UNIDENTIFIED SPEAKER: (MS?) For fear, rejection, denial, and discrimination. He’s terrified of the fact that (MS?). Education, productivity, work, (MS?). The President of the United States declared AIDS (MS?).

(MS?)

I would like to introduce my partner in this demonstration, (MS?). And professor of the University of Pacau (MS?). Now I introduce our speaker, Lynn Smirls (MS?). He’s the president of the (MS?) the world’s largest membership alliance (MS?).

LYNN SMIRLS: Good morning. Jonathan Mann (MS?) is a pioneer in the world of (MS?) and AIDS. He recognized early in his career that his responsibility went far beyond the single patients before him, and so he became an epidemiologist, and the clear facts that he earned (MS?) to an inescapable conclusion. Humanity faced an historical challenge. On a personal level, Jonathan accepted that challenged and turned it into his life’s work. Many considered his early projections of the global spread of AIDS to have been overblown. History has shown them to be conservative, just as history will show last week’s U.N. AIDS projections to also be conservative.

From his work in Zaire in the early 1980s, his path took him to found the World Health Organization’s global program on AIDS, which has grown to become today’s (MS?). But Jonathan’s insights, and his pursuit of the truth about AIDS did not end there. He recognized the basic challenge to humanity was not the virus itself. It was, rather, our own inhumanity that allowed that virus to take hold, to spread, and to increasingly dominate societies. Drugs, vaccines, these are important tools in our battle against the virus, but at the heart of effective and lasting response must be a devotion to justice. Dignity is at the heart of justice. A respect for the dignity of each individual, which is the cornerstone of all human rights. And so our fight against AIDS must be based on a commitment in deeds, not just words, to human rights.

Jonathan Mann did not survive to witness the fruition of his life’s work. Along with his wife, he perished in an airplane crash in 1998. But he lit the way for the global health community, and we celebrate in his name those who through their deeds bear witness to the force of human rights. On behalf of the worldwide members of the global health council, I am privileged to introduce this year’s speaker of the Jonathan Mann memorial lecture.

Irene Fernandez is a true hero to those familiar with her lifelong devotion to human rights and dignity. She did not come recently to her principles. A native of Malaysia, she began her work three decades ago as a witness to human rights’ abuses. Imprisoned by Augusto Pinochet in Chile for her work, she has continued to speak proof to power at great personal risk. Today, she is under criminal indictment in Malaysia for speaking the truth about the treatment of migrant workers, particularly women migrant workers in her own country. She needed special permission to be allowed out of Malaysia to speak here today. Irene is the director of Tanaganita, which means Women’s Force, and chair of Caramasia (MS?). For the past decade, she has devoted herself to protecting the human rights of migrant workers, which has led her inescapably to the centrality of women in the fight against AIDS and for their own human dignity. It is indeed an honor to invite Irene Fernandez to present the Jonathan Mann memorial lecture.

IRENE FERNANDEZ: My dear friends, especially all people living with AIDS, mothers, wives, daughters, children who are crying in hope for a life for the future, activists, leaders, ladies and gentlemen, (MS?) and a very good morning to all of you.

I must apologize to the Spanish-speaking friends here that though I have a very beautiful Spanish name, Irene Fernandez, I cannot speak Spanish. Please forgive me.

It is indeed an honor and privilege for me today to be here to deliver the second Jonathan Mann memorial lecture. I am very happy that is a community in ensuring that Jonathan Mann’s life and work is brought back into our deliberations as we begin this important conference with the theme, “Knowledge and commitment into action.”

Mann dedicated his life into constructing a response to the AIDS pandemic(MS?). He, as we all know, is a living example of how we can translate knowledge into commitment and action. And today, more than ever, we are challenged to strengthen, deepen and consolidate what Mann left behind. The global response to the AIDS pandemic. He, very consistently, brought to the world’s attention that human rights, if denied, increases vulnerability. And he said continuously that it is in each society those people who are marginalized, stigmatized and discriminated against before HIV/AIDS arrived have become over time those at the highest risk of infection. It is to these people that I want to dedicate this sharing this morning to you and my global battle cry against AIDS is how is a right not a commodity.

Dear friends, Brazil became the winning team in the World Cup with four R’s as a factor. Ronaldo, Rivaldo, Ronaldino, and Roberto Carlos. In my sharing to you today, I also have the four R’s that must become the winning factor, as well, and that is, what is the reality? What are the reasons? What is our resolution to the pandemic and how will we respond at the global community? The reality, my dear friends, is, as we take a closer look at the world today, we see increasing and sharpening inequalities that we are actually in two worlds. The world that is small, that has small populations is wealthy, is powerful, and is united like one Europe. The pandemic is under control. Treatment is accessible. The other worlds, my dear friends, is a world that is poor. That is divided, controlled, and quite often in despair. There is increasing vulnerability to HIV/AIDS. There is little or no access to treatment, and there is no or lack of resources. And as we look at this world, last year, 500,000 people in the north were on antiretroviral drugs. 25,000 died of AIDS. In the other world, only 230,000 people were on antiretroviral drugs, and 2.2^million people died of AIDS in Africa alone. This inequality is indeed becoming wider, and if we look at Asia, it is worrying because the three most populous countries – China, India and Indonesia – have tremendous increase in the pandemic. China, as the U.N. AIDS report states, is on the road to catastrophe. But unfortunately, many of our countries are denying and not taking it seriously. The two countries in Asia, (MS?) and Cambodia went into a commitment, have actually brought down the rate of infection. And so, why do the situation? If we look again at what is happening in the world today, the inequalities and disparities are (MS?) by increasing stigmatization, discrimination and growing xenophobia in the developed world. This is a new form of harsh and racist policies against migrants, refugees and displaced persons. Canada that had a reputation for respecting human rights today has mandatory testing. Migrant workers going to work in specific countries have to go through all forms of medical mandatory testing with no counseling, no pre consent. If found positive, they are immediately deported. In many cases, the worker is not even told whether he or she is positive. On returning to their communities, they are further stigmatized, ostracized, sometimes even jailed as criminals. Last month, I was at the World Food Summit in Rome. We are aware that poverty is one major factor that increases vulnerability, yet what was disgusting for me was that the new plan of action that was drawn up was exactly the same that increased poverty and hunger in the world. This new plan of action compounds the error of more of the same failed (MS?) with destructive prescriptions of trade liberalization, privatization and modification of basic needs and resources. Power, we witnessed increasing brutal repression of social movements and human rights. Initiatives resisting this new form of world order. The mantra of the GH practitions is that trade will set us free. But how can this be true when the United States itself developed its own protectionist qualities of putting in $190 billion as agricultural subsidies and the European Union $160 billion while the countries in the south have to lift to the subsidies that today we have a contraction in India where the (MS?) are filled with grains, but millions go hungry. This is the hypocrisy of the world.

