Remarks on the Five-Year Strategy for the President's Emergency Plan for AIDS Relief

February 23, 2004

Ambassador Randall L. Tobias, U.S. Global AIDS Coordinator remarks on The Five-Year Strategy for the Presidents Emergency Plan for AIDS Relief. State Department photo by Franklin Jones. Ambassador Tobias: Thank you very much, Secretary Powell and Secretary Thompson and Administrator Natsios for taking the time to be here this morning and, more particularly, for the kind of support that I think you can see here.

As you all know, in the State of the Union Address in 2003, President Bush called for an unprecedented act of compassion to address the ravages around the world of HIV/AIDS. The President committed $15 billion over five years to address this global pandemic -- more money than has ever been committed before by any nation for any health initiative.

Nine billion dollars of the $15 billion will go to new programs to address HIV/AIDS in 14 of the world's most affected nations, with a 15th country to be added to that focus country list in the next few weeks.

These countries account for more than 50 percent of the world's AIDS infections. Five billion dollars will go to provide continuing support in the approximately 100 nations where the United States currently has bilateral HIV/AIDS programs. And $1 billion will go to support our principal multilateral partner, the Global Fund to Fight AIDS, Tuberculosis and Malaria that Secretary Thompson chairs.

Well, today, President Bush's vision is becoming reality. Just four and a half months after we launched the Office of the Global AIDS Coordinator, and less than one month after Congress appropriated the funds for the first year of the President's Emergency Plan, $350 million, but the first release of not only the plan, the first release of this year, is today going into the hands of service providers in these focus countries.

This money will go to scale up programs that are providing antiretroviral treatment, prevention programs, including those targeted to youth, and safe medical practices programs, and programs to provide care for orphans and vulnerable children. We expect to be funding several national safe blood programs very shortly, but they are not included in this money.

These target areas were chosen because they are at the heart of the treatment, prevention and care goals that are the focus of President Bush's plan. The programs of these specific recipients were chosen because these are organizations that have existing operations on the ground; they have a proven track record; and they have the capacity to rapidly scale up their operations so that we can begin having an immediate impact when these dollars are out the door.

Our intent has been to move as quickly as possible in order to bring immediate relief to those suffering the devastation of AIDS. And by initially concentrating on scaling up existing programs, that is exactly what we believe we are able to do.

With our next round of funding, we expect to place an additional focus on also attracting new partners who can bring expanded capacity and who can bring innovative and new thinking to this effort.

Now, with just this first round of funds, an additional 50,000 people living with HIV/AIDS will begin to receive treatment, and that will nearly double the number of people currently receiving treatment in all of Sub-Saharan Africa. In addition, prevention through abstinence messages for young people will reach about 500,000 additional young people, and resources are being provided to assist in the care of about 60,000 additional orphans.

In addition to announcing this first round of funding, today we are also submitting to Congress a comprehensive, five-year strategic plan. This is the strategy called for in the authorizing legislation, but this is also the strategy that will direct our work in implementing the President's Emergency Plan for AIDS Relief.

This strategic plan will guide us in deploying our resources to maximum effect. We will be concentrating on prevention, treatment and care, the three areas that are the focus of the President's Emergency Plan.

In the focus countries, over the five years of the plan, we will provide treatment for 2 million people, we will prevent 7 million AIDS deaths, and we will provide care to 10 million people who are infected or affected by the disease who reside in those focus countries.

As Administrator Natsios said, we are not starting this effort from scratch; rather, we are capitalizing on the existing core strengths of the United States Government, by using established funding and disbursement mechanisms, by going to school on nearly two decades of expertise in fighting HIV/AIDS around the world, utilizing a field presence and strong relationships with host governments in over 100 countries, using well-developed partnerships with nongovernmental, faith-based and international organizations who can help us deliver these HIV/AIDS programs.

We are not implementing a new bureaucracy, but rather we are implementing a new leadership model for all of these existing capabilities and adding new capabilities to that. We're implementing a model that will bring together, under the direction of the United States Global AIDS Coordinator, all of the programs and all of the personnel of all of the agencies and departments of the United States Government who are engaged in this effort.

This plan is built on four cornerstones.

One, rapidly expanding integrated prevention, care and treatment services in the focus countries by building on existing successful programs that are consistent with the principles and goals of the plan. That's similar to what we have already done with the $350 million that we've just announced.

