, Nigeria, in front of nearly all Africa’s presidents, Kofi Annan put it sharply: “The war on AIDS will not be won without a war chest.” Back when UNAIDS began, about $200 million were spent on AIDS in developing countries, and by the turn of the century it was still below $1 billion. There’s no way that you can stop such a complex epidemic worldwide with that kind of money.

We simply had not been bold enough in our thinking: there was no precedent for a sudden and long-term billion-dollar financial commitment in international health, and the donor governments kept hammering that the money wasn’t there. I was constantly reminded of the letter I had received from all donors on June 10, 1998, which concluded with the warning “that funding for HIV/AIDS activities will not come easy in the next few years.” But they had not grasped at least four major factors: the swelling influence of the AIDS movement; the catastrophic impact of AIDS deaths in parts of Africa, which led to calls for help from more and more African leaders; the declining price of HIV treatment; and the growth of official development assistance after years of decline.

The donors’ strategy of “demand containment” was slowly disintegrating; they just didn’t know it yet. In 1993, when Michael Merson, then director of WHO’s AIDS program, called for $2.5 billion per year to prevent half of all new infections, people were shocked. But the figure didn’t include the cost of treatment, as there was no treatment for AIDS in 1993. While preparing for the AIDS Summit at the UN in 2001, we refined the estimates and came to a figure of closer to $10 billion, assuming the price of treatment would continue to decline. Because the world’s economy was in a growth phase in the late 1990s, these had not been impossible demands—a bigger pie meant that we did not have to take away money for AIDS from other important issues. In fund-raising it is essential that you are clear what the “ask” is; now it was very clear, but very daunting.

There was another important, perhaps decisive, factor that tilted the balance in favor of massive AIDS funding: policy makers felt we now had a solution even if objectively it was not. The “Lazarus” effect of antiretroviral therapy, which brought life back to the dying, made for spectacular and poignant human stories, and also could be relatively easily measured and quantified. In contrast to what academics may think, policy decisions are not always driven purely by metrics and evidence. I met on one occasion with the board of directors of South African mine giant Anglo American, at their headquarters in Johannesburg. I had been lobbying them to offer HIV treatment to their employees, since the government was not providing it. Their head of medical services, Brian Brink—a soft-spoken physician who later played an important role at the Global Fund—was a strong supporter, and it was an easy meeting: I barely had to make the case at all. The CEO and chair of the board announced their decision to provide antiretroviral therapy to all staff who needed it. The only difficult questions were what to do with their families, many of whom were infected with HIV, and what would happen when the miners’ contracts ended and they returned to countries without such treatment. When I asked whether I could see the economic analysis of how they had come to this important decision, Tony Trahar, the CEO, told me that they had tried to embark on one, but it was too complicated. Simply, they felt this was the right thing to do, because AIDS was affecting their workforce (and their bottom line—AIDS increased the cost of producing an ounce of gold by 70 Rand). But they would monitor carefully the program’s impact and cost.

Here was a sophisticated company with some 100,000 employees, and it had made a decision—a sound one—in the absence of detailed economic analysis. In contrast, donor agencies constantly pushed me to provide economic justification of why HIV treatment should be considered cost-effective on the scale of a whole country, and even the planet.

My frustration mounted. I knew that treatment alone would not stop the epidemic. But without major funding for treatment, the real solution—prevention campaigns—would, I thought, be a nonstarter in communities with massive mortality from AIDS.

US CONGRESS REPRESENTATIVES
Barbara Lee (Democrat) and Jim Leach (Republican) attempted to create a special fund for AIDS and TB in 2000. My policy adviser Jim Sherry worked hard with congressional staffers to provide technical underpinning for the proposed legislation. The bill proposed to create a special fund in the World Bank to channel money to developing countries. There was no better mechanism at the time, and I thought that as a matter of principle we should use existing institutions rather than create yet another international agency. The bill was passed, but then died a quiet death, mostly because of opposition from the US Treasury Department.