Similarly, the infamous Breckinwoods institutions of the IMF and the World Bank have pushed nations to privatize services under their structural adjustment programs. Through this privatization process, the IMF and the World Bank have allowed the market forces to determine the priorities in house needs, and consequently, what we have is a growing house industries that is denying millions of people the right to fair and treatment. The insurance health industry does not accept HIV positive people that can then buy the insurance, and then HIV/AIDS positive people are denied access to care and treatment. (MS?) has become industry of commodity. Health is now for profit, not for the people. It is not surprising that the agenda of the World Health Organization for all has failed miserably because when house services were privatized, primary health care flew out of the window, and health care services got compromised. In turning health into a commodity for profit, what we have done is we have created a pall around for the virus to multiply. And so one of the key factors is verbalization processes of (MS?) and pricing and privatizing of the health care services. Through this form of trade liberalization, we have now given the power to the drug companies and governments have surrendered the possibility and responsibility of health care of the citizens. The poor are spending every penny they have on the sick and dying. Any wonder private out of pocket spending accounted for 93% of total HIV/AIDS spending while only 7% came from government and donors. Such high dependence, my dear friends, is indeed a growing concern because it is the wage earners who are dying. And so it is not the lack of knowledge that is the bottleneck. It is lack of resources. Drugs are beyond the capacity of Africans where people live on less than $1 a day. But if there were resources, then millions of lives could be saved. Why, my dear friends, is there this lack of resources? And as I mentioned earlier, it is not just the structural adjustment programs, the market forces, but also that there is a lack of commitment.

There is a lack of global commitment to the globally. The special session of (MS?) calculated that up to $10 billion would be needed by 2005 to tackle the disease, but today we have only got $2 billion, a little above $2 billion. Dr. Peter Puron of U.N. AIDS said, “We haven’t reached the peak of the AIDS epidemic yet. The money that is needed to be spent is not asking for the moon, but any standard that I use for breaches of security, that’s peanuts.”

He went on to say, “It’s almost a scandal that the national community has not given what it should have. The world cannot afford a whole continent, Africa, to be decivilized because of AIDS.”

The GDP countries are continually in default. In the 1970s, the timidity of all these agree that 9.7% of GDP should be the foreign aid quota for the rich nations. But if we look at what that is today, it is indeed very worrying. The country that makes the most noise, the vetoes constantly the issue of human rights is the country that is the least committed, and you can see from what that commitment is of the United States. George Bush, at the financing for development conference in Monterrey said that he would increase American foreign aid by $5 billion overall annually by 2006. But this, it comes to only 20% of the original target. Similarly, the European Union computes and committed to another $7 billion, which again only comes to half of the GDP promised in the ‘70s. Canada also said that it would increase, but my friends in CITA has told me that the CITA budget has been slashed tremendously. Now, if the countries had lived to their commitment of the 1970s, we would have $200 billion, and that would have saved millions of lives in the world pandemic. Again, if we look at the new partnership for African development, HIV/AIDS is hardly mentioned, and yet we know that if we do not tackle the AIDS issue in Africa, there will be death (MS?). The three key indicators for development are education, health and food. Last year alone, 1 million children lost their teachers to AIDS in Africa. How can that be development? Many state that there is a lack of political will. For me, there is a formidable political will at the global level. Scores of billions of dollars were mobilized overnight to arrange the horrendous deaths of 3,000 people, and the war on terrorism contributes with even greater zeal. Tell me why, tell me why so much value was given to those 3,000 lives. Why so little thought and political will for the millions dying of AIDS? Why is the war against terrorism so sacrosanct, but the war against AIDS meek and weak? It therefore demands from us as a resolution a new paradigm shift where health can no longer be a commodity but health must become a right. And if it’s this paradigm shift that must be recognized because unless and until we put health as a right, recognize healthcare as a responsibility of a nation and that health must come out of the world trade organization.

We have to continuously challenge this, and I am indeed very happy that challenges are taking place with a court victory in Africa and south Africa with brazil, and I must congratulate brazil for AIDS. Very proactive time. While it has brought thousands into antiretroviral drugs, what is the direction we have to take? That must be the global response of challenging the world trade organization in each of our countries and making access to treatment a key factor for all of us. The new paradigm is access to care. It’s beginning to take effect, and long-standing global inequities are being challenged. From this fields before the world trade organization to court cases, the principle of preferential pricing for HIV drugs, for low and middle-income countries has largely been accepted in the industry. Prices have begun to drop, but that is not enough. We need to go further and attack the root process. The global funds can help, but the global fund cannot be a dole out, and while we sustain health as a commodity. It must be a right where equity and healthcare must be the thrust for all governments, and the responsibility and accountability and treatment is in the hands of governments and not surrendered to transnational drug companies. Human rights, therefore, has to be the basis for our program and process. And this has already happened because the right to health ahs been officially adopted in the committee on economic, social and cultural rights. Also in the U.N. solution to human rights resolution 201.33 on access to medication. That must be the framework and paradigm for our struggle to justice. Jonathan Mann, as he became more and more passionately involved in his work with affected communities realized that we have to confirm vested interest. We have to challenge the political and societal status quo, and therefore, the time has come for us to consolidate our knowledge and experiences and strength to the global movement.

The global movement must break the barriers, bridge the widening gap of inequalities by challenging the status quo at all levels. Today more than ever, the movement of struggle to create equitable access to drugs and treatment for all people in affected by AIDS. And this we can only do if the people in the north continue to challenge their governments, their drug companies and their corporations that assented in that part of the world. And so today, the millennium goals can only be achieved if we commit ourselves to protecting the rights of our people infected with HIV/AIDS. Health has to be people centered, and here I would like to quote, as we construct and consolidate a global movement to protect and promote health and human rights, equity and dignity, Jonathan Derella (MS?) who died of AIDS two months ago who was a dear friend of Caram Asia (MS?).

When I was told of the result, I was shocked. I felt too weak, and until today, I never knew how I managed to get home. This was when I finally realized that life was beautiful and should never be taken for granted. That is a gift from God. Yes, life is a gift from God. Life, let it be from New York, Mozambique, India, or China, it’s the same value. And to continue this commitment and treatment, access to treatment – to continue this battle cry and global response, it is the young who must now heed to this response. I am privileged to have my son with me today, and I would like to call him up so that I can see this commitment continue to the direction with the young to light the lamp that is there for, as a sign, as a symbol of hope and commitment. I would like to call Camera (MS?).

Thank you very much. Muchas gracias.

UNIDENTIFIED SPEAKER: Thank you, madam chairwoman. It’s my great pleasure to be able to introduce Dr. Bernhard Schwartlander, who is the director of the HIV/AIDS program at the World Health Organization in Geneva, where he’s responsible for guiding and supervising WHO’s work in HIV/AIDS prevention, care and support. Strategic information, research, monitoring and evaluation. Between 1996 and 2001, Dr. Shartlander was senior epidemiologist and director of strategic information at the joint United Nations pro-ram on HIV/AIDS where his team was responsible for (MS?) HIV/AIDS epidemic. Publishing widely on its dynamics, determinates, demographics, and economic impact including the agency’s reports on the global AIDS epidemic. And perhaps most importantly of all, more than ten years ago, he was a visiting scientist with us at CDC, where we think we taught him all he knows about surveillance. Dr. Schwartlander.

BERNARD SCHWARTLANDER: Thank you, Harold. (MS?). It is indeed an honor to be invited again. It’s always challenging for this technical presentation at the beginning of this conference. The slide behind me, it shows the global toll of HIV/AIDS to the end of 2001, and the number of deaths and the number of new infections is known to all of us. You already know the number of HIV infections has grown exponentially over the past two decades. As individuals, we almost take it for granted that each year from conference to conference, a few million more have to be added to these roles. The numbers may change from one conference to another, but the effect they have on us are continuing. I cannot possibly hope –- there’s no need to cover every aspect of this complex epidemic. Much more information will be presented to you during this conference, and much more will be presented during reports of (MS?) including the country by country statistics and the report that you have all gotten in your conference packs. It is my time to focus my presentation and analysis, not what these numbers are, but what these numbers mean. Looking at the global prevalence map at the end of 2001, just some key points. First, HIV is now found in virtually every country in this world, and you all know that the epidemic has reached disaster levels in certain parts of Africa, but as you can see from the darker zones of this map, the Caribbean, Asia, Latin America and Eastern Europe are not being spared of these epidemics, either. By every measure, the number of people living with HIV/AIDS, the number of infections or death, the (MS?) is being experienced in those countries which are least equipped to tackle it. Of the 40 million people currently living with HIV/AIDS, 94% are in developing countries. Then all seven countries, all of them in southern Africa, the countries in dark red on this map here, their HIV prevalence rates have reached 20% of the total population. In four of those (MS?), one out of three adults now carry the virus. An important to remember that these are just national averages. In these seven countries, prevalence rates are consistently between 30% and 50% of the major cities. (MS?) every second or third person sitting on a bus, walking on the street is HIV positive. It is almost impossible for me to get my mind around these figures. And yet probably ten years, that it was happening. As an epidemiologist working in the field, I simply would not have believed that this would be possible. But prevalence can only provide us with a snapshot of a situation at any given point in time. We must remember that the epidemic is still in its early phases. And it’s changing rapidly. Africa has moved so far in terms of numbers, we are seeing increases in the number of new factions in some parts of the world and in some of the most populous nations in Asia, of those in the middle east, and especially the Eastern Europe as presented by the bars on this slide. We show the proportional increase of HIV infections between 1996 and now. In eastern Europe, the number of new infections has grown so rapidly that the bar just goes off the map. These are the regions in which the HIV epidemic is most dynamic and unstable, and where (MS?) by significant social and economic change. This brings me to my first point. No society is immune. The virus is now present in virtually every country in the world, and no longer can any society consider itself immune to the virus. And once HIV is in a country, is in a region, it can quickly spread across the map. Just look at eastern Europe. Less than half a generation, the HIV infections had been reported anywhere in eastern Europe. Only Poland and Romania had isolated pockets of HIV infection. But Africa, U.S. and western Europe were in the grip of advancing epidemics. Most countries in this region at clinging to hope that maybe AIDS is only a disease of the poorest countries or the richest. As you can see here, country by country, year by year, the number of new infections began to rise in this region. It began with the first widespread outbreaks in the Ukraine and Belarus. These were followed in rapid succession by other countries. Moldova in ’96, Russia in ’98, and then Latvia and Kazakhstan in a very short few years, eastern Europe now has more people living with HIV/AIDS than all of western Europe combined. In Geneva, the world’s fourth-most populous country is another example of just how suddenly an HIV epidemic can take off. The ingredients for (MS?) for long time, but after years of silence and nothing really happened, even the more (MS?) just like myself started to think maybe Indonesia or countries like Indonesia are immune against the virus, but it was just at the point in time when prevalence showed up amongst drug users and among sex (ms?) in many parts of the country. Then they moved into the population at large as shown as the steep increase of HIV prevalence among blood donors since late ‘90s, as you can see on part of this chart. (MS?) the two countries, (MS?) the epidemic is slowly but steadily taking hold. We just heard this from the previous speaker, as well. The populations of these two countries are so large that they could determine the future goals of the global epidemic alone. The world’s richest countries are not immune from growing epidemics, either. In the last two years, increasing worrisome reports have come from major cities from almost all developed countries. Incidents are increasing, especially among certain groups such as young men who have sex with men, among women and some ethno cultural communities. Mobility and mortality have been incused with highly (MS?). But developed countries have failed to sustain the initial successes of prevention and treatment optimism is not the only cause alone. We have to come up with much more effective and credible responses towards this very worrying trend. And let’s not forget that every infection, particular in a situation where the resources and the knowledges available is one infection too many.

I’ll come to the next point of my presentation. In worst affected countries, HIV/AIDS is beginning to erode some of the hard-won development gains of the past. In countries where a social and economic foundations were fragile to begin with, the cracks are now widening. For some time now, data has (MS?) a potential impact such as an estimated 2%, 2.6% reduction in GDP in countries with over 20% of HIV prevalence, or a drop in national economic growth from 2% to 4% in cross Africa, as a whole. But a problem is such figure is that GDP does not have a face. Growth rates do not tell us about people that have all these and about their communities. We still have only a limited indication and data from a few studies of an impact of death on households. The decline in nutrition because money is spent on medicines rather than food. The prospects of a girl who leaves school to care for the younger siblings. We need to know much more so that we can work to engage such impact in the future.

This slide was shown for the first time for you two years ago during the same event. It says to me one of the most telling illustrations of the way in which the epidemic can actually distort societies. The AIDS epidemic, you would expect the population of Botswana, widely prosperous African country, grouped by age with males to the left and females to the right to bulge in the middle with the most active and productive members of the society in the middle. That’s illustrated by the shape of the blue bars on this slide. But with AIDS, in just less than 20 years from now, you see getting whole. A classic population pyramid is turning to a narrow chimney, as illustrated by the red bars in the middle. This whole means a society where parents aren’t caring for their children. That ranks of teachers and doctors and police have thinned as schools are empty because children have to take care of their younger siblings. The old people have to go back to the fields to bring food to others that nobody brings to them. I honestly don’t know how these societies by themselves will be able to cope with this disasters. And even if we reduce infection rates now, we still have to fill this gaping hole. We’re beginning to comprehend how the loss of workers stands to undermine the key sectors of society. In 2020, more than 25% of the work force in some countries may be lost to AIDS. (MS?) Some countries will have prevalence as high as 40% when soldiers in Kenya, AIDS accounts for three out of every four deaths in the police force. And health workers are being infected in high numbers everywhere, as also as illustrated in this slide on the right side of the chart. This is a double bow. You know, who cares for the career?

Countries must ask these people questions now so that they can plan to mitigate the losses, preserve security, keep the people, care for the sick, educate children, and keep the countries going. And let’s not forget the figures we are seeing here deal with death. They don’t even begin to reflect impact of illness, burn out over time spent with caring for others. In education, HIV/AIDS has the potential to erode both the supply of teachers as well as demand for education, and therefore may set back a fundamental aspect of development. Future death rates in some countries have doubled or tripled in recent years. (MS?) 13,000 new teachers over the next 17 years just to keep services at their 1997 levels. We’re talking about an increase. That means they would have to train 7,000 more teachers or twice as many as we would have to train if there were no AIDS.

The demand for education, the number of people who are there to be taught is also being affected. Numerous studies in all parts of these worlds has shown again and again that children whose parents have died have substantially lower levels of education, as you can see from comparison between the green and the red bars on this slide. An analysis has been released during the conference by UNICEF, (MS?) estimates that 13.4 million children under the age of 15 have lost a mother, father, or both parents to HIV/AIDS by the end of 2001. And this number’s expected to grow to more than 25 million by 2010, just eight years from now. On this message of strength and to support these children, AIDS will undoubtedly contribute to decreasing levels of education, probably the single most factor for development.

Of course, it’s not only education that they’re seeing the impact of the age of the epidemics on the young, which brings me to my next point. One of the most worrying trends of all is that nearly half of all infections that are happening in the world are among teenagers or young adults aged between 15 and 24 years of age. That is over 2 million new infections in young people in 2001 alone. Nearly a third of all adults living with HIV/AIDS today, 11.8 million are young people, and almost two-thirds of these are young women and girls. And in some cities in eastern southern Africa, for every infected boy, there are up to five young girls. This state of affairs, as indicated in the poor and young people released by UNICEF, (MS?). Just last week, we present both a crisis and an opportunity. It is a crisis because the extreme vulnerability of young people to this disease is placing the very future of our societies at risk. Let me show you just a few examples how vulnerable young people are in all parts of this world. In Myanmar, nearly one-third of female sex workers are still in their teens, up to 19 years of age, and half of them are HIV positive. In only a few years, reported infections in Russian adolescents aged 10 to 19 who inject drugs rose from 300 to more than 10,000 cases a year, and this trend shows no sign of abating. 70% of drug users in Buenos Aires say they started injecting before they turned 18. A fifth was 16 years old or less when they started injecting. And after 30% of African teenagers coming into clinics to give birth to a child are found to be HIV positive in some parts of Africa. This is not a good start into adult life. There are many reasons why young people are vulnerable to these disease. One of the biggest is that we have not done enough to help young people to take charge of their own lives. (MS?) in many countries have heard of AIDS, there is still an enormous gap between the disease and having sufficient knowledge to protect themselves from infecting again by comparing the green bars, which means having heard of AIDS, with the red bars, that show the proportion of those who have heard of AIDS who know what to do to protect themselves form the virus. The differences are staggering in all countries. But more importantly, in addition to being a crisis, having young people at the center of the epidemic is also major opportunity. They may be the hardest hit right now, but experience shows that young people can also be a powerful force in reversing this epidemic. In every country where reductions and transmission rates have been achieved. In countries such as Thailand, Cambodia, Uganda, Brazil, the young people. Given the right inclination and tools will change their behavior first. It is now time to channel the energy and enthusiasm of young people to guide our homes to the global epidemic. This brings me to the last part of my presentation and probably the most important.

We can do it. We can reverse this epidemic. The number of countries that have been successful in bringing down infection rates is increasing. In south Africa, data released just last month showed an encouraging reduction in prevalence among young women for the third year in a row. And once more, the trend is with the young. We now have to hope that these encouraging must be seen in other age groups and the older age groups. As example, I have a track record of bringing down the number of new infections in various parts of the world, rich and poor. It can be done. at the same time, we cannot just accept that millions will be left to die. As we all know, since 1995, highly active antiretroviral therapy has resulted in dramatic reductions and limiting mortality and cradling qualities of life and those with access to it, as illustrated here for the example of Western Europe. Looking at the trends for South Africa, it is painfully clear that developing countries have not at all benefited from this so far. Friends, there is no longer any reason to believe that this would not be possible in poorer nations. Even if we do not fully close this gap between the treated and the untreated, between the rich and the poor, you can prolong life for millions more. We already have many examples of antiretrovirals being successfully used in developing countries and poor countries, and Brazil has shown the way. Brazil has shown that it actually costs less money to give people arv’s than just let them die. They do know that if they don’t pay for care now, they will have to pay dearly later. Prior to United Nations general assembly special session just one year ago, an analysis was formed to determine what coverage and preventation and care services is actually feasible, and what would be the resources needed to implement this. At that time, we estimated that $10 billion per year were needed to implement comprehensive response to HIV/AIDS in developing countries. We’re still far from reaching that goal. We now have taken this analysis one step further. (MS?) two days ago. In this analysis, we estimate not only what it would cost, but what could we actually achieve by implementing comprehensive prevention and care packages. The results show that without the comprehensive package of interventions, there will be another 14 million people living with HIV/AIDS by 2010, just another eight years to go. However, if countries, both rich and the poor, live up to the commitments that meet the United Nations special session, 29 million of these infections or more than 60% could be averted. Delaying this response for just one year will cost us another 5 million lives. The time for excuses has run out. Challenges remain, but this is why we’re here. But the pieces are coming together finally. In (MS?) presented political commitment and the framework for accountability, and you heard about this yesterday in the opening ceremony. Price reductions have placed drugs within the reach of the poor for the first time. The use of simplified regimes and monetary is concerned to be feasible. And major refunding opportunities are opening. The global fund, the global bank commitments, private foundations and many more. And yet it makes the ordinary community of activists to help us. One of them are here, just as you heard the speech this morning, but there are many around in this room and many at the front line. And you still have long way to go, but we would not have gotten where we are without you.

Two years from now, when we meet again in Bangkok, let this presentation, not just look at the numbers that we have to add to this roll. Let’s look at how many lives we have saved. Thank you.

UNIDENTIFIED SPEAKER: (speaking foreign language)

ROBERT SILICIANO: Thank you. I’d like to thank Dr. Gotell for the kind invitation to speak at this wonderful conference. Today, I’d like to discuss two questions related to the theoretical potential of antiretroviral therapy. First, will it ever be possible to cure HIV infection with antiretroviral therapy alone? And if not, will it be possible to maintain patients on therapy for life without disease progression? Let’s begin by reviewing what happens to plasma virus levels when highly active antiretroviral therapy is started. David Hoe and George Shaw (MS?) showed that after the initiation of therapy, there is a very rapid drop in the level of plasma virus. And this reflects the fact that the cells that produce most of the plasma virus live only a short time. These are activated cd-4 positive t-cells and once infected, they only live for about a day. Once these cells have mostly died, a second phase in this decay becomes apparent, reflecting the slower turnover of another population of cells that live about two weeks after becoming infected. And this second phase brings the level of plasma virus down to the limit of detection. And would allow eradication of the infection in two to three years if there were no other mechanism for viral persistence. In people who are doing well on treatment, what we see is this. Just a series of measurements that are below the limit of detection. We also see a pattern like this occasionally, and this represents a case in which there are intermittent low level positive readings suggesting that what therapy has done is to bring the level of plasma virus down to a new plateau that is simply below the limit of detection. Reflecting the fact that viral replication may not be completely suppressed by the drugs, and the persistence of virus in reservoirs. Now, the reservoir that we understand the best is a small pool of resting memory t-cells that are in the state of post integration latency. And because of the importance of these cells as a major long time reservoir for the virus, I would like to review our theory of how this reservoir arises, beginning with the normal physiology of cd-4 positive t-cells. These cells emerge from the thymus and circulate as small resting cells until they encounter an antigen that they can recognize. They then become activated, proliferate and carry out their functions. Some of these cells survive and go back to a resting state as memory cells, and these memory cells persist for long periods of time, allowing responses to the same antigen, again, in the future. In the presence of HIV, it is the activated cells that are preferentially infected, and in these cells, we quickly go through the process of reverse transcription, integration of the viral DNA into the host cell genome, virus gene expression and virus production. And then as we said, many of these cells die very quickly. Resting memory cells are not readily infected, but if some of the activated cells that have integrated HIV go back to a resting state, you end up with a stable integrated form of the virus in a cell that’s designed to live a long time. And it’s worth remembering that these resting t-cells are among the most pliescent cells in the body. As is evidenced by their unique morphology. They’re all nucleus and no cytoplasm. These are cells that are designed to wait. They’ve turned off expression of (MS?) genes like cytosine genes. And the virus has taken full advantage of the biology of these memory cells in the sense that it regulates the expression of its own genes by co-opting host cell transcription factors that t-cells use to turn on and off affector genes. For example, (MS?), transcription factors that are turned on in activated t-cells and turned off in resting t-cells. Therefore, a virus gene expression can be turned off in these resting t-cells. So what we have is a stable integrated and transcriptionally silent form of the virus in a cell that’s designed to live a long time. We call this post integration latency. If these cells encountered the relevant antigen, they become activated and permissive for virus production. Several years ago, we developed methods for detecting these cells, and together with Tony Falchi (MS?) and Doug Richmond (MS?), showed that they were present even in patients on suppressive heart regimes. And the question then became, would this reservoir ever decay with long term treatment? So what I’m gonna show you now is what happens to this reservoir in patients in highly compliant group of patients who’ve maintained suppression of viral replication on heart. And I want to emphasize that the time scale here is years. First, for purposes of comparison, here are the first and second phases of decay of plasma virus. On the same time scale, this is what happens to latently infected cells. Here the slope is slightly negative with a half-life of 44 months. But in fact, the slope is not statistically different than zero. Here are the actual data representing sequential measurements on this cohort of patients who’ve maintained suppression of iremia (MS?) for as long as we’ve followed them. The half-life, surprisingly, is even longer than the reported six-month half-life for individual memory t-cells and uninfected humans. Now, there are two factors that are responsible for the remarkable stability of this reservoir. First, the stability reflects the intrinsic biology of memory t-cells. Viewed in this context, the stability of this reservoir should be no more surprising than the fact that immunity to measles lasts for a lifetime. HIV has taken advantage of the most fundamental aspect of the immune system, and that is the immunologic memory that is stored in long live lymphocytes. Now, memory cells, individual memory cells may last only for six months, but what happens after that six months is not that they all die. Instead, some of them divide, and therefore preserve the relevant specificities. And because HIV is incorporated into the genome of these cells, no amount of antiretroviral therapy can eliminate this reservoir since it’s being maintained by cell division, not viral replication. Therefore, what’s relevant is not the half life of individual memory t-cells, but the half-life of memory t-cells and their clonal progeny, which could be much longer than six months. Now, the second factor that contributes to the stability of this reservoir is a low level of viral replication that continues despite treatment with heart. In some studies, patients who have maintained optimal suppression of virinia as evidenced by the absence of (MS?) show a decay rate that approaches this six-month half life. But these have been short-term studies, and in order to forecast a slow decay process, what is needed are observations at long time points. And therefore, (MS?), we have studied a group of patients who have maintained suppression of viremia to less than 50 copies with no glyphs for five to seven years. And here are the cd-4 and RNA profiles in these patients with the open symbols being plasma virus measurements below the level of detection. Even in this remarkable cohort of patients, the frequency of latently infected cells falls on this line consistent with our original predictions. At this rate of decay, it would take 73 years to eradicate a reservoir consisting of only 1 million cells. In children with prenatally acquired infection, we see the same stable pattern of persistence.

This leads us to conclude that the latent reservoir in resting memory cd-4 cells guarantees lifetime persistence of the virus and makes the disease intrinsically incurable with antiretroviral therapy alone. Now, I realize that this is a difficult conclusion to hear, but in order to provide the best treatment for all of those persons living with HIV, we have to understand the limitations of this therapy. There are some important treatment implications here. First, early initiation of aggressive therapy with a goal of eradication is not likely to be successful, nor is intensification of therapy with the goal of eradicating this reservoir. Because of the stability of this reservoir and the cumulative long-term toxicity of drug regimes, some experts are now suggesting that therapy should not be initiated until later stages of disease, for example, when the cd-4 count has fallen to 300. Now, in addition to these treatment implications, I’d also like to point out that intrinsic incurability of the infection with antiretroviral drugs is as powerful an argument for prevention efforts as we are likely to have.