Second, we will be identifying new partners and building more capacity to sustain a long-term and broad campaign.

Third, we will be encouraging bold national leadership in countries around the world and encouraging the creation of sound, enabling policy environments in every country for combating AIDS and mitigating its consequences.

And finally, we will be implementing strong strategic information systems that will provide vital feedback and input that will direct our continued learning, the identification of best practices, the knowledge about what is working so that we can fund more of that, and what is not working so that we can stop funding that and put the money in places where we think it will work.

Within this framework, we will strive to coordinate and collaborate our efforts to respond to local needs, which will vary from country to country and from place to place within countries, and to integrate our efforts with those of the host governments with their strategies and with their priorities.

In addition, we intend to amplify our own worldwide response to HIV/AIDS by working closely with international partners, partners such as UNAIDS, the World Health Organization and the Global Fund, as well as working through NGOs, faith-based organizations, private sector companies and others, who can help us in many ways, help assist us in engendering new leadership and help leverage the resources to fight HIV/AIDS.

I think there is no doubt in anyone's mind that this is one of the greatest challenges of our time, and it's going to require constant and concerted commitment from all of us working closely together, if we are to get a handle on it and to defeat it. The limits of what we can accomplish in eradicating AIDS and its consequences are defined, I think, only by the limits of our collective moral imagination.

And one of the things that inspires me, as we embark on this effort, is the remarkable self-help already underway in fighting HIV/AIDS by some of the most under-resourced countries and communities in the world. These communities have, in many cases, responded in whatever way they can to their fellow community members in need.

But with our support, we hope to amplify and sustain their efforts to combat the devastation of this disease. And that is why getting this first wave of funding released today is so important.

Finally, before I open the floor to your questions, I just want to say how grateful I am to be working for President Bush, who is so committed to defeating this HIV/AIDS pandemic, and also for the support of Secretary Powell and others, without whose help in creating this new model and bringing everything and everybody together and getting everybody pointed in the same direction would have been much more difficult.

That leadership, starting with the President, has facilitated the speed with which we are responding to people in need, and that commitment, I think, will help ensure our success. I do not want to underestimate, for a moment, the degree of difficulty associated with what we are taking on. But I do believe we can bring hope, and I do believe we can really make a huge difference.

Our success will be measured in the lives saved, in the families held intact, in the nations moving forward with development. And I can think of nothing more important to be doing at the moment.

And now I will be pleased to take your questions.


Question: Adu-Otu, You have said that there is going to be information mechanism to -- for feedback, as to what is going on. Would you consider any mechanism for checking fraud and other improprieties in this kind of program?

Ambassador Tobias: Well, checking fraud and other improprieties in this program will be a very, very important element of our monitoring mechanisms and approaches to this. We will use -- and I think this is one of the strengths in starting by using mechanisms and capabilities and procedures that are well-established. We will principally be using those same mechanisms to monitor the use of the money and be sure that money is being used properly and for the purposes for which it is intended, and we will add to that whatever other mechanisms that are needed.

In addition to that, we will be monitoring to ensure that the money is used for the programs for which it is being granted, as we go forward. And most particularly, we will be monitoring the results that are achieved through these expenditures against the goals that have been established and will be established in each of these programs going forward.

But all of that monitoring and feedback is very important for a whole variety of reasons, from the integrity of the process all the way through to being sure we're using the money in the most effective, useful way.


Question: Mr. Ambassador, you said that you are not -- your goal is not to create a new bureaucracy. I was wondering if you could tell us, sort of, what you see as the scope of your office, how much personnel. And also sort of ask the question why do you need to exist, given that we do have the Global AIDS Fund?

Ambassador Tobias: Well, I would remind you that the United States Government has been doing this for about 20 years, and the Global Fund, which we view as an extremely important partner and an organization that's going to be very important going forward, is an organization that's only two years old. So the Global Fund is really just getting started.

I think they're doing an excellent job. We're working very closely with what they're doing. But the kinds of things that the Global Fund can address are, to some degree, different from the kinds of things that we will do in our bilateral programs.

People are always trying to draw me into sort of a competitive discussion, and these are really two important parts of the overall strategy. That's why President Bush was involved in the launching of the Global Fund, in fact, made on behalf of the United States Government the first contribution to the Global Fund.

