( applause ) >> Thank you, Frank, for your
generