MALE SPEAKER #1: We’re starting last plenary of the conference. I think this session is one of the more challenging ones and it’s a pleasure to announce it. We’ll have people of high-standing levels in their field with experience, and we’ll be talking about the things that the conferences have considered very important: programs, policies, scaling-ups, challenges. This session will be shared by Suzette (MS?) Mosebotten (MS?) and Pat Needle (MS?). Suzette Mosebotten is the Director of the National AIDS (MS?) Program in San Martin, that’s Caribbean. She provides a unique combination of experience and her skills in all HIV/AIDS programs areas. Firmly grounded in reality based on her personal experience including her work as a member of the Caribbean Network of People Living with HIV. And Pat Needle is the Director of the Conference Secretariat for the Fourteenth International AIDS Conference. And in her other life she’s the Director of International Programs of the National Institute of (MS?), U.S. National Institutes of Health. I just want to let you know that because Mr. Julio Frenk is leaving to Mexico this morning, we have make a change. So he will be speaking secondly and Paolo Teixeira will be the last speaker for this morning. Thank you very much.

SUZETTE MOSEBOTTEN: Good morning. It is indeed a great pleasure and honor to be afforded the opportunity to chair this plenary. The Caribbean, and particularly people living with HIV/AIDS on the region, are heartened by this gesture of inclusion. It is a significant step for my region towards bringing to reality the concept of meaningful inclusion of people living with HIV and AIDS. CRN Plus is committed to strengthening the involvement of people living with HIV and AIDS at all levels of policy, programming and decision making, and we continue to develop national, regional and international partnerships to strengthen and step-up our response, as people living with HIV/AIDS, to this epidemic. We look forward to the action globally, regionally and nationally following the commitments made during this conference and reiterate that together we can all win the war and not merely the battle.

It is also important to note that the Caribbean, as a region, has made great strides towards becoming the region whose experience can be used as a model of best practices, and this is by no means a small achievement. However, it must not be overlooked that the region is still in need of support from its international partners, both technical and financial, as we continue to move forward from regional commitment beginning at the highest political level to actions which will affect all those within our communities.

This first speaker on today’s –- for the plenary today will by Mr. Paul Farmer (MS?) from the United States. Paul is a medical anthropologist and infectious disease doctor who has worked for the past 20 years in Haiti. He has pioneered a novel community-based prevention and treatment strategy for sexually transmitted infections including HIV, drug-resistant typhoid, and tuberculosis in resource-poor settings. The medical facility in Haiti directed by Dr. Farmer follows over 2,000 patients living with HIV. Over 10% of them are receiving directly observed therapy with highly active antiretrovirals. In August 2001, Dr. Farmer convened a human rights symposium in rural Haiti that attracted 2,000 patients and their families, as well as others from the community. This meeting facilitated the writing of the patients’ declaration of the right to HIV care, the first in the world written by patients in a resource-poor setting who are actually receiving antiretrovirals. Dr. Farmer.

DR. PAUL FARMER: It’s an honor to be here and to be accorded this great privilege. (MS?) as they say here. I’m going to, in my 18 minutes, share ten lessons learned from an experience in rural Haiti, and I will start by asking a couple of general questions. Why would we want to introduce antiretroviral agents to settings of great poverty? And there are several reasons, and they become, I hope, less and less important to debate each year.

First of all, they may not be highly effective, as we sometimes call them, but they’re effective, and they will reduce suffering and mortality, and they may even help us in our prevention tasks.

Number two, because there is an ever-growing outcome gap whereby the rich world has more and more and the poor world less and less. Into this growing outcome gap all of our efforts, as the scientific and public health community are now becoming enmeshed. We can’t avoid taking on these issues, these larger issues of social justice.

Third, because we can reinforce our HIV prevention efforts by paying attention to people living with HIV and paying attention to their families.

And then fourth and most importantly, because we should introduce these agents in resource-poor settings because that’s what we’re being told by people living with both HIV and poverty.

There are two slides, two curves that I want to show you. This is an acceptable curve. Even in a country without a national health program, even in a country without a good health care program, the impact of these drugs on survival among those living with HIV has been profound. A very similar shape appears when you look at the projections made many years ago by UNAIDS of the impact of HIV on life expectancy in sub-Saharan Africa. And I believe that these projections have now been proven true, alas. So we have an acceptable curve and an abominable curve.

Now why don’t we use these agents in resource-poor settings? Well there’s conventional wisdom, and like most conventional wisdom, there is truth in some of what is said, but we need to use these arguments as a point of departure, not a way of stopping debates. First, we hear a lot about lack of infrastructure. But we need to ask more critically what sort of infrastructure is necessary to get going –- to get a project going. Second, it’s clear that if we continue to use the lack of infrastructure argument in order to not introduce more rapidly antiretroviral therapies, we’re going to be denying access to precisely those people with the greatest need. That is, the places with the most HIV are largely the places with the least infrastructure. Third, even if we decide only to do good HIV prevention, which, again, is becoming less and less tenable as a position, we do need infrastructures to get this work done. And I’ll get back to what sort of infrastructure we think is necessary based on our experience in Haiti.

Also, the cost of drugs is prohibitive. This is true, of course, for generics will soon become available, and so this debate is never going to go away. Also, some countries may choose to invoke certain clauses in the TRIPS (MS?) Agreement. There’s going to have to be a way around these very high prices for antiretrovirals; that much is clear.

Now, the question that many of us are asking this summer -- because this is the summer before everything will change. A lot of going to happen this year, and I think a lot of it is going to be good -- good for people living with HIV, good for people without HIV but who are at risk of HIV. A lot is going to happen this year. So we need to be ready now to ask ourselves, “Do we really want the poor to bear the burden of proof?” We already know that these interventions can be effective. We know this from Brazil, which has been the world leader in building up a national treatment program in a large and very complex country. We know this from Europe and the United States. We know this from Cuba. We know this from many settings. So asking the poor to rejustify again and again our disbursements of resources back towards the poor instead of away from the poor is something we should be very careful to avoid.

Now, I think the common –- the statements we hear about cost-effectiveness of interventions and comparing them is not the best way to proceed. These are just two articles drawn from the last few months, taken from a very prominent international health journal. As you can see, one of them says in the abstract that data on cost-effectiveness in sub-Saharan Africa -- and again, these papers are written about Africa but they don’t come from Africa -- this one comes from the United States -- show that prevention is 28 times more cost effective than antiretrovirals. Another example -- this one’s from Europe but about the poor -- is that treating people with antiretrovirals is the least cost effective of interventions currently available. However, there are many reasons for us to be cautious and humble. Let me start making cost-effectiveness analyses. One, is the costs are changing rapidly, as I’ll show from our experience in Haiti. Two, is we don’t understand the impact on transmission of good care programs. Three, what is the cost of letting the rich world get ever richer and the poor world get ever poorer? Surely there is a cost to that. And then, finally, there are ethical problems from having double standards of care or triple standards of care. This has been our own experience in a very small project from 1996 -- when we started buying antiretroviral drugs for Haiti -- to now. And as you can see, the prices dropped. So again, cost-effectiveness analyses have to take advantage of the rapidly moving target. But perhaps more importantly are the ethical objections. Right now what we’re doing very often is offering first-world diagnostics and third-world therapeutics in the same project. And this has become the subject of increasing debate within the HIV community.