What we're doing is to take all of the resources that exist principally in USAID and in the Department of Health and Human Services, and within Health and Human Services in the Centers for Disease Control, those are the principal field programs, but in HRSA, in NIH, elsewhere in the Office of Global Affairs, elsewhere in HHS; and then there are pockets of program activity and other opportunities that exist throughout the government.

For example, in most of the stricken countries, the prevalence rates among the military tend to be higher than the population, in general. I believe there are ways that we can reach military to military through the resources of the Defense Department, as but one example.

There are things the Commerce Department is doing and can do to help reach the private sector in various countries. There are things that the Department of Labor is doing with respect to workforce issues. So there are a number of things that we can do.

I have about 20 people who work directly for me at the moment, most of whom are borrowed. I've been trying to explain to people about the Hotel California, where once you check in, you can never check out, because I've got some incredibly capable people who have been detailed here from various parts of the government. I would expect at our peak that we would not be more than 50 to 60 people, at the most, if you count the people who are going to directly report to me. But if you count all the people who are involved in all of these programs, I have no idea how many. I suppose they're in the thousands.


Question: One of your cornerstones appears to be the promotion of abstinence. What do you say to the African nations, the other nations that say, you know, "This isn't what we need. You know, it's not up to you to tell us how to live our lives"?

Ambassador Tobias: I think that's a message we're mostly hearing from Americans. The abstinence program directed at youth in Uganda, in particular, which was initiated by the Ugandans in 1986, is the program for young people that tends to provide the best statistical data that seems to be making a difference.

But let me just take a minute, if I could, and explain what we're talking about when we're talking about the so-called ABC model of prevention, which is abstinence, be faithful, and the correct and consistent use of condoms when appropriate.

I think some people see that ABC model and see that as multiple, so take your pick. It's not that at all. If you start with young people, and recently I was in a primary school in Uganda with the Ugandan Minister of Primary Education looking at the program that they have initiated, that they use in their primary schools. They have two assemblies a month, and the first thing you have to realize the context that exists there.

There are children in those schools whose father has died, their mother has died, maybe aunts and uncles have died, their teachers have died. They're seeing death all around them, and for starters they need hope. And the first part of the message that these children are taught is a message of self-esteem and a message of taking control and the opportunity that there are things that they can really do to take control of their own lives.

And as they get a little older, and it's age-appropriate to do so, then they are given more specific messages about how HIV/AIDS is spread, and about the importance of abstinence until they get to the age where they get into a committed relationship, hopefully in marriage, but if not, in a committed monogamous relationship with a single partner.

And there is a lot of evidence to suggest that in Uganda, by simply delaying the average age of a first sexual experience, which is what's happened in Uganda, that average age has moved out by a year or more, that can have a profound effect on the infection rates.

Then the message shifts to one of being faithful. The Ugandans use a phrase about "zero grazing" to describe what they're talking about. But the idea is that for a couple in a committed relationship to both be tested, to both know what their status is and to be faithful to each other.

But ABC does have a "C," and the C for condoms means that there is a role for condoms to play. Condoms are a risk reduction tool. They're not a risk elimination tool. But for people who are engaged in high risk behavior, condoms can play a very important element.

So these are all elements that target specific segments of the population. But with young people, the abstinence message is really the message that has proven to be most effective over the years in really changing behavior, and thus having an impact on results.


Question: One of the concerns of the AIDS groups is that this will be -- there will be -- on the treatment aspect, there will be a focus on, kind of, brand name prescription drugs, and not kind of using the kind of generic drugs that will allow more people to be treated.

Can you talk a little bit about that?

Ambassador Tobias: Yeah. I keep saying what our policy is. I keep getting asked the same question. And until we get to the point of actually buying the drugs, I think it's a logical question.

What our policy will be, will be to buy drugs that are safe and effective at the lowest possible price. Now, if those happen to be drugs that are manufactured by generic companies, fine; if those are drugs that are manufactured by brand name companies, fine. But it's very important that there be some standards, some principles by which we can make those decisions.

So, at our encouragement, the United States Government, led by the Food and Drug Administration, is having a meeting in March, co-sponsored by the World Health Organization and UNAIDS and the Southern Africa -- I'm sorry. I forget exactly what the name of the organization is, but it's sort of the regulatory oversight organization for the countries in Southern Africa.

