HELENE GAYLE: (MS?) HIV prevention. As I had mentioned Dr. Drew Altman is the National AIDS Control Program of Reform, Dr. Peter Piot, Director – Executive Director of UNAIDS and Dr. David Zuata (MS?) from (MS?) University at – in Depaul (MS?), Uganda, at the Institute of Public – or Institute of Public Health. Dr. Bernard (MS?) Schwartzlander (MS?) from the W.H.O. HIV program (MS?). I also just like to acknowledge, that maybe you can raise your hand, the other members of the Prevention Working Group who are here with us and who, will afterwards will be available. Providing a rational description of the Global HIV Prevention Working Group and then ask Dr. Altman to say a couple of words at the (MS?) from the standpoint of Kaiser Family Foundation. We’ve thought – this was an extremely important working group to pull together for a variety of reasons. First, it’s important because this is unprecedented gathering of international experts in HIV, particularly people who have had many years working on prevention and from diverse fields (MS?) opportunities for having a real impact on prevention to hold together a group of this sort. So, I would just turn over to Dr. Altman to say a couple of comments before we begin the official part of our panel.

DR. DREW ALTMAN: I’m truly pleased to be co-convened with this effort. I would like to (MS?) very publicly give her credit for the original inspiration and idea, which is an important one that were invited to co-convene and we’re very happy to do that. The last time there was an International AIDS Conference in Durbin, we conducted before and after surveys of the American people. Now granted this was the American people, who can be a little bit peculiar on some of these issues, but we actually found and documented scientifically that the conference and also the media coverage of the conference had a real impact on public awareness and understanding of HIV. Nearly a demonstrative impact and so I hope we find the same thing this time and that the combined message of the working group and Lancet Study gets through to people in many countries, which is that the worst really doesn’t have to happen and that resources truly do and can make a difference. At the same time, I think we should not have our heads in the sand, those of use who’ve been doing this for a long time, about the obstacles that we face in mobilizing resources and political support for much wider scale convention activities. Probably the most important of those obstacles is just the cynicism which lingers about the effectiveness of prevention. And so for me, the most important finding varying the Lancet Study and the analysis of the working group and in our presentation made yesterday by David Harrison about the potential impact of HIV prevention in South Africa, is the finding that modest and achievable changes in certain key behaviors to delaying sexual activity, limiting numbers of partners, STD treatment, you’re all familiar with them, and condom use can have a huge impact. And I hope that gets more attention because it helps establish the scientific case that will (MS?) persuade (MS?) effective prevention is not just wishful thinking, that it’s feasible, that it’s practical and that it’s doable. And so I think that’s a particularly important message. I may say more later but I’ll quit with that. We’re very happy to be part of this conference.

HELENE GAYLE: (MS?) a brief recap of the (MS?) plenary that I hope most of you saw today and some of the studies from the Lancet article that was – that came out on July 6th. Just to review a couple of points, as I think most of you know that article that came out on the Lancet on July 6th projected a 45 million new infections will occur by the year 2010 if we continue doing what we’re doing at the rate that we’re doing it and that’s without massively expanding prevention effort. But on the other hand, if we really were to scale up at the level that UNAIDS and other groups that call for increase our prevention effort, spending annually $4.8 billion, we could avert 29 million new infections by the year 2010. So instead of having 45 million new infections by the year 2010, we could, by scaling up, massively our prevention efforts avert 29 million new infections using this proven strategy that we already know exists today. The types of strategies for reducing sexual transmission treatment of STDs, voluntary counseling and testing, expansion of condom distribution, access the information, particularly for young people with school health programs, worksite activities and for mother-to-child transmission access Nevirapine (MS?) and other antiretroviral therapies for pregnant woman who are HIV infected, and of course, blood-born infection, access to clean needles and syringes and clean and safe and clean blood supply and securing a safe and clean blood supply. So all of these are mentioned in the study. We know what works. We know what could make an impact and I think the importance of using what we know now is what is clearly highlighted in that study.