We need to do operational research. That much is clear. But we can’t do operational research if there are no operations. We have to put in place projects to serve those living with the twin scourges of poverty and HIV. I’m told, by the way, “Paul, you don’t need to talk about this anymore. People now agree prevention and treatment go hand-in-hand.” So, I’ll trust the people who told me that.

The short version of Haiti -- and I’m very proud that today we have 16 people in the Haitian Delegation, the Minister of Health is here this morning. A large group is here from Haiti. And I’ll say –- I would like to say to my colleagues from Haiti, (MS?). And I would also like to say that the conditions of working as a public health practitioner in Haiti are among the most difficult in the world. And this is true on the district level, on the village level, and, I think, on the level of running the ministry itself. HIV complicates their tasks, of course, as it has elsewhere. The major complication is that the people we serve are living in great poverty, and they’re eloquent and bitter about this. This, for example, in a picture taken by our group, by a visitor to our project -- this is the inside of the house of a woman who is, during pregnancy, received AZT to prevent mother-to-child transmission. Her child will very, very likely -- and it now looks -- is to be by now sero (MS?) negative. But unless we’re going to have this child be a sero negative orphan facing terrible conditions, we have to pay attention to this baby’s mother.

In 1986 we diagnosed the first case of HIV from someone in our region. In ’88 we introduced free serology. Didn’t have a lot of people interested so this is lesson two. Lesson one is, of course, operations take place in people’s homes. Who goes to these patients’ homes? That’s the infrastructure that I’m going to talk about. It’s not doctors and nurses who go to those homes. It’s community health workers. Lesson two was people aren’t interested in HIV testing if you have nothing to offer them. When we introduced AZT into the prenatal clinic in our –- in Haiti, the demand for testing went up incredible. Over 90% of women offered testing accepted it. And more like over 95% when we had AZT to offer. So that’s lesson two.

Another lesson -- there’s no way around HIV. Saying, well, we’ll focus on treating tuberculosis. We’ll focus on STDs. We’ll focus on anything but treating HIV. Even though we had to do this 1995 because we didn’t have the tools we needed. Up to 40% of all of our hospital admissions there, even in rural Haiti, were related to HIV. That is, someone comes in with acute pneumonia, but they were found to have HIV at the same time. You can treat the pneumonia, but the patients will be back. So there’s no way around this problem. You cannot skip dealing -– you can skip slides, but you can’t skip dealing with HIV.

Now we began using antiretrovirals in combination, in my view, tardily. And I think we should be very apologetic –- our group -- about how small our project is. But we couldn’t find any funding partners because they said it’s not cost effective to do this in rural Haiti. It’s not sustainable. Some people have even said it’s not appropriate technology to do this in Haiti. And there are people in this audience who know that we tried for many years to find a way of scaling-up this project from 1998 on. Instead, we had to count on private donors, on patients in the United States who gave us their unexpired medicines, on volunteers, on activists, on others who believe that it might be a human right to have access to these medications. And so I’m very grateful to the people who were there from the beginning to help us do this.

What we have done in following now over 2,000 patients with HIV is to delivery directly observed therapy with antiretroviral drugs, and this is the secret, I think, to how to move forward in the poorest places. We’re not going to be able to put infectious disease doctors and nurses in these places quickly enough to serve our –- the patients, the people living with HIV, nor do we need to. Community health workers can and are ready to do this work. And we have called them our accommpanators (MS?) in Haiti because they accompany the people living with HIV, those taking these medicines, and making sure that the medicines are taken correctly. And I might add that many of our accommpanators are, of course, themselves living with HIV. This is one of our accommpanators visiting a patient in his home. And she may do this one time a day. Often, however, the accommpanators go five times a day just because they become friends, as you imagine, of the patients.

This is where we are now. I’m going to speed up a little bit to get to the -- more of the lessons learned, as I promised the organizers.

This project is effective even when we send bloods up to Boston to find out, “Are these patients suppressed?” Yes, the patients are suppressed. It’s not as if poor people are different –- a different species. These drugs work for everybody.

We also have reduced hospitalizations. We’ve reduced mortality dramatically. It’s going to take time to document this, and I’ll get back to documentation. But among patients living with HIV who are on antiretrovirals, we haven’t lost anyone. None of our patients have died. One person died a few days after starting therapy, and this was, in our view, not related to either the therapy or to an adverse reaction but because we started too late. And isn’t that the lesson of the last 20 years? We started too late. We always start too late.

Now, expecting the “unexpected.” I’ve used quotation makes around “unexpected” because I don’t believe that these are really unexpected lessons. We’ve learned all these lessons before. We learned them with tuberculosis. We can’t learn them again now with HIV. Care has to be available based on need. That’s what determines who has care -- who needs the care most? If we allow only market mechanisms to settle this affair, we’re going to have much more MDR HIV –- multi-drug resistant HIV -- because patients and their families are not going to stand by and die peacefully of this disease even if they live in some slum somewhere in the south. They’re not going to do it. They don’t do it in any country that I know. And they don’t do it in Haiti, and they’re not going to do it anywhere.

The unexpected challenges are the same ones you’d think we might have found. First, the social conditions of our patients. I don’t even want to use the expression “forecasting demand,” because that makes it sound like we’ve been listening to the poor and people living with HIV all along. We can’t forecast demand. It would be far more accurate to say what we need to do now is to forecast our own ability to stop ignoring demand.

And then lesson –- I said ten lessons. Okay, this is lesson eight through one thousand. Beyond the clinic, of course, our patients live in extreme poverty. We know this. We need a way to respond to this poverty, which is, as the Haitians say, “indecent poverty.” And if the Haitians say that there is indecent poverty, they are, of course, also suggesting there is such a thing as decent poverty. Very few of us know it, that’s for sur5e. But there’s a big difference between living in a house with a cement floor and a house with a dirt floor. There’s a big difference in living –- in living with HIV when you have a thatched roof over your head that leaks through half the year. Or having a tin roof over your head. There’s a big difference between hearing your children crying with hunger or sending your children off to school every morning. These are the things that our patients talk about. And we have to listen to them and not say, “Well, this is beyond the scope of our operations.”