Now, because of the importance of this issue, I’d like to provide some additional proof that this reservoir is intrinsically stable, even if viral replication is completely suppressed. And this comes from studies showing the long-term persistence in this reservoir of viruses that are highly unfit under the ambient conditions, and therefore should not be able to replicate. For example, drug sensitive viruses in patients who developed high levels of drug resistance and have been maintained on therapy. Consider, for example, the case of this child with perinatally acquired infection who started on azt shortly after birth and continued on azt, or azt plus ddi regimes for seven years, leading to development of high levels of resistance between starting heart. The heart regime in this case was not completely effective, and additional resistance mutations developed. In all, there were a total of 11 years of partially suppressive therapy. If we look in the latent reservoir, an individual clone is a replication competent virus. We can see in red, the AZT resistance mutation selected by the prior nonsuppressive therapy as well as newer mutations to nelfinabur and 3tc. What we can also find viruses that are completely wild type, that have no drug resistance mutations. And if we compare the fitness of this wild type virus to the fitness of this highly resistant virus, in the presence of the drugs the patient is taking, we see this. The resistant virus replicates just fine in the presence of this drug cocktail, but the replication of the wild type virus is very strongly inhibited by 3,000 fold. And it is the persistence of viruses that are so unfit under the ambient conditions in this reservoir that suggest that the mechanism of persistence is independent of viral replication, just exactly as we would expect if the virus is persisting in a latent form in resting memory cd-4 cells. Now, these wild type viruses can re-emerge if therapy is stopped because they are actually more fit than the drug resistant viruses in the absence of drugs. But it’s also extremely important to remember that just as wild type viruses are stored in this reservoir for long periods of time, any drug resistant viruses that arise are also stored in this reservoir and remain there for life. In a sense, the latent reservoir gives the virus a way to remember any mistakes that are made in treatment. Now, additional evidence for the stability of this reservoir comes form a phylogenetic analysis of latent reservoir sequences, which essentially shows that this reservoir stores viruses that have evolved at earlier time points and changes very little after affective therapy has started. From these studies, we conclude that the latent reservoir serves as a permanent archive for all wild type and drug resistant viruses that have previously been generated. And the persistence of these archival viruses and the lack of temporal structure in this reservoir argues strongly that at least a significant component of this reservoir is intrinsically stable and does not turn over. So, is there any way that we can target this reservoir? Well, this depends on the mechanism of latency. And in particular on whether latently infected cells make any viral RNA or protein. And that is, because if they do, then they may be susceptible to therapeutic strategies with RNA or protein targets. For example, cytotoxic t-cells. Now, some theories of latency suggest that the production of viral mrna’s blocked due to absence of (MS?) host transcription factors or other mechanisms listed here. Other theories of latency suggest that viral RNAs are made, but defects in virus production remain for other reasons. And in order to distinguish between these two alternatives, we developed very sensitive (MS?) for viral RNA and used them to look in resting cd-4 cells from patients on heart. And these assays were validated with in vitro transcribed radial chemically quantitated RNA standards which were taken through the entire procedure. And with this assay, we can easily see a single copy of a viral RNA standard, but have very difficult time finding multiply spliced viral RNA in cells from patients. And in fact, the level of multiply sliced RNA works out to be less than one molecule per DNA positive cell. Suggesting a high degree of transcriptional silencing in these latently infected cells. And this finding all but eliminates any hope for selectively targeting these cells. Just to show you what we’re up against, this slide compares a latently infected cell with its uninfected counterpart. The frequency of latently infected cells is only one in a million, but we can’t tell which one it is because these cells are not making any viral RNA or viral protein. The only difference between these two cells is a little bit of extra DNA representing the silent HIV genome. Essentially the virus is existing as pure information, and the survival of the cell is decades. So is there anything that we can do? Well, we can’t wait for natural decay. As I’ve shown you, it’s too slow. Some groups have advocated flushing out the reservoir. But since we can’t tell which cells are the infected ones, we would have to activate all t-cells, and this is likely to be too toxic. Ideally, we could specifically activate virus gene expression in latently infected cells, but this is difficult because of the intimate linkage between virus gene expression and t-cell activation. Finally, some groups have advocated eliminating this entire memory t-call compartment, but this is likely to be dangerous, and even if we could do this, there may be other reservoirs, for example, infected macrophages for virus persisting in follicular dendritic cells. So in the final part of my talk, I’d like to turn to some more positive findings, and these are related to the question of whether heart can stop virus evolution. And this work involves an analysis of the low level of plasma virus that persists in patients on heart. Roger Pomerantz (MS?) has shown that even in patients who have suppression of viremia to below the limit of detection, there is a little bit of virus that continues to be released into the plasma. We haven’t been able to clone and characterize this virus. And what we see in patients who started on heart with no prior resistance is that the virus we find after three or four years of treatment is completely wild type. And we even see this in patients whose regime includes the drug 3TC for which a single point mutation gives high-level resistance. This suggests that viruses that are completely sensitive to all three drugs in the regime continue to be released into the plasma at a low level for years without the accumulation of even the earliest of resistance mutations. And this result suggests that heart can stop virus evolution. In patients who’ve had prior nonsuppressive therapy, what we see in the plasma once they’re on heart is what looks like the random release of archival resistant viruses selected by the prior nonsuppressive therapy with no new drug resistance mutations. So these results suggests that in patients on heart who have suppression of viremia to below 50 copies, there is a little bit of virus that continues to be released, but it’s archival in character and is in fact very similar to viruses found in the latent reservoir. This suggests that heart can stop virus evolution.

So to summarize, although current heart regimes cannot produce eradication of the infection due to the existence of a stable reservoir and resting memory cells, heart can completely stop virus evolution, making permanent lifelong suppression of viremia possible. Now, this will require the development of available, affordable and nontoxic drug regimes. In addition, there’s a very exciting possibility that the development of strategies for enhancing HIV specific immune responses will allow patients to come off treatment and control viremia on their own. This is an idea that’s been pioneered by Bruce Walker. These things will not be easy, but with the tremendous amount of goodwill and expertise and commitment, as so evident at this conference, I think this is a goal that can be achieved. Finally, I’d like to thank the people in the group who did this work. This work was a collaboration with Dr. Debbie Prusad(MS?). My wife, Janet, did the longitudinal studies on the latent reservoir along with Jolene Kades(MS?). Jili Zhang (MS?) did the work on resistance and Monica Hermanpova (MS?)did the work on transcription. We’ve also had help from many fine physicians at Hopkins including Stuart Ray, Tom Quinn, Joe Margolick (MS?), John Bartlett, Joe Galant and Dick Chason. And also from (MS?) from the University of Toronto. Finally, I’d like to thank the patients who contributed to this study. Thank you very much.