Let me turn for a moment to focus on the main point in the report that was produced by the Prevention Working Group that we mentioned. Let me just go through some of those in some scale to give some of the highlights. As everyone knows, we have these varying die projections about what may occur. Forty-five million new infections over the next decade. Interestingly, in 1993 the World Health Orientation (MS?) program on AIDS estimated that 20 million people could become infected with HIV by the year 2000 but that with investment as little as $1.5 billion, which is in the range of what we spend today, we could have half the number of new infections. This would not only prevent tremendous suffering and loss of life but it also would have saved $90 billion in associated costs. So had we invested $1.5 billion back about a decade ago, we could halved the number of new infections and reduced the associated costs by $90 billion. Instead we failed to invest our resources accordingly and they result in (MS?) million people are now living with HIV and they estimate a continued expansion of the epidemic.

I think if we could identify one theme that’s emerging here in Barcelona it’s importance of expanding and scaling up access to prevention as well as for treatment. And I think the bottom line message for this epidemic is that we need to massively expand what we’re doing in prevention, massively expand what we’re doing in treatment and do that in a comprehensive and integrated fashion and that’s where we’re going to have an impact on this epidemic.

Let me just review some of the other findings that were mentioned in this report. First of all, our report would bring to scientific evidence on HIV prevention. It identifies some of the key obstacles to a massive scale-up that is urgently needed as mentioned. And it makes specific and concrete some of the recommendations for action. The overall plan as I mentioned again, is that there is an urgent need for scaling-up of prevention but scaling-up for prevention in an integrated way. Just as we have combination treatment that hits the virus in multiple different ways, we also need combination prevention that hits risk behavior and supports reducing this behavior in multiple and reinforcing routes. It’s not just one intervention but it’s the integration of all those interventions at an appropriate scale that would make a difference.

What are some of the obstacles? Clearly, lack of resources is the key and most important obstacle. We estimate that currently we spend somewhere in the range – and these are UNAIDS estimates, somewhere in the range of $1.2 billion per year but the estimates are that we need $4.8 billion in order to have a real impact on prevention. There’s clearly a gap in action. Only one in five people who are at risk for HIV worldwide have access to key prevention information services.

Secondly – second obstacle, a key obstacle in human and technical capacity. In many low-income counties there’s a major lack of human capacity to scale-up this (MS?) intervention in (MS?) part because donors have not focused resources on capacity building and resources have all gone on project-specific and project-related costs only but the needs for scaling-up and really developing capacity at the country level have not been matched by adequate resources. Clearly we need to devote new resources for training local personnel and providing necessary technical – transfer of technology to sustain efforts over the long haul.

Third obstacle is an obstacle is inadequate political support. We know that every country that has ever turned the tide against HIV has had strong political leadership. It has been able to be vocal and provide for support for prevention and so [several inaudible words] that political support has often been lacking in the countries that have been most effected by this epidemic. So mobilization of political leadership to support large-scale, (MS?) phase prevention efforts and policies that will fight stigma, that will fight poverty and help to look at other social issues like gender inequality that are so critical to having an impact on this epidemic.

And finally, the need for new prevention tools such as microbecides (MS?) and vaccines. The report recommends that and is similar to recommendations that UNAIDS and other organizations that the investment in vaccines and microbecides peaks the increase by – to $1 billion each year – by $1 billion – increase by $1 billion each year by the year 2007. So massive increase in research devoted to new tools and technologies such as vaccines microbecides.

And the report also strongly supports the expansion of access to treatment. It’s a humanitarian imperative but it’s also necessary for prevention efforts – successful prevention efforts. It’s clear that this debate about treatment versus prevention, as many people have said, should be at this point a dead debate. This is about prevention and treatment. They have to go hand-in-hand. They are synergistic and one cannot receive without the other. Treatment enhances prevention by encouraging things like voluntary counseling and testing and fighting stigma. And prevention enhances treatment by reducing the burden by health care systems. It is not treatment or prevention but clearly the two much go hand-in-hand.

I just wanted to highlight some of the overall points and recommendation in our report and what some of the obstacles are and recommendation to overcome those. And I would now like to turn to Dr. Peter Piot to talk a little bit about the report that UNAIDS released and how this puts in context some of the work of the HIV Global Prevention Group – Work Group.

DR. PETER PIOT: Thank you, Eileen. Good afternoon, everybody. Since the report that we issued a week ago [several inaudible words] I won’t go into that. Again, let me just to say that recommendations of the Working Group on prevention fits appropriately well in the overall global effort. And I would like to really thank the members of this Prevention Working Group for putting together a really excellent report which is going to be useful for our (MS?). (MS?) progress in summarizing what is (MS?) of prevention and advocating for increased commitment. As I believe that we are now in a time of enormous opportunities when it comes to slowing down, to say the least, the spread of HIV, provided we apply what’s in the report. It’s not that we need to reinvent the wheel. If we just apply what we know that works in what we find in the report and we can advert as many as 45 million new infections over the next ten years as the study by John Silver (MS?) and colleagues from UNAIDS and W.H.O. demonstrates, as least in the computer simulation.

And the – as Eileen said, there is not a single magic intervention that is going fix this. It is a combination of efforts. And it’s a combination of two things. One a combination of prevention efforts and secondly, it’s a combination of prevention and treatment. We have been actively involved in the Working Group and before it was set up, Eileen and I had some discussions and one of the things I said is that (MS?) support it. It’s necessary also to get the consistency for prevention but it should not be interpreted and, how should I say, a backlash of prevention only versus what we have today as (MS?) approach and that it is that [several inaudible words]. That’s on the (MS?) to our support.

I would also like to say that prevention remains essential both in the emerging epidemics and in world-established epidemics. It’s not when you have 30% infection rate in a nation that everything should go to treatment. Prevention has to continue. And it’s not because you have only very low prevalence rates at the moment that treatment has no place. So that is also, for me, a very important message from this report.

I’ll – I’m moving forward now to follow up on this. This is obviously a living document because we are (MS?). Our experience evolves over time. It will be very important in this time of increased resource. To demonstrate that there is a return on investment and to be able to plan very precisely where to put the money so that there is good (MS?) results and that a few years from now in UNAIDS we can finally issue a far more optimistic report than we have had to do over the last – since our existence – since our creation (MS?).

HELENE GAYLE: Thank you. And I’ve asked David (MS?) to give his perspective from his many years of experience in Uganda.

DAVID: All right. Also, what I’d like to sort of discuss with you how really this report really relates to [several inaudible words]. You have heard a lot about (MS?) affecting in controlling the HIV epidemic. And I would like to very briefly, in three minutes also, discuss with you probably how this come about and how this relates in the report.

In this report we talk about strong leadership. We talk about we need for strong leadership to be able to make an (MS?). I would like to say that in Uganda, as you have heard before, probably over and over, leadership was a very important factor. The leadership does create an environment in which you could be able to have intervention. If you have a leadership [several inaudible words] dependant of our country, was personally involved in HIV giving out the messages, mobilizing the population, (MS?) on the general community right to the grass root. That in itself does create a good environment for which information – education and information can really get to the people. I think (MS?) this report does point out (MS?) demonstrate.

The other thing (MS?) leadership (MS?) Uganda was to encourage many other groups to work together. It actually realized very, very early on that we need (MS?) six or upwards to combat in AIDS. Many AIDS programs of intervention, particularly in evolving countries, change by nature of what they promote (MS?) promote (MS?) sex behavior, use of condoms, by nature tend to be (MS?) or with other government (MS?) organization like the church. And what the Uganda did was actually involve leaders from the church or other leaders organization to help – to be part in parcel of these fights. How did they do this? They put up in (MS?) organization called Uganda AIDS Commission and actually made sure that the church leaders, all the other (MS?) leaders are part of it. It is not [several inaudible words] where people were likely to be [several inaudible words] they are pushing ahead when brought. These creates an environment in which a lot of innovative interventions could be kind of and re-evaluated. We do know, because of the environment, that, which encourage a lot of the (MS?) that we [several inaudible words]. And this can work on a fairly large scale, as evidenced by (MS?) numbers [several inaudible words]. We do know that mother-to-child transmission (MS?) transmission to the mother’s children, as evidence by the [several inaudible words] in Uganda. We do know that STD (MS?). In East Africa we have (MS?) of having our civil trials (MS?) STD. Some who suggest [several inaudible words] intervention does work. We have the – or Uganda has been able to (MS?) to fight [several inaudible words] demonstrated that their (MS?) prevention strategy that actually do work. They’re showing me. As we pointed out in this (MS?) report I can [several inaudible words] very well to Uganda. The challenge is (MS?) scaling-up. We have to be able to produce to (MS?) programs, how to scale that [several inaudible words]. Voluntary testing and counseling, mother-to-child transmission, [several inaudible words] mother in Uganda do have access to this intervention. What is required is to try to scale-up (MS?) this intervention to all mothers. We do realize that [several inaudible words] and prevention is expensive and it requires funding and this funding has to be sustained. But we also do know that when environment that our government has created has also enabled funds (MS?). And we find there’s (MS?) come into Uganda for prevention strategies.

What else do we find? We find that actually that we have [several inaudible words] to absorb this fund if your infrastructure is not able to take it up. We need to keep up the infrastructure. We need – we have limitations [several inaudible words] to be trained (MS?) to be able to deliver (MS?). These are the challenges. And let me point out that actually [several inaudible words] reduction in HIV (MS?) that infection in Uganda [several inaudible words]. And we still need to be able to scale-up this intervention, to be able to make (MS?) that would really bring [several inaudible words] that is manageable. Please don’t go on the impression that Uganda [several inaudible words] needed. [several inaudible words] very in (MS?) population and we do need [several inaudible words] to be able to bring it any further down.

HELENE GAYLE: Thank you, David. Now I’d like to ask Paolo (MS?) to talk a little bit about Brazil’s experience, particularly (MS?) countries who’s had the best experience in integrating prevention with treatment programs.

PAOLO: Okay. I would like to thank [several inaudible words] for inviting me to be part of this press conference and in for asking [several inaudible words] global HIV/AIDS prevention for what we do. I would also like to [several inaudible words] and international (MS?) including government, [several inaudible words] private sector and community.

I would like to take advantage of this opportunity to raise a few of the issues that are included in (MS?) and that are key questions to the AIDS prevention and health promotion (MS?). One of the first talks that [several inaudible words] for the human rights of people (MS?) with HIV and AIDS. In fact, the development of activities related to human rights [several inaudible words] stigma and (MS?), issues that are of crucial importance and (MS?) prevention. [Inaudible section] or activities that integrate prevention, care and treatment and also that offer (MS?) such as condoms, disposable syringes and needles, then they promote access to the most advanced technology for both prevention and treatment. In this regard, it goes without saying the importance to [several inaudible words] access to antiretrovirals [several inaudible words]. [several inaudible words] in many developing countries. [several inaudible words] political commitment on the part of government. [several inaudible words] hardest hit regions of the world.

In Brazil such implementation of such [several inaudible words] to 40%. [several inaudible words] was reduced from 49% to [several inaudible words]. [several inaudible words] four percent to (MS?) 50% in ’99. Thousand of new AIDS cases have been avoided through the free and (MS?) and with the right treatment. [several inaudible words] saved lives. More information about the Brazil [several inaudible words] and integration of action (MS?) prevention, treatment and support to the human rights can [several inaudible words]. [several inaudible words] can be a powerful instrument in [several inaudible words] through implementation [several inaudible words] HIV and AIDS. It can also force of the sharing of experience amongst countries besides promoting greater access to prevention supplies and new technologies [several inaudible words]. [inaudible section] Thank you.

FAMALE SPEAKER #1: Thank you very much. We’ll now open it up (MS?) part of our formal comments and we’d now like to open up to questions to any of our speakers, as well as I mentioned there are several of the other members of the Prevention Working Group in the audience who are also prepared to provide answers to questions. So I’ll take the first question. Yes.