But all of these organizations are co-sponsoring a meeting to come together to try to define some principles. They're not going to turn into a regulatory body, but they're going to try to define some principles by which people who are making these decisions can be examining the alternatives in the market, in order to ensure that the money is being spent for drugs that are safe and drugs that are going to be effective, and that can be purchased at the lowest possible cost.

Now, in the meantime, a number of the intellectual property issues that have been a source of great concern have, by and large, been resolved, I think, and the prices have come down dramatically.

So I think that once we get past these issues, the next issue, which is sort of a good news/bad news issue, is going to be, if we are successful in getting the infrastructure in place and getting these programs ramped up and getting more people under treatment, then the next issue is going to be having a continuous supply with ensuring that there is adequate manufacturing capacity in the world.

Because, as many of you know, but, perhaps, some of you don't, when you put someone on antiretroviral treatment, it is every day for the rest of their lives. It's not like treating somebody for cancer, where you get them under remission, and then the treatment backs off.

If you treat somebody for seven years, and they have to take the medication at the right time, in the right order every day and not miss a treatment, if they do that for seven years, and then stop taking the treatment, they will immediately go right back to where they were before they started.

So it would be a terrible thing to put people under treatment, and then find out the supply of drugs was no longer coming and was no longer dependable. So we have to have both short-term and long-term solutions to this.

There are also very complicated issues relating to drug resistance, and some of those kinds of things that a lot of technical people are looking at.


Question: Has your office, since it was created, come up with any new approaches, new ideas in dealing with the issue of AIDS, or are you merely plugging into the organizations and ideas that already exist?

Ambassador Tobias: I'd say it's more of the latter. It's more plugging into the ideas that exist out there, but there are a lot of ideas that exist out there that have not been particularly well-known and scaled-up. So we're beginning to get into understanding what those things are and what programs people have used in various places that seem to be working. And I expect that this will be a learning experience going forward.

You'll find in the letter that I put at the beginning of the Emergency Plan the fact that I want everyone to understand, starting with the people in the United States Government, that this has to be a work in progress. This is not a case where you can go out, figure out what the answers are, put them in a document like this and go forward, because there is so much to learn and so much we need to bring together here.

Question: Can I just follow up?

Ambassador Tobias: Yes.

Question: Do you -- does your office intend to try to come up with new approaches and new ideas, or are you going to be the global equivalent of AID, in that you hand that money to --

Ambassador Tobias: Well, I think we will do some of both. I don't see our office as being a think tank in that regard, where we will have people whose job it is to creatively think of new solutions. But I do see it as providing a strong, assertive leadership role in finding out the things that exist and the things that are working. And out of that, I'm sure that new ideas will emerge.

But the reason we set it up was not really to be a creative think tank, per se, but more to provide leadership for all of the efforts that are underway.


Question: A lot of different organizations have said that the absorptive capacity argument isn't completely valid. And, for example, they often cite the Global Fund, which needs -- which is saying they need a lot more money. Why is the President not pursuing the global need that has been established by development experts, which is 5.4 billion for FY '05?

Ambassador Tobias: Well, let me first point out that the United States Government in 2002 and 2003 provided funding for international HIV/AIDS activities equal to the funding provided by the rest of the world combined.

In the fiscal year 2004 budget, which is the budget that was just appropriated, if you start with the assumption, which I hope is a false assumption, but if you start with the assumption that the rest of the world's contributions stay flat to where they were in 2003, then the United States Government in 2004 will be giving twice as much as the rest of the world combined.

So in terms of measuring what are we doing relative to what other people are doing, we're doing an enormous amount already. But you're asking a different question, and that is what is it that needs to be done going forward. And I think the starting point is to get the rest of the world to begin to step up to what President Bush and this Administration have done.

At the same time, as we begin to understand what can best be done and where can it best be done and how can it best be done, then we can begin to get a handle on what really are the definitions of the needs going forward and figure out where that money is going to come from.

But right now, for people who are close to the situation in Africa, I think a lot of what you hear, a lot of what I hear about "we need more money" is a virtuous argument, mostly related to the magnitude of the problem.

But a different question is: How much money can we effectively, efficiently use right now and put to work? And you know, the Global Fund has done, I would say, an excellent job for a brand new organization. But they -- and when I say "they," we are very much a part of "they" -- they are not able to get all of the money out the door instantly relative to the needs that they have identified and the grants that they have approved. I don't anticipate that we're going to be able to do that either.