David Nabarro of the UK Department for International Development was the first one to propose a “ring-fenced” fund associated with UNAIDS, which basically would pay for drugs and condoms. However, I knew that in practice we would not be
able
to operate transfers of huge amounts of money with any degree of efficacy, as we were dependent on the administrative systems of WHO and UNDP. These were slow, bound up in red tape. I also knew that the Bush administration and US Congress were not fans of the UN, and feared that it was unlikely they would accept a massive new UN fund. Except for Mark Malloch Brown, the politically very astute head of the UN Development Program, the other cosponsoring agencies were keen on a UN fund.

Luckily, Kofi Annan and his deputy Louise Frechette shared my view. Louise had an even darker view of UN efficiency than I did, and Annan felt that no US Congress would vote for billions of dollars in new funding for anything to do with the UN. So while still negotiating lower antiretroviral drug prices, we started an assertive campaign for a special financing mechanism for AIDS in 2001.

By early 2001 there were a number of proposals by various donors to set up special multilateral funds for AIDS, for malaria, for tuberculosis, and for other infectious diseases in developing countries. (It was quite chaotic, and the developing countries most affected by these diseases were not at the table, not even consulted.) We could also build on a commitment made by the G8—the eight richest nations—in Japan, in 2000, that they would work on a fund for infectious diseases in developing countries. However, around March 2001 we all reached agreement that it would be nonsense to create multiple funds. We would all work together toward the creation of a single fund—though WHO announced at a meeting of donors and UN agencies in London in April that it “did not endorse UN consensus on this,” causing consternation among participants. It was only after Annan and Brundtland met at the African AIDS summit in Abuja a week later that WHO joined our ranks, and after that worked very closely with UNAIDS throughout the process. Lieve Fransen from the European Commission started playing a convening role. The same month Kofi Annan raised the need to create a global fund for AIDS with President George W. Bush, who was supportive, but asked for a strategy and clearly stated deliverables.

From then on things accelerated dramatically, and what had seemed a naïve dream suddenly became a real possibility. During the special session of the General Assembly in June 2001 we lobbied hard, and every country signed off on a paragraph calling for a special fund. This gave it universal legitimacy, and we now had a mandate to move forward with the creation of a special mechanism that would move large amounts of money, fast.

I had no time to enjoy the success of the June AIDS summit in New York, or for any rest. First I had to get my budget through the UNAIDS board—always a week of great stress—and we then had to start immediately with preparations to create the fund. We could not afford to lose time; without even being able to imagine the unimaginable September 11 attacks, I was always concerned that the political winds would turn away from us. I had discussed our agenda with Kofi Annan, whom I represented in the negotiations. We fully accepted that the new fund would be independent from the UN. It would focus on AIDS, have a small secretariat, and include on its board developing countries, the private sector, and nongovernmental organizations—not only donor countries. It would provide additional resources, and not simply subtract money from other health or development issues. And it would itself not implement programs, but work with existing institutions.

Starting in Brussels in July 2001, a series of long meetings of a working group tried to figure out the best solution. I put Jim Sherry and Julia Cleves on the challenge. Julia worked closely with her husband Andrew Cassells, who was representing WHO—an unusual stress-test for a wonderful couple. The negotiations were very tense, as the interests and political views among countries diverged widely. But the major donor countries and the European Commission agreed on one thing: they were on a war path against the UN. I often had to swallow my pride, as when France proposed to replace UNAIDS by a pharmaceutical company representative, or the United Kingdom expressed “regrets that UNAIDS was not withdrawing from the working group” and blamed us for increasing the size of the group.