Now I’m going to –- this, by the way, is all available on the Web, and I’d like to close by asking some questions about the Global Fund.

Now, first of all, what is the purpose of the Global Fund? I think we need to be very clear as a community of people gathered here. The purpose of the Global Fund is to remediate inequalities of access to proven strategies. It is not to advance new research. We need to do research but it should be operational research. And we should also have other partners helping us, instead of hindering us, to deliver these services if we know they’re effective. In other words, the job of the Global Fund is to do a better job bringing the fruits of science of public health to those who need it most. This is a quotation from Richard Fechum (MS?) made, I think, before he became the Director of the Global Fund, and I agree with it whole heartedly. He’s talking about small programs like ours. What is their job? It’s to scale-up and to be -– to give an example. And as already been said, the Haitians have given many good examples to the rest of the world. They gave a good example in 1804, and I can’t -– I have to say, “What did the rest of the world do when Haiti gave the example in 1804 of becoming the first nation to get rid of slavery?” We started an aid embargo on Haiti in 1804. And we have another aid embargo going on right now against Haiti. And this is not the way for the international community to respond to the needs of the Haitian people.

Now the burden of proof has to be away from the floor. I’m going to -- this is all in the presentation available. But let me just show you an example of the contradictions that we hear in our community. Some people say, “Well, we can’t use antiretrovirals because the stigma is so great.” Others say that stigma is reduced by using antiretroviral therapies in poor communities. Well, let the people with HIV speak. This is Samuel, who asked me to use his name and his images in this meeting. This is Samuel the day he started therapy, and Samuel two months later. And as he put it, “Now my children are not ashamed to be seen with me in the street.”

My last words. When we do this work and talk about things like local corruption -- if you’re working in a place where a hungry crowd tears down a warehouse to get at the milk inside that has been set aside for women who have HIV –- of babies of women who have HIV. Where does the problem lie? Is it the corruption of the locals? Or is it yet more evidence of the apparently insatiable appetites of the rich world? I think there’s a lot more data to show that it’s the rich world that’s wrong. Thank you very much.

SUZETTE MOSEBOTTEN: Thank you very much, Dr. Farmer. You have indeed raised some salient points, and, yes, we know we have started late, but like any good runner in any race, if you’re late out of the start and last, it means you need a burst of energy for acceleration so that you can indeed still win the race. You have also offered a great measure of hope to my neighbors and the people of Haiti, and for that, as a representative of the Caribbean, and particularly the Caribbean TWN Movement and Network, thank you very much.

Our next speaker will be Dr. Julio Frenk from Mexico, and the title of his presentation is “Accountability and Responsibility beyond UNGASS. Julio Frenk is the Minister of Health of Mexico. He assumed this post on December 1, 2000 when Vicente Fox became the new President of Mexico. Prior to his present position, Dr. Frenk served since 1998 as the Executive Director in charge of evidence and information for policy at the World Health Organization in Geneva. He was also the founding Director General of the National Institute of Public Health of Mexico. Dr. Frenk was born in Mexico City and received his medical degree from the National University of Mexico. And at the University of Michigan, he obtained a Doctorate of Philosophy in Medical Care, Organization, and Sociology. His written productions include 28 books and monographs, 44 book chapters, 80 articles in academic journals, and 103 articles in cultural magazines and newspapers. Dr. Frenk.

DR. JULIO FRENK: Thank you very much. Good morning to everyone. I would like, first of all, to thank the organizers for this great opportunity. I was moved from the program from being last to being second because I need to catch a flight, but I have seen that it was not a very good choice since, now, following Paul Farmer is always a very hard act to do. And I will, in a sense, move from the local experience, a very rich experience, to more of a national policy-making view. But I think these are complementary views. I think these are exactly the sort of harmony that we need to achieve and to make sure that those, whether it’s in government or in national civil society organizations, that everything we do gets actually translated into the work –- facilitating the work of people who are in the field, like Paul and like so many other AIDS fighters throughout the world.

I would like to thank very much several colleagues of mine who have helped in this presentation: Stefano (MS?) (MS?), Patricio (MS?) (MS?), Roberto Tapia (MS?) and Madio (MS?) (MS?).

And what I would like to do is really address three issues -– take off from what the historical event that UNGASS represented has to lead us in the future so that we can move from commitment to action. Then look at some of the challenges that those of us in the public health field and the field of human rights need to address if we want to make this promise a reality. And then finally, bring back the centrality of human rights. And I will close with a few conclusions.

I hardly need to reiterate that the United Nations General Assembly Special Session on AIDS was a truly a historical event. If, 54 years ago when the U.N. was founded, someone had said that a General Assembly session would be devoted to a virus, everyone would have dismissed the idea as a crazy thought. But of course, we know the issue, of course, is that HIV is not just a virus. It is not just the top public health priority of our time, but also as Secretary General, the Director of the World Health Organization and many other international leaders have stressed, it is, indeed, the main threat to global development and security.

Now we need to place the UNGASS in its broader context. There’s been a series of international meetings that I think are the beginning of a Change, a shift of paradigm, starting with the Millennium Summit where the Millennium Development Goals were adopted by the U.N. in September of 2000. Moving then to the UNGASS on AIDS on June of 2001, then translating that into commitments for financing in the Summit of Financing for Development in Monterey, Mexico, very influenced there by the findings of the Commission of Microeconomics and Health, following up to the recent summit on children, organized by UNICEF. Here where we’re now, which I see as a major step, and then going on to Johannesburg to look at the hard issues of sustainable development. The central and common thread that I see here is a shift in our thinking, particularly among those who are making financial decisions. I think we’re arguing in an increasingly convincing way that health, apart from being intrinsically valued, is also a key means for achieving development goals. And these are not contradictory. I think we need always to stand up and say and state and restate that access to high-quality health care is an intrinsic right. But in addition, we’re finding that this is also what makes economies growth. This is also what generate global security. And in all of this, AIDS has been clearly, clearly a key topic and a focus of many of these commitments. And this, of course, has not been just a spontaneous situation, a spontaneous shift. Many of the civil society organizations, many of the academics of the world, have been key in bringing about what I see as this new form of thinking in which we’re bringing in health much for centrally into the equation of development.

Now, obviously, as you know, and I hardly need to remind this audience of the various commitments that the General Assembly Special Session made on HIV/AIDS in leadership and prevention and so forth. However, this is one point that I would like to underscore. Most of the commitments are national. Only the ones that are listed in this light have an important (MS?) national component. Obviously, there has been a change in leadership -- as I said before, a new way of thinking and bringing health matters, including AIDS, to the center of development. However, the list, I think, is short and some topics are clearly missing, as I will argue later on, particularly the topic of human rights.