So there are really two separate issues here. What is the magnitude of the problem? Right now, in all of Sub-Saharan Africa, I don't know what the number is but it's -- there are probably maybe as many as 6 million people who could benefit from being on antiretroviral treatment. In all of Sub-Saharan Africa, the best number I have would suggest that there are about 50,000 people in total on antiretroviral treatment.

So when you compare 50,000 to a need of 6 million, the need is enormous. But when you say, "Well, why is it only 50,000?" it's because it takes human resources and physical resources and other capabilities that need to be scaled up in order to make this happen. And that's what we're all working so hard together to get done.

I really think we need to stop spending all the energy beating up on each other, and trying to figure out how can we all get moving in the same direction, moving ahead.


Question: Mr. Ambassador, we heard the word "integrate" several times at the beginning --

Ambassador Tobias: I'm sorry. The word?

Question: Integrate.

Ambassador Tobias: Integrate, yeah.

Question: "Integrate" in the opening remarks. Can I ask, how will all these bilateral and multilateral programs effectively mesh together? And, in particular, how will existing USAID, NIH and CDC programs in the field be folded in? And what are the opportunities to further coordinate and streamline the international response to create synergism? I'm thinking not just of the Global Fund and WHO, but the World Bank.

Ambassador Tobias: Yes.

Question: And lastly, could I ask you to comment on the joint U.S.-UK task force announced in December?

Ambassador Tobias: Yes. Well, that's a very important, overarching question because the good news is that more and more organizations are arriving in all of these countries to help; the bad news is that more and more of these organizations are arriving and they're going to put a huge strain on host country resources unless we are all headed in the same direction.

The President of Botswana described to me early on, after I arrived in this job, about what he was describing as kind of a domino effect of the first international agency arrives, they're there to help, and the first thing they do is hire away some of the best people from the ministry of health.

The next organization arrives. They hire away the people the first agency hired, who, in turn, hire more people away from the ministry of health, and there's nobody there to coordinate all these efforts. So that's just one simple reason of how and why we have to get together.

I've spent a good deal of time with the head of the World Bank, the head of the World Health Organization, the head of UNAIDS, as have people on my staff and their staffs, talking about ways that we can collaborate.

The first thing we are doing is trying to harmonize the measurement and evaluation tools and techniques that we are using so we're not placing duplicative demands on every country as we try to get a handle around, you know, about what we're doing and the way in which we're going to measure these results.

There need to be some kind of coordinating mechanisms. In some countries, there are some things that we can probably use that already exist. In others, we're going to have to create some things. They may be formal, they may be informal, but I think they're going to have to take place at a country level.

As you made reference to, I went with President Bush last -- early last fall, I guess, to 10 Downing Street and his meeting with Prime Minister Blair, and the entire focus of that meeting was on HIV/AIDS. The President and the Prime Minister invited health ministers from five countries in Africa and a number of other AIDS activists and others from these five countries in Africa, where both the UK and the U.S. have bilateral programs, to talk -- or hear from them about what the particular needs are.

And out of that, we -- the two countries -- the President and the Prime Minister entered into an agreement to try to coordinate our bilateral efforts. Ambassador John Lange, who is one of my deputies, is in Dublin at the moment at a meeting that the EU is having focused on HIV/AIDS. And one of the activities that he will engage in while he is there is to have another follow-up meeting -- there have already been some -- with his colleagues in the UK side about how we're going to coordinate together. But there are all kinds of opportunities for this sort of effort.

**Mr. Casey: Ambassador Tobias, I'm afraid we're just about out of time, so if we can take one more question.

Ambassador Tobias: Okay.

Question: It's a short one. Why the delay in identifying the 15th focus country? Is there some kind of problem?

Ambassador Tobias: Well, in the President's plan, there were 14 countries. When the Congress appropriated the funds, they designated in the appropriating legislation that the Administration is to select a 15th country, and that country is to be somewhere other than Africa or the Caribbean, where the first 14 are. So that was done less than a month ago.

I've got some work underway to sort of look at the criteria that we might use in making that selection, but I've been kind of up to my eyeballs in this. But now that we have this done, I would expect to do that fairly shortly.

Thank you all very much.

Ambassador Randall L. Tobias is the U.S. Global AIDS Coordinator.

This article was provided by U.S. Department of State.


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