UNIDENTIFIED SPEAKER: (speaking foreign language)

UNIDENTIFIED SPEAKER: Now I’m pleased to present our last speaker, Milly Katana from Uganda. Milly, an advocacy officer, (MS?) grew up in Uganda. (MS?) Also, she joins the board of the global fund to fight AIDS, malaria and tuberculosis. Representing southern (MS?) board members, (MS?) from developing countries. Milly, you have the floor.

MILLY KATANA: Thank you very much, my old friend, Eddie. And the other co-chairs, colleagues, my friends living with HIV, ladies and gentlemen. I’m very, very mindful of time, and I know in the next ten minutes, half of us would be out of here, but I’ll try to do my best.

I’m grateful and honored this morning to have been assigned this responsibility of speaking about the committee movement in the response to HIV and AIDS. What I want to share with you this morning is a joint effort of many individuals, friends and colleagues from all parts of the world. I cannot mention all your names, but thank you very much. In particular, however, I would like to recognize one friend from (MS?) whose name is Winston Zulu (MS?) who specifically asked me to tell you how denial has almost caused his life. Winston is one of the key figures in the committee movement against HIV and AIDS in Africa. At some point about three years ago, he was not sure whether that HIV he carried would cause him AIDS. He went off all his medication, and now he is confined to a wheelchair. He proved on his own body that HIV, indeed, causes AIDS. With the theme of this conference being giving scientific knowledge into action, there’s no better place or institution to move this knowledge into people’s lives, homes, workplaces, villages and townships and in the communities themselves. I would like to state here that in many parts of the world, communities responded to the epidemic long before we had the scientific breakthroughs. Not even the diagnosis of what the disease itself was. And in many countries when scientists and political leaders took the no action when they identified the culprit of this slim disease, as we call it in many parts of Africa, communities were already on the ground offering support with no knowledge of what this disease was. Therefore, friends, ladies and gentlemen, during this part, I would like to remind all of us of the central role communities have to pray now that scientific knowledge are with us.

In addition, I would like to analyze opportunities available for communities to pray this role, and finally, (MS?) for an effective community inspection in the response to HIV and AIDS. Before I go any further, I would like to state that the community involvement has always been synonymous with deprivation. The community that has people that volunteering time, food, clothing, blankets, many with very little resources at their disposal. What then is the central laws of the community movement in the response to HIV? I think I’m preaching to the converted, but I would like to remind ourselves that one of the key central roles of us as a community movement is offering care and support. And this care, which I can do in all sorts of different ways, ranging from care to economic empowerment. (MS?) countries with HIV and AIDS double at the same time as the poorest in the world. Therefore, with this kind of minimal resources and infrastructure, we as a community need to take a lead in altering care where the people live which will cost us minimal resources which we indeed do not have. In the richest countries of Africa, health care system is inadequate, so we still have to play a major role offering the best care to parts inspected and affected with HIV. With the statistics with which we are reminded every day, often to AIDS and fortunately, 14 of them in my own region of Sahara in Africa, we as communities need to marshal all resources we can find from loose parental guidance, education, health care and food. Complement the government’s efforts. And also support government’s efforts in distributing whatever resources they have to their (MS?) HIV and other problems in their developing country. Medical care is a cure-all we have to play as communities involved in the response. Scientific breakthrough has indicated that indeed HIV is not necessarily a death sentence. And being reassured this morning that we can have a permanent separation of HIV if we use antiretroviral drugs. So I think after this conference, as communities, we need to engage a higher idea to move and offer medical care to people infected and infected with HIV, now that the drugs can be priced as low as $300 in some countries, to $1,000. So we have a cure all, indeed, and I know it is possible.

Counseling is another issue which is so much needed for people living with HIV. We face all sorts of challenges on a daily basis, and as communities, we need to engage our efforts in carrying out our counseling efforts to all communities and individuals living with HIV, whoever they are. Another key for communities is advocacy for yourself. We have been advocating for the past 20 years, but now we need to change tactics and insist on results. Yes, I mentioned that leaders who do not deliver should consider losing their jobs, and with the (MS?) we have well-articulated expectations, and all of us need to work together in a changing AIDS competent policies. Which policies people base and things that are on people’s needs. Another key advocacy agenda is stigma and discrimination. I feel very sad after all these years talking about stigma and discrimination to realize that stigma and discrimination are still with us. What then is the role in the community groups in addressing stigma and denial? One of the key issues is for us to create an enabling environment and demystify AIDS. (MS?) information about ways of transmission of HIV to AIDS. Ladies and gentlemen, you will be shocked from the statistics to realize that until today, many people are still unsure of how they can contract HIV and how they can protect themselves from HIV. This carries with it stigma and discrimination, imaging that even casual contact with people who are suspected to be living with HIV can lead to infection. Another advocacy piece for us as a community is new leadership for change. Singles out leadership at all levels of society, and a special component for an effective response to this epidemic. But who is going to provide this leadership? We as communities have offered leadership, and we’ll continue to offer leadership as epidemic unveils itself in different parts of the world, which we’ll start with denial. However, we are not talking about ordinary leadership where we wait for such big meetings and big side shows before or after our surnames. We are talking about new leadership, which is committed to people’s needs. And community groups should lead the way of transformation to a very best leadership, which is accountable to results gender sensitive and genuine about the position of people living with HIV and are willing to be part of the transformation process itself. Ladies and gentlemen, another key role we have to play as a community is prevention. According to the statistics, you will realize that less than 1% of the world’s population is actually infected with HIV. 40 million is big enough, but of the 6 billion population of the world, we have over 99% to ensure that these people actually do not get infected. So this is a cure all. We should not slide back. We need to push for prevention if we have to change the status of the academics in the world. In (MS?) we struggled so hard to break the silence over HIV. But sadly to report, silence still persists in different forms. It is characterized by denial, hypocrisy and there are standards as we deal with this problem. And collectively, denial gives rise to marginalizing the HIV burden in regard to policy and decision making. Therefore, the community movement needs to give a face to HIV as a daily reality both in the hardest hit region of Sahara in Africa and also in the Asian counties which have been a new epidemic.