What I’d like to do in the remaining of this talk is to focus particularly on the last two topics. I won’t talk about children, orphans, or AIDS in conflict, but talk about the challenges we’re facing on the research front, the generation of evidence and, particularly, deal with the question of sustainable resources.

Now some of the resources, again, these have been extensively discussed here. We now have the Global Fund to fights AIDS, tuberculosis and malaria. There’s the map. There are increased bilateral donations. These are clearly all steps in the right direction, but, as I underscore in this slide, these are all still under-funded relative to estimated needs. And this graph, which, of course, is now slightly out of date because it has numbers from 2000, shows the way we really ought to be accounting for the commitments, which is not so much in absolute terms as in relation to gross national income. And there, as you can see, the developed countries still have a long ways to go when we make the overseas development assistance contributions to the fight against AIDS relative to national income.

How do we change the situation so we can move from commitment to action? I think to change this reality we need to face the challenges that we’re facing in terms of the sustainability of funding, and this is my second topic. I think we need to squarely face some of the barriers to sustainable funding that may explain some of the reluctance to commit all the funds that are required.

And I’m going to address, basically, three major issues: the uncertainty about the effectiveness of HIV prevention and care interventions, the lack of confidence that these funds will be spent effectively, particularly with respect to purchasing a location and management, and then the uncertainty about which country needs how much and for what. And we need to squarely address this if we want those of us in the public health field to move ahead. Let me quickly address each and every one of those.

Are HIV programs effective? I mean, if this hall was filled with people from the world’s ministries of financing and planning, believe me, I would not ask this question. But the reality that we need to face is that many of those who actually control the purse strings still see spending on HIV/AIDS as something that they are getting forced into by political pressure, and that’s something that diverts funds from more productive uses. We need to get the evidence -– the convincing evidence -- first of all, to put to rest the full dilemma between prevention and treatment strategy as Paul Farmer has just very cogently argued. And secondly, to get the evidence to show as has been now in the discourse -- that investing in HIV/AIDS makes a lot of sense in terms of the human rights of people affected with the disease. But it also makes a lot of sense in terms of achieving development goals. We need to get this evidence right. And we now, I think, have some new tools.

Clearly, some of the UNGASS commitments provide us with opportunities to improve the evidence base. However, we cannot expect individual countries and projects to adequately fund rigorous, prospective impact evaluation, which is really what we’re interested in. This is an international public good. We should never, never put national programs in the dilemma of spending the funds to actually run the programs or carry out evaluations. But furthermore, as a good –- as an international public good -- this requires international collective action. That is to say, we all learn, we all benefit, from the production of this evidence. And this, I believe, should be a key role that the new Global Fund could play. Clearly, also, national and international research institutions should pay more attention to this sort of impact evaluation and the kind of operational research that Paul was talking about.

Secondly, how are we doing on the way the funds that are allocated are being spent? Obviously there’s still many challenges to face, and clearly, the most glaring inefficiency and inequity is in the field of purchasing. In my own region of Latin America and the Caribbean, it is really a painful part (MS?) as has called it, that countries with the greater -– with greater buying power actually pay less for antiretrovirals than countries that have less buying power. And this means that drug prices are not being driven by any market logic of market segmentation according to purchasing power, but, really, they’re being driven by the negotiating power of the purchasers. Now, if this is the case, then we do have a solution in hand, which is joint purchasing. Such a mechanism has been suggested by Dr. Zapula (MS?) recently at –- for Latin America and the Caribbean -- at the recent meeting of International Development Bank. It would make even more sense for Africa, and this could be one of the goals of the New African Union.

It would also help to change the presentation of drugs to make them more suitable and more adapted to regional contest. This is a clear example of international collective action where counties join forces to have a much better bargaining position to drive prices down.

The second question regarding efficient allocation is that we need to get better our evidence about what is the correct mix of interventions. Even in countries with very similar situation in epidemiology show enormous variation. And again, this is an area where we need to have the international strength to generate evidence on what works and what doesn’t work. This is also a global public good. Each experience with each AIDS program in the world generates information for the rest of the world. If we don’t have a mechanism to systematize and share that, that is information that effectively gets lost. We need to find a way to make that information available, that experience available, and engage all the countries in a process of shared learning.

And just to give you an illustration, which I’m sure you’re all familiar --even in my region -- there you see very, very different ways of combining different prevention strategies in countries with similar epidemiological situation. We need to get that information.

And finally, we need to make certain that we and show how to allocate the funds in a way that makes sense. I think, again, the Global Fund provides a very important step forward because by consolidating oversees development assistance for AIDS into a global fund, then we can make priorities follow epidemiological priorities. But for this we’re going to need new ways of thinking, and particularly, I think, that the international community has been saying that it is really time for a second generation of surveillance --that prevention priorities should be given on the basis of where the epidemic is likely to go, based, for example, on risk behaviors and sexually transmitted infections, rather there where it has been. Internationally, we’re still focused on data that tells where the epidemic has already occurred. But we need to move towards a second generation of surveillance that anticipates the epidemic rather than just reacting to it when it has occurred.

And we need even to go further than an anticipatory vision. We need to make human rights a more central part of our epidemiologic surveillance efforts.

And this leads me to the third and last of my topics. As I showed before, in the UNGASS declaration, human rights are not identified as a supernational commitment. And I think this is a flaw because, clearly, every nation-state has to do everything in its power to protect human rights. But the concept of human rights as the adjective “human” implies, is not bound to belong into a particular polity. It is a universal concept. It is this thing from civil rights in the fact that it does not depend on which country you live in. So this is clearly one of those areas that require international commitments. We –- I think there’s very growing consensus that protection of human rights is a necessary condition for effective prevention, care, and support. But we need to move from documenting to preventing human rights violation. And for this we need to reduce HIV-related stigma and discriminations. We know -- and this has been amply discussed by such great pioneers as Jonathan Mann (MS?) -- that human rights are intrinsically linked with the spread of this pandemic. Through increased vulnerability of people, through discrimination and stigma, it impedes an effective response. Again, Paul was just giving an illustration from the ground. But we need to move beyond rhetoric. And we need really a tool kit of interventions that may protect and promote human rights in different settings. We need a third generation of epidemiologic surveillance that makes it possible to document: Were those issues leading to stigma, leading to increased vulnerability, leading to reduced effectiveness as promised, are really impeding effective action on the ground? And make that part of our surveillance efforts. When we do that I think we will have taken a major, major step forward.