Bill Steiger tried to remove UNAIDS and WHO from the working group completely. He was a Bush protégé representing the United States and he micromanaged the US international health relations from his position as the director of the Office of Global Health Affairs, including by vetting all US scientists and public health experts who attended WHO meetings as advisers. Bill was a sharp man, who went through the details of all the papers before a meeting, and although he could socially be very likable, he was ferocious in his never-ending attacks on the UN and WHO. I did agree, though, with his insistence on strict accountability regarding the special fund’s finances.

Going over my detailed notes of these meetings, I am amazed that serious diplomats could come up with some of the scenarios we considered. There was a proposal that the Rockefeller Foundation distribute the funds; I doubt whether anyone had bothered to ask the foundation whether it would even consider this. Outside the official meeting room, the pressure on us from AIDS activists was intense. The main controversies were whether the fund should be independent or be hosted by the World Bank, where it should be based, who should head it up, which health problems it would finance in addition to AIDS, which countries could benefit, whether it would only pay for commodities such as drugs and condoms or also for actual programs, who would decide where the money would go, and much, much more.

But we managed to hammer out a completely new organization in record time for this kind of international enterprise. (I’m sure a few PhD theses will come out of it.) In January 2002, the Global Fund to Fight AIDS, Tuberculosis, and Malaria was launched in Geneva under the aegis of Dr. Chrispus Kyonga, the Ugandan minister of health, whom Kofi Annan had asked to chair. It fell to me to tell the South African minister of health, who had been running for this honorary position, that she had not been selected. Needless to say this did not help our already parlous relationship, but that’s how it goes the world over: the boss offers the job, and people like me bring the bad news.

Uniquely for a multilateral organization, the Global Fund board seated three NGO representatives with full voting rights—moving communities of people living with HIV from activists to decision makers—as well as representatives from the private sector. Together with the World Bank and WHO, UNAIDS was a nonvoting
ex officio
member of the board, to avoid conflicts of interest. Thus for the next seven years I served on the board of this fascinating institution. Countries received funding only after approval by a national committee whose members came from government, business, NGOs, activist organizations, and academia. This bottom-up approach was a breakthrough. Many countries had no democratic tradition of civil society dialogue with governments. I believe that in some countries the AIDS response contributed to greater democracy and transparency, via the Global Fund’s “Country Coordination Mechanisms” and UNAIDS’ campaigns for the involvement of people living with HIV.

At a board meeting at Columbia University in New York in April 2002, Richard Feachem, a British global health professor at the University of California at San Francisco, was elected as the first executive director of the Global Fund—despite his earlier opposition to HIV treatment in the developing world on the grounds of cost-effectiveness. The able US candidate George Moore, a former ambassador to the United Nation in Geneva, was hamstrung by the lack of diplomatic experience of the US delegation. The United Kingdom, the European Commission, and the NGOs campaigned aggressively for Feachem, whose experience at the World Bank proved very valuable in setting up the systems of the fund.

The world was shifting. UNAIDS had developed enormous credibility in a short space of time, and AIDS had surged to the top of the world agenda, despite the terrible events of September 2001 and the new preoccupation with terrorism. One of the fund’s first decisions was to fund generic drugs. Our strategy of establishing a dedicated funding mechanism to boost financing for AIDS had worked, but we were at risk of becoming the victim of our success. Paradoxically, the establishment of the Global Fund meant that UNAIDS was no longer the only game in town, and it meant, too, that we did not control the money. Many of our staff felt threatened, and some media and Geneva diplomats predicted (once more) the end of UNAIDS. Developing countries courted the Global Fund, and donors asked me probing questions about our added value.

The UNAIDS staff had grown to over 600 people, with offices in over 60 countries. I told them that our job was to assist countries to prepare strong proposals for financing from the Global Fund, and then to assist with the actual implementation. In every country, we were the paramount group of HIV experts. The fund had the money—and that job can be a headache—but we were the global guardian of AIDS policies, we evaluated the impact of programs on the ground, and it fell to us to do the still much-needed political work of high-level advocacy. So I reoriented our work in that sense, and after some hesitation, the donors continued to support us.