As we know, the issue of gender relations is a key driving force behind the HIV epidemic. Indeed, in the hardest hit regions of Africa, we know that more women are being infected than men, and we are seeing this also in the industrialized countries of western Europe and not America, but we still have a big job to do, this time in a different way. Another role we have to pray is that over (MS?) orientation. People the world over have wonderful and complicated cultures that keep them together as a people and unique in lifestyle and give them the sense of self esteem. But since we’ve had an AIDS epidemic, we have realized that some of these people have not been very friendly to HIV prevention efforts. There are so many examples ranging from (MS?) in some parts of western Africa. There are also other dangerous sexual processes like dry sex which is very, very common in parts of Africa. So as a community, we need to move this time with renewed energy to address these cultural issues in a way which is sensitive to the people who value these practices. As I mentioned, I’m very mindful of time. Excuse me if I move at a speed which is not the usual way I do things. I would like to briefly look at opportunities that are available for us as communities to respond to HIV.

One of them is the distance of the groups themselves. Men of the groups all over the world have experience in planning out specific activities ranging from orphan care in Zambia (MS?) activities in northern Thailand. Many of these groups have identified what is their comparative advantage. So this is an opportunity that is at our disposal which we need to put to maximum use as we address the new epidemic. Another opportunity available to us is the partnerships and networks of community groups. Usually a community groups, we are very small, and if we pull together our energies through partnerships and networks, we create a big force which can move even the hardest challenges we face as a community. Another opportunity, ladies and gentlemen, that we have as a community is the (MS?) of commitment. In the past three years, we’ve been struggling with different levels of commitment, political leaderships, but since June last year, many governments signed onto this commitment, and we need to use it as a tool to (MS?) and also move our agenda of addressing HIV the world over. And in addition, different countries, different sub regional groupings have taken on this commitment and have adopted each of their situations. We have the (MS?). Southeast Asia association of countries, and many other sub regional groupings like the commonwealth of independent states have taken on the (MS?) and adopting it to their specific situations. So what does this imply to us as a community movement? We have a full political backing to annotate our activities. However, much of this commitment is yet to transform into action. But on a general scale, we have an enabling environment to address the epidemic in different parts of the world. Another opportunity we have is the infrastructure.

Yes, I mentioned (MS?) and we know in many poor countries, our infrastructure is so weak and feeble, but we have some things to start with. It’s not entirely true that there is nothing on the ground. Even in the poorest countries like my own, we are able to go and see a doctor, test your blood in the laboratory and be told how to take your medication. So this minimum infrastructure is a big tool for us to engage ourselves in a new way to address the HIV epidemic. Another opportunity for us is the mainstreaming efforts. In the past two years, HIV and AIDS was centralized in the ministries of health.

But the new leadership that is on now, all government ministries are being entirely to HIV in their programs. So if their different community groups addressing different issues, education, gender issues, we have an opportunity in the different government sectors to fasten our wheels as we do our work. And a big opportunity that I don’t want to skip is the (MS?). I mentioned area, less than 1% of the world’s population is infected with HIV, so this is an opportunity in which we must take on and make sure that the rest of the population do not get infected. Even in Sahara in Africa, less than 50% of the southern African countries are actually infected, so we still have a big population to target with our prevention efforts.

Quickly, ladies and gentlemen, I would like to mention what are some of the core requirements that we need for an effective community response. One of them is photo transformation. We cannot continue doing business as usual. We have a new set of (MS?) by the U.N. special session on HIV. And in order to attend these, we need transformation (MS?). We also need effective communication at all levels. Being small groups, we need to create a formidable force amongst ourselves in order to be able to address the challenges that we face in our response. Another key requirement is the involvement in planning forces. Ladies and gentlemen, I’m mindful of time, but I would like to mention that the first round of proposals of the global fund have revealed to us how difficult it is for us as communities to find out place in government managed planning processes. Yes, there is general commitment that communities play a role, but when it comes to planning, when it comes to issues of money, it’s very difficult for us to find where to sit and be part of the processes.

We also need capacity enhancement. We cannot go to scale with small community organizations, doing small pieces of work here and there. Given the research with the epidemic is spreading, especially in the Asian countries. Another issue that we need is to raise our voices. Ladies and gentlemen, the world today is (MS?) than it has ever been probably. We think we have bigger priorities than HIV. Therefore, speaking in whispers they make us go and hide over issues which we think are important to be had. Therefore, we need to push the agenda, talk and talk and talk until when the people who are responsible for implementation and policy makers realize the need of the people and the issues on hand.

Another requirement is the proper environment for people living with HIV. I do not need to over articulate on this. Issues of stigma, discrimination, lack of access to care and treatment, all of these issues make it very possible for people living with HIV to play an essential role in the response. My friends in Botswana say, nothing for us without us, and I think this is very, very critical. If we are to sustain the activities of people living with HIV, we must have them play a central role in whatever programs we design for them.

And we need additional sources. Yes, we have the global fund. Irene mentioned of the $10 million that was netted. We have only $2 million, and we wonder what we need to do in order to get more resources, and this is the big appeal. We need more money in the global fund. In my capacity as a board member of the global fund, we need more resources to put into the global fund to be able to get this money to where people are suffering, to where people are being infected if not efficient resources are delivered to do this work.

Finally, we need to lose our denial. I have created the issues around denial. I would like to mention here that a branch, and it’s long, that some countries in Asia are criminalizing activities which are believed to be high risk in form of HIV transmission. But what this does is to drive the epidemic under ground, and the people who are being hunted by the law will not show up for services, and instead, they will deliver their anger to the very community the laws are attempting to protect.

We also need genuine hope. People living with HIV, the communities themselves have worked so hard in the past years with minimal resources, with no access to care and treatment. But now that treatment is with us. The only genuine hope we can apply is getting the medication to the people who need it. I just learned (MS?) so the question now is willingness to put the dollars, to put the shillings, to put the coins to where people need the treatment.

In conclusion, ladies and gentlemen, I sincerely apologize. This is not the way I do things always, but (MS?). We need to work to reduce stigma and discrimination. And there’s nothing limited in the force to HIV and AIDS. And at the end of the day, who is the community? Everybody is part of the community. I believe I did want to mention anything to do with challenges because we use this as an excuse not to do what we are supposed to do. But madam chair and the co-chairs, the only one challenge I would like to mention is that as the community movement, we need to do things differently. And I thank you very much for listening to me and thank you for staying after the last end.

UNIDENTIFIED SPEAKER: Thank you, Milly. You deliver your message with a lot of feeling from the reality and the lesson we learn. Finally, thanks all the participants, all the speakers for their contribution and let’s continue discussing during the conference. Ciao.