Let me close with a few conclusions. On “How do we build on the legacy of UNGASS?” UNGASS was truly a historical event. We need now to take the next steps forward. First of all, I believe we’d need to expand international collective action to improve both the goals of efficiency and, very centrally, the goals of equity. Part of that is to invest more in generating the global public goods of two kinds: better evidence for shared learning on those solutions that we already have in hand, like (MS?), and R&D for new solutions. These are typical public goods. The Commission of Microeconomics and Health has called for a much, much expanded investment on these public goods. They will not happen only at the national level. They require a summing up of efforts from all countries of the world.

Secondly or thirdly, we need to expand the second generation of surveillance to anticipate the course of epidemic. We must move to a third generation of surveillance based on human rights. I think for all of this, the Global Fund can be a very powerful instrument to advance on all these fronts. And I think it’s critically important that we make this fund truly global. For example, middle-income countries ought to be making contributions. They will not be the big contribution that will make us reach the ten billion a year goal, but symbolically, it is important that this is not seen simply as the rich countries providing subsidies for funding to the poor countries. Certainly middle-income countries that can afford contributing to the fund must make that contribution, and Mexico, my country, will make such a contribution, even if it’s only symbolically important. It has to become truly a global effort where everyone participates to make this a reality.

Finally, I would say that UNGASS does provide a very solid foundation to face AIDS, which is truly the major health and development issue of our time. By building on and strengthening on this foundation, I believe we will be able to look forward to better times.

So let me leave you with a phrase from one of the true champions and giants of the defense of human rights, Martin Luther King, Jr., who wrote almost 30 years ago -- it really boils down to this, that all life is interrelated. “We are all caught in an inescapable network of mutuality tied into a single garment of destiny. Whatever affects one directly, affects all indirectly.” I believe these words really capture the essence of the struggle that the whole world is involved in. We are together in the fight against AIDS, and I am convinced that humanity will win this fight and, that in doing so, it will truly open a new horizon for global health, development, and security. I thank you and for your attention.

SUZETTE MOSEBOTTEN: Thank you very much, Dr. Frenk. We’ll take your words to heart and certainly your presence here as the Minister of Health of Mexico. And a number of other ministers of health from all the regions at this conference is certainly a sign of commitment of these countries and regions and perhaps together, united, we can all achieve the delivery -– some of the deliverables of achieving the goals of efficiency and equality. Thank you very much.

I’d now like to ask my co-chair, Ms. Patricia Needle, to introduce the other two speakers.

PATRICIA NEEDLE: Thank you, Suzette. It is an honor and privilege to introduce our next speaker. Ms. Graca Machel, the former Education Minister in Mozambique, is an international advocate for children. She is the founder and president of Fundacao para o Desenvolvimento da Comunidade, a community foundation in Mozambique. Also, she is a member of numerous international boards, including the United Nations Foundation, the International Crisis Group, ACORD, the South Center, and the Forum for African Women Educationalists. She’s currently the chancellor of both the University of Cape Town and the United Nations University of Peace and is leading the Global Leadership Initiative, which is part of the Global Movement for Children. We’re delighted to have Ms. Machel with us today. Her topic, “Reversing Development HIV/AIDS Impact.” Ms. Machel.

GRACA MACHEL: Good morning, friends, colleagues, advocates, activists, and maybe I should say also, Excellencies, ministers, and I would have hoped that we would have heads of governments and the heads of states in this session. And I’ll tell you why. It is really a pleasure to join you here and to add my voice to yours in this struggle to change the course of this pandemic. I’ve been asked to speak of reversing development. I apologize and ask for your understanding that this is not what I’m going to talk about.

You all know the impacts of HIV/AIDS in the human, in communities, in nations. Many of you have been here since the beginning of the week, and you have been bombarded by statistics and all (MS?) sorts of information which I felt it has been good enough for your sanity. So I’m not going to talk of statistics. I’m here today because I believe, despite all the knowledge of the destructive impact of HIV/AIDS, we can still stop this pandemic. And I’m coming from Southern Africa. I’m coming from Africa. Along this stage you have been told how terrible things look like at home in my continent, in my own country of birth. But I still believe we can turn around this tide. And I prefer to talk of the positive aspects of what we can do instead of telling you the terrible face of things which are going on.

HIV/AIDS has proved itself to be an incredibly aggressive and comprehensive virus. It attacks the human, the individual, and it attacks physically, emotionally, mentally, psychologically, spiritually. It attacks the strength and the well-being of the whole individual in a very aggressive manner in which nothing is the same after it introduces itself into the whole body. It affects the family. It attacks our communities and our nations. And I don’t think I need to elaborate about it.

Our region, Southern Africa, is known as the most heavily affected region in the globe. So it means from the individual to family to community to nations to regions, it never leaves behind the same situation as before. But what I want to talk about is this. I don’t think that all of us -- despite the good efforts we have been making -- I don’t think we’re attacking the virus and the pandemic as aggressive and as comprehensive as it is. You’ll be disappointed because I know many of you are doing a very good job. You are very committed people. But in terms of results of what is happening, if we look back home, we realize we are not attacking it as aggressively, as broadly, as comprehensively as (MS?).

Let me give some examples. The response of our government. It has been said this morning we started too late. But even worse, the response is still very slow. It’s limited and sometimes even partial. Some governments in my region have already embarked on prevention, but they are still unclear as far as treatment and care is concerned. We have, all along our continent, wonderful experiences of NGOs (MS?) and civil society organizations, which are trying to tackle the epidemic. But they act isolated. NGOs sometimes are territorial. They do not share enough information with others. They don’t open their doors to learn and to give to others. So although they are making an impact in the very small scale, the impact at national level, it’s not as impressive. Our private sector. In many big companies, in our region at least, they don’t even have strategies to combat HIV/AIDS. If they do, they look at their own workers. They don’t expand enough to be working with the families of their workers, with the communities where their companies are settled. Even more, the contributes to the national efforts because they have the resources, they have the management skills, they have knowledge which could be used in this combat. But they are too territorial to share these with the nation. Even religious groups -- we still have them debating philosophical questions. Whether it’s moral or immoral to use condoms. Instead of using this trends which they haven’t -- two reasons. Why? Religious leaders, they have such an importance in touching the beliefs of people. More than politicians or academics or NGOs, religious leaders can touch what people believe, which not always can be explained. But what my spiritual leaders say, people will attend to in a different manner.

Secondly, they have the biggest networks we can find in most of our countries. They can reach even the most remote areas of rural communities. Instead of using this, they are still hesitant and questioning whether they should engage and how they should be engaged. That’s why I’m saying despite our efforts, despite what we have learned and we know, we are not attacking the pandemic in aggressive, comprehensive and broad manner.

My question is all of us. The title of this conference is “From knowledge to commitment and action.” No one is going to make an impact and to turn the tide of this pandemic unless we act in a very concerted, very articulate -- we move really as tides, and tides of social mobilization which can put all of our nations together from young to old, from women to men -- all sectors of our societies to fight the epidemic.