AUDIENCE #1: Yesterday, U.S. Secretary Thompson announced that the U.S. government had set a goal of reducing by 50% HIV affecting the United States by 2010. This report has not been endorsed by the two members from the (MS?) National Institute of Health or CDC and I would like to know if the U.S. government will be addressing the recommendations within, including the recommendations of [several inaudible words] as a proven strategy for funding for interrupting transmission of HIV?

HELENE GAYLE: Thank you. If – first of all, the people who participate in the Working Group participate as individuals, not as representing their particular institutions and that’s to mention they are – and is also on the Working Group report, the people who are (MS?) are people who had, by the time of printing actually endorses. So parts of – most of the people who have not endorsed that cannot because of timing and the number of international people who are part of it been able to endorse it by the time of printing. But the most important thing is all the Working Groups participated in their own individual rights and not as representing any particular institution. The United States government has reports that it puts out that are official recommendation of the United States government. This is a report of individual members who have expertise in prevention.

AUDIENCE #2: [inaudible section]

HELENE GAYLE: Yeah. Unfortunately, (MS?) the person who was in Working Group just left a few minutes ago, Dr. (MS?) who’s the Director.

AUDIENCE #3: The question is what’s been done on HIV in Spain (MS?). I recently read (MS?) report and one of the things that impressed me very much really is the policy of with injecting drug users who have HIV which is (MS?) of the epidemic and the fact that HIV problems among in prison, injecting drug users and injecting users [several inaudible words] in Spain. I think it is something that is not world appreciated how (MS?) how difficult is it to do that and how important it is that (MS?) so think that is a very good example for other people (MS?).

PAOLO: [inaudible section] About Spain. I think that it’s very important to highlight the fact that Spain has had the best experience on (MS?) prevention of HIV among the (MS?) because they respond to (MS?) early and also because the problem has been very, very [inaudible section].

HELENE GAYLE: Yeah, I think important (MS?) not this is a collective experience that we’re trying to accumulate and get across this report. (MS?) asked maybe Peter Piot to also add from UNAIDS perspective. This Working Group is not intended to be a new organization. It’s not intended to replicate the work of other organizations. It really is, as several of the speakers have said, an opportunity to put together, in one place, our best information and put forth collective recommendations about what is necessary to have an impact on preventing the spread of new infection globally. The Working Group report is something that we hope that other organizations will use. We hope that it will an important report for people at the country level who are looking for sources of information and also for something that they can share with policy makers about what makes – what will make the biggest difference. So we don’t expect that this group is going to be a new organization but can be a network of people who have brought experience about prevention that can be shared with the organizations that have responsibility for actually implementing programs.

DR. PETER PIOT: Just as a compliment to that, our job in UNAIDS is to provide a policy guidance exactly [several inaudible words] in the report but it’s very important for us that we can rely upon independent groups of experts who will bring together opinions, review it and then [several inaudible words] what are exactly the policy guides. In that sense (MS?). Clearly from a selfish perspective it’s an extremely important group. But there are others in the world who have been doing it and we (MS?) regional level because where as the principle are (MS?) how do to it, how that can change (MS?) region-to-region or country-to-country.

HELENE GAYLE: Yes. Let me ask somebody who hasn’t had a chance. You had your hand up. Yeah.

AUDIENCE #4: Thank you. Looking at U.S. prevention efforts [several inaudible words] people of color, people in prison and (MS?) drug users they just sky rocket in the U.S. How – my question is how do we expect the U.S. [several inaudible words] U.S. models to be affected.

HELENE GAYLE: Now again, this was a collection of experiences, putting together the best science throughout the world and we expect countries and individual level to take this report and adapt it to their own circumstances. So this was not a recommendation to any particular nation and we expect that different countries will use this information and see how it will impact and how it can enhance their on-going efforts.

MALE SPEAKER #1: But on the other hand there have been a lot of (MS?) interventions that have been evaluated in African countries and they have [several inaudible words]. There are a lot of reports from East Africa. STD. There are a lot of report from East Africa. Mother-to-child transmissions. So we (MS?) interventions that have been evaluated that can work in a developing country (MS?) that we think can also be – we need to scale-up and [several inaudible words].