The second point I’d like to raise is we agree that prevention is the key to turn around the tides. Forgive me if I have to say, at least at home among young people, it seems as the message, it doesn’t produce the results we wanted. Many of our young people, especially in urban areas, they do know what HIV/AIDS is. They know how it is transmitted. They are told how to prevent it. But nevertheless, attitudes and behavior is not changing. And my understanding is, we are sending a message, which addresses practices. We are not sending a message which shakes the value system behind which attitudes and behavior and practices are sitting. That’s why the weight of the value system of what children hear at home in society is such that, although they know, it doesn’t shake them to be able to change.

My message is, we have to revisit the message of prevention, to make sure that it goes deep into the value systems which puts girls and boys in a situation where they accept themselves as equal to equal. We have to change the balance of power within our families, within the education we give to the young generation, so that they will face sexuality in a completely different basis of what they do today. I think we need to look at the different (MS?) we instill -- we ourselves, including we as mothers -- in our girls and boys since early ages.

I have been told that this conference is understood as -- that the pandemic is a women’s pandemic. I hope, we as women, we are not going to leave this conference taking a message of victimization of women. For one simple reason. Feeling victims is not going to take us anywhere. It should, anyway, empower us to become much more outspoken, to be more bold, more aggressive, again, as I started at the beginning, and more uncompromising manner in which we will have to challenge even our husbands, our sons, and our brothers, starting at home. This is not a balance which has to be changed only in public gathering. I mean the virus itself, it attacks in a very private manner. It has to start up also in the privacy of a relationship among those who are the target groups. And this, I think, we, as women, because we know we can feel what it means when I feel my child is threatened -- let’s become like a lioness when it has to protect its little babies, to say I will challenge tradition if need it be. I will challenge the values I have told as a woman that this is my position. I’ll challenge even my spiritual leaders, but I’ll make sure I build a difference balance of power so that my child and my grandchild is not going to become a victim of this situation.

I know it is tough. I know it is very difficult, especially for women in rural areas or even in urban areas, who are dependent of men as breadwinners. How can they challenge them when they run the risk of the following day to be kicked out and not know where to go? I know I’m starting some. That’s why I say we have to go to all levels, including community leaders who have not only to join us, but they have to be in front of us. Men have to be in front of this battle. It’s not women’s battle. It’s family and society’s battle. And this, again, because it seems to me when we say young people from the 15s to the 24 ages, for instance, we go specifically for girls. I agree. But unless we have girls and boys together, change will not be effected.

I think also having spoken of the message, the second thing I wanted to say is, commitment at the highest level of our society. I wish, that’s why I said, I wish we would be talking here, being together with some heads of states, prime ministers, and my ministers of finances. The issue of funds and resources has been disgusting, to say the least. We meet in conferences and there are promises and pledges which are being made. But when it comes to release resources, those who hold them are found lacking. We find ourselves reciting pledges from one conference to the other but we doubt, really, the change which is needed to act as in emergency situation, which cannot wait.

And here I come to a point which I’d like to stress. How can our governments, even the poor government, explain that having promised to increase their health budgets, they haven’t been able to do it at the extent -– at least they send a clear message of commitment. We know that it would never be enough, but the message of commitment should be clear. That this is how far we can go to show that we value human life and we are not going to compromise. This is one. Second. How can rich countries explain that knowing, and talking of the epidemic as we do, they come to a conference like this, and they promise resources and say, “There will be a relief in five years’ time, in three years’ time.” What I’m being told as an African mother is, I’m molding my child of 13, 14. I have a possibility to give to this girl a life of ten years’ span and those who have the money say, “Wait. In five years’ time we’ll give you money to save your child.”

How can we explain it? Is it -- we are told that resources are not available? Who would question we wouldn’t accept it? But it’s even more outrageous when they say, “Yes, money is available. We’ll delay the death of your child. We’ll give it to you in three and five years.” I think there is a problem of morality here, which I cannot understand.

It seems as if the deaths which are taking place in our part of the world, they can be tolerated. They can be accepted for sometime. But I would ask where is the basic, very fundamental principle in which we say every single human life is precious. It’s sacred. It has to be protected. And now, where is it?

I would also ask when we have the pharmaceuticals. I know they are there to make money. Nobody’s to question this. But what we’re saying is, make your patents. Relieve this question of patents so that we’ll have generics available to the millions of people who need them. Is even -– even if it’s a question of money, if you sell your medicines to three million people, you’ll make money in some ways. If you sell them to thirty million people, of course, you can bring it down but you still are going to make money. So it’s not the business of money, I think. And I think, yeah, we have to raise this question very seriously. When it comes to human lives, we should not be asked –- we shouldn’t be asked to understand that there’re technical things which prevent us of acting urgently and effectively because of money. We have to wait to weigh what is what and what we are here for.

I’d like also to move to another issue which is very close back home, too. It’s orphans. I know it has been discussed very at length that this is a crisis which our societies are not prepared yet to tackle. Yet, when you have thousands and millions of orphans in a very dilapidated situation of resources, even the solidarity –- the African solidarity -- is no longer enough to deal with this. We still do not know exactly how we’re going to deal with it. But we hear many times concerns which are going only to the needs of orphans. And the question I want to raise is that these children have rights, even legal rights to be protected in what is their inheritance, their private property, land which can be the only thing they can hold to when the parents are not there to be able to survive. To be able to have a roof and to be able to continue. Yes, education. Yes, health. Yes, food. But legal protection of the rights of these children is something I didn’t hear enough in debates and I think we have to take into account.

And finally, I want to say that the issue of orphans and young mothers is completely related. If you have a young mother of years of her twenties. If she gets treatment, she will be able to live more ten years. Instead of leaving her child orphan now, she can plan for her children. She can also prepare to know how she leaves her children when she has to go. So the question of treatment here. It’s really a question of life and death for the mother but more importantly, also for orphans so that we reduce the tide of orphans at least in the rhythm it comes. We should take this into account in our strategies too.

Finally, I want to say something. I know it maybe unfair. But I really believe we are at the crossroads of our civilization. This pandemic is raising very fundamental moral issues which have -– we have never faced before. I think it’s time we questioned whether the governments are there to serve people and because of people or they are for the sake of themselves and they can afford then to postpone people’s needs and rights because there are plans and there are elections to take into account. I think these are fundamental issues we have to raise. Also, even in multilateral institutions, the considerations of how a country can or cannot get access to resources. I think it has to be challenged in this situation when you are having –- I mean, we are talking of millions of millions of millions of people who are dying. What is happening when people hear this they don’t feel their conscious shaken? What happens when they manage to go to bed and sleep and think in a span of time of five years’ time instead of solving the problem? It think there’s something wrong, which doesn’t bring close the face of the people in the decisions which have to be made. That’s why our leaders, even multilateral institutions, can afford to find excuses to act with urgency, with aggressiveness, as I was saying, and as global as it should be.

Now I want to finish and say, I know here I’m talking to a converted community. But our responsibility is to build movement, to make really a movement which moves from community to nations to regions to global. To be a movement. Where we shouldn’t allow inertia to continue. We cannot come in two years’ time here and talk in the same level we are talking now. We have to come and say how many lives we’re able to save. How many resources we’re able to move. How many researches we have been able to put into the hands of practitioners. We should come here as an active movement and not only planning and planning and planning. It’s a question of urgency and aggressiveness. I thank you.

PATRICIA NEEDLE: Thank you. Thank you, Ms. Machel, for bringing your voice, your experience to motivate us in moving forward with our actions, on the part of all of us, families, individuals, communities, leadership, governments toward –- as we have always been talking here -- toward the changes that are so urgently needed and for your confidence. I feel your confidence in the capacity of people to intervene to make these changes. Thank you.

Our last speaker for this session I’m pleased to introduce. Dr. Paolo Roberto (MS?) Teixeira is a dermatologist with specialization in public health and the epidemiology of AIDS. Dr. Teixeira is one of the pioneers in the fight against the AIDS epidemic in Brazil, creating the first state AIDS program in Sao Paolo in 1983, where at that time only four cases were known in Brazil. From 1996 to 2000, Dr. Teixeira served as a senior consultant of the Joint United Nations Program on AIDS for Latin America and the Caribbean, working on strategic planning and support development for theme groups. Dr. Teixeira has succeeded in bringing back to Brazil many internationally recognized awards, acknowledgements for his important work around the world. With the free and universal distribution of AIDS drugs as part of the Brazilian program, which has been kept going thanks to local manufacture of generic medications and continuously defended by Mr. Teixeira and international forum, Brazil has attracted worldwide recognitions for the quality of this work in AIDS. And it has succeeded in obtaining the support of foreign NGOs and an appreciable number of awards from international organizations such as the U.N., WHO and the World Trade Organization. Since March 2000, Dr. Teixeira has been the Director of the National STD/AIDS Program and the Ministry of Health of Brazil. He is here today to discuss with us Program Implementation and Scaling-Up: Barriers and Successes. We are honored to welcome Dr. Teixeira.

DR. PAOLO TEIXEIRA: Good morning, Ladies and Gentlemen. I would like to congratulate the organizers of the Fourteenth International AIDS Conference Barcelona 2002 for the wonderful job they have done. I would also like to thank Dr. George (MS?) Cassabona (MS?) and Dr. Joseph Mardia (MS?) Catel (MS?), conference co-chairs for inviting to address this plenary session. I’m very glad about the positive feedback you have received here in Barcelona regarding the results Brazil has achieved. Although cautious about generalizations, the intention of my presentation today is to extract out of our results as (MS?) and lessons learned, a few recommendations that might be useful to other countries and the international community. Brazil is a federative republic with approximately 117 million inhabitants. At the end of the year 2001 it had a gross domestic product per capita of roughly $3,000 U.S. Such numbers, however, hide the huge income inequalities as well as the deeper regional disparities that exist within Brazil. More than 220,000 AIDS cases have been reported to the Ministry of Health since the beginning of the epidemic, with approximately 105,000 cumulative deaths. Current estimates put the prevalence rate in the total adult population around .6 percent. This figure might seem very low from the epidemiological point of view, especially when compared to much dire numbers coming from other countries. However, we cannot ever forget that behind such figures there are real people. And the Brazilian society feels strongly that what we have in Brazil is actually a tragedy that cannot be tolerated. The loss of lives, the suffering of infected and affected people, the mourning of disintegration –- the disintegration of families that there’s 7,000 orphans from AIDS. These are also real features of this tragedy.

We have less then 600,000 HIV-positive people in Brazil -– less than 50% of the number predicted a few years ago by the World Bank. Brazil has also managed to achieve a significant reduction in the rate of incidence, particularly within more vulnerable population as men who have sex with men, sex workers, and intravenous drug users. The consistent use of condoms has been brought to new grounds. We observed a dramatic increase in the proportion of condom use in the first of sexual intercourse to levels of much wealthier countries. It’s schools had been a major factor behind such an increase. Currently, about 70% of all public and private schools develop activities related to HIV/AIDS prevention, reaching about 30 million students. In the meanwhile, the number of new AIDS cases has dramatically dropped. The number of death from AIDS has also fallen dramatically, especially after they have gotten a highly active antiretroviral therapy.

I started presenting in (MS?) in this conference by a colleague from Brazil, Dr. Ricardo (MS?) (MS?) has shown that survival has increased substantially. The median survival time before the ability of combined therapy was less than six months. And now it’s close to five years, a 12-folds increase. More than just survival, quality of life has also improved substantially. Most of patients go on working normally and interacting with their friends and families. Such gains must not be underestimated. The Brazilian policy has also managed to keep the average longevity of the Brazilian population nearly at the same level throughout the last decade. This information takes on its full meaning when we compare the evolutionary path of the Brazilian and South African lines and taking in account that both countries had approximately the same infection rate about only ten years ago. However, I must acknowledge the Brazilian experiences is too subject for future improvements and expansions. For instance, we’ll still are unable to fully offer the same levels of care and support to the Brazilian females. I’m certain that none of these outcomes could have been achieved without embracing a balanced prevention and treatment approach. And the same advocacy of the human rights of people living then with HIV and AIDS.

Interestingly, this brings forth an integral part of the declaration of commitment on HIV/AIDS adopted last year at this special session promoted by the U.N. General Assembly on Disease. This lead us to an important conclusion. There is no Brazilian model. What we have been doing is to put into practice principle that have long been recognized by the international community. At their very core is the universal declaration of human rights adopted more than 54 years ago. (MS?) work is further reinforced by a prevention approach that emphasize the need to direct special attention to more vulnerable groups such as men who have sex with men, injecting drug users, commercial –- and commercial sex workers. Ensure access to prevention supplies, especially condoms, syringes and needles. Ensure preventative actions in health care services.

Controlling the AIDS epidemic also passes through mobilizing the entire national capacity to offer antiretroviral treatment even when the optimal infrastructure is not available. It’s very difficult to mobilize a country to undertake prevention when there is no harmony between government and their population. The provision of treatment is essential to this end. The experience in Haiti, which was presented by Paul Farmer, is a clear indication that it is possible to achieve to excellent results in very adverse conditions.