MALE SPEAKER #2: [inaudible section].

MALE SPEAKER #3: [inaudible section].

HELENE GAYLE: And the (MS?) obstacles that we have pointed out are often global and cut across different national circumstances and in many countries, including in the United States clearly the investment to prevention has not been as great as it can be. And the overriding recommendation is the need to scale-up around the globe but particularly in countries where the epidemic is having its greatest impact.

AUDIENCE #5: I’m wondering (MS?) Brazil have on the Uganda example. What role do you think the media has played in your success and in prevention and what can we learn from those experiences?

DAVID: I think that’s a very good question. I think the media has a lot of role (MS?) role actually in Uganda [several inaudible words] that there is something there going wrong with some part of Uganda. I think the media was [several inaudible words] completely unaware [several inaudible words]. The media involvement in HIV in Uganda is right from the beginning and it continues to be very important role in educating the people. I’m very happy to note that there are people in Uganda media in this particular [several inaudible words] try to continuously inform the people. I would like to even see much greater role not only informing but it also keeps to make the issue of HIV more forefront to the policy maker, to the government so that [several inaudible words] I can see this role just growing.

PAOLO: [several inaudible words] we did not have any money to make information available to people (MS?). [inaudible section]

AUDIENCE #6: [inaudible section]

MALE SPEAKER #4: The last year in preparation for the special session for the (MS?) general assembly we are [several inaudible words] specialists in economics and in (MS?) of what it would take to (MS?) low and middle-income countries to bring down the number of (MS?) infections and to have a certain coverage of treatment for those who are infected and then also how to – how much would it cost to take care of orphans. These were the three major components. And it was made on the same interventions that are used in the article [several inaudible words] going from condom promotion to media and all that and then we have extrapolated from the (MS?) what kind of coverage would be and that’s how the (MS?) was achieved. This obviously is a provision of (MS?). It’s something that each country should do. I mean, when we have a national plan you need to know what are you trying to achieve? What are – what is your coverage? How much is it going to cost and so on.

(MS?)

MALE SPEAKER #5: I just wanted to pick up (MS?) question about media coverage. Obviously media coverage is central to any effective prevention effort especially (MS?) for young people. But a different point is news media coverage, not prevention as a tool – not media as a tool of prevention but news media coverage of prevention programs around the world. Ironically, prevention which is about sex seems to be less sexy than say coverage of the latest big fight about HIV drug prices and more news coverage of prevention would make a huge difference. And I think a role for this Working Group is simply to be a resource for journalists who are committed and are interested in trying to cover the apparently less interesting story of prevention programs around the world.

HELENE GAYLE: As many people know the Kaiser Family Foundation has really led the way in (MS?) channeling and youth and partnership with media for health efforts.

AUDIENCE #7: [several inaudible words] I would like to know how have you managed to handle typical issues, like traditional (MS?) in Uganda?

DAVID: Yes. The question was how have we managed to handle (MS?) like condom use, traditional practices. As I pointed out in my opening remarks, this has been a very touchy issue especially from the (MS?). I think one of the (MS?) has been in [several inaudible words] HIV to actually involve the various leaders. We have, what we call Uganda AIDS Commission, which [several inaudible words] efforts to HIV. And actually the chairman and the members of this commission, 25% are (MS?) leaders. Typically you got a group’s [several inaudible words] groups involved into problem. And with education and persuasion, I think they have come around to be involved. Actually with (MS?) in Uganda are very (MS?) involved – are very much involved in HIV problems. We do realize that actually there are a lot of people [several inaudible words] for health problems [several inaudible words] and there has been a lot of effort through media and actually through local – they have local organizations to actually involve their traditional healers. [inaudible section] it was a very common thing and really what (MS?) traditional healers and (MS?) educating people it has turned around. But I think the most important point, I think the (MS?) message is to get them involved.

HELENE GAYLE: Other questions? If not, thank you very much for your attention and (MS?) see you throughout the rest of the conference.