In Brazil the average cost for a patient year in an antiretroviral therapy decreased by half in the last years. I’m sorry. Okay? Okay. By half in the last years. This reduction occurred because of a combination of two concomitant actions. First, investments made by the Minister of Health to set up the domestic national laboratories. Currently the Brazilian Minister of Health distributes 15 antiretroviral drugs of which 8 are locally produced.

Secondly, the effective negotiation based on (MS?) with drug companies. As consequence, deals were made with (MS?) cutting the price of four drugs by more than 50%. National production under (MS?) relationship has been a strong argument to push these companies to the negotiation table. This is, in rather brief and general terms, the Brazilian experience in its carrying out a program of continental proportions.

Nevertheless, I will not have accomplished the task I have been given if I do not comment on the lessons we have learned both in the national and international levels, and based on them, make respectfully some suggestion to national governments and to the international community. From governments the international community expects accountability. Countries must mobilize the necessary political commitment to put together all national resource and to (MS?) fight against cultural, religious and legal barriers to prevention. Despite the low costs involved, minority groups are still discriminated and excluded from national response in both rich and poor countries. It’s encouraging in this regard that the global HIV/AIDS prevention working group and that the leadership of the (MS?) foundation includes these aspects in its reports. No time can be spent with ambiguous prevention messages. HIV transmission happens majoritarily (MS?) through sexual contact and prevention is made through condom use. Or the alternatives such as postponement and abstinence are indubitably incompatible with our global reality. The allegedly ethical and religious director of such initiatives is today one of the main enemies of effective prevention. In what concerns treatment availability, countries must be more resolute. It is inconceivable that a large number of the proposals received by the Global Fund in its first round did not include the provision of the antiretrovirals to the affected population.

Additionally, governments cannot exclude or chose the NGOs which they intend to work with. This simply doesn’t work. The current level of international funding directed to fight AIDS in the developing world is simply outrageous as already pointed by -– out by Stephano (MS?) (MS?), President of the International AIDS Society. It becomes even more shocking when taking account that 20 years have passed. And dozen of millions have already died since the beginning of the epidemic. Truly, the key lies in mobilizing a new Marshall Plan to stir up national responses in poor countries as it was done by the United States to Western Europe right after the Second World War. We now face a tragedy of similar proportions. We need the United States, along with Japan and Western Europe, to assume at last their responsibility in changing or (MS?) situation.

The vast majority of infected people worldwide simply lack the minimum resource necessary to intervene in the (MS?), no matter how much the prices of the antiretrovirals are reduced. It is not only an issue of international solidarity. Rich countries are rich because they drain the greatest part of the world’s wealth in royals, (MS?) diamonds, (MS?) and interest.

Besides the Global Fund, we need the agencies of the United Nation’s system to scale-up their program as (MS?). In one hand, technical assistance in their various area of expertise, as is the case of WHO, regarding treatment and care, and on the other hand, financial assistance on the part of the World Bank. To UNAIDS we have recommend taking its supports of coordination and advocacy even further. Brazil is also particularly engaged in sharing her experience with other developing countries. For example, (MS?) corporation is highly effective and must be supported by international funds. In the last three years, Brazil initiated more than 30 different corporation projects with other developing countries, and Brazil has repeatedly offered -- I think this important -- to renew this plan once again to transfer toward their countries, at no cost, the technology necessary to manufacture them.

Equally, we (MS?) our willingness to actively take part of other initiatives, both bilateral and multilateral, to increase the global availability of generic drugs and to reduce international price. At the same time, we are committed to pushing forward in international forum. In this regard, we strongly fought at the board of directs of the Global Fund to make antiretrovirals (MS?) good for procurement and at the World Trade Organization to make (MS?) more flexible in relation to AIDS drugs. Although, the loan agreement Brazil has with the World Bank accounts for no more than 10% of the total financial resources deployed annually in Brazil to fight AIDS and does not include the purchase of antiretrovirals, the existence of such institutional backing has been important element in strengthening the Brazilian response.

A third loan agreement to be effective by 2003 is currently under negotiation, and we allow Brazil to further improve her activities and invest in technology development to increase the national capacity to intervene in prevention and treatment, including the development of new drugs and vaccines. Nevertheless, the basis of the World Bank in agreement, including the levels of their interest rates, must be reduced. More favorable conditions must be offered to middle-income countries, as well as grants to poorest nations.

Successful experiences based on intervention (MS?) prevention treatment prove that will be impossible to control the extent in the long-run without an effective vaccine. In this aspect, results are rather disappointing. There was few significant scientific challenge to vaccine development but scientists believe that these barriers can be overcome if adequate resources are deployed. Brazil has pledged to deploy $6 million in the next three years to building a national infrastructure to vaccine research and development. Brazil is also part of the WHO UNAIDS Vaccine Committee and signed yesterday a protocol of corporation with (MS?), a major leader in this regard.

I would like to finish my speech by speaking directly to all of you that have overcome great barriers and distance to be here in Barcelona. In the last two months, to have repeatedly received hundreds of demands of people living with HIV and AIDS, their families and their friends from other countries, but especially from Latin American and Caribbean and Africa, requesting Brazil’s assistance to obtain ARV treatment. Some of them are related to one-time donations, other to (MS?), but many request to Brazil to export antiretrovirals in large scale. I’m sure that some of these groups and people are here in this room today. I would like to reassure you that we have been doing everything that is within our reach, everything that our own poverty allows us to. I am also saddened, as you are, by the death of people in a time of when effective treatment exists. And I also feel the same indignation as you when it happens. The (MS?) of the matter, however, is misplaced. No matter our decision, no matter how much or little we sell abroad, it is the responsibility of each and every one of our governments to undertake measures to increase access to antiretroviral therapy at the national level.

The logic of the local production in Brazil is not simply driven by the achievement of the lowest possible price. It embodies an important strategic element due to the role local manufacturing place in regulating domestic price. Redirecting, therefore, our production for export, we mean to fundamentally alter the mission which Brazilian (MS?) collaborators serve. Nevertheless, I do not deny the responsibility we have before you in expanding access to antiretroviral worldwide. Despite our limited financial resources, the Brazilian Minister of Health decided to establish, in May 2002, the International Corporation Program for the Control on HIV and AIDS in other developing countries. The program involves donations in kind of locally produced drugs and technical assistance adding up to $1 million annually, split in ten pilot projects. NGOs, governments, and other organizations are eligible institutions. Guidelines have already been established and the demonstration effect -- we hope this project will create is the single most important pressure we can exert on foreign governments.

This is not a game where there are winners or losers. Without urgent, decisive action, the entire humankind will be defeated. Thank you very much.

PATRICIA NEEDLE: Thank you, Dr. Teixeira for sharing some information and the progress of the Brazilian experience, a model for AIDS intervention for many countries. And thank all of you for attending this session. And we’ll see you at the later parts of the conference today. Bye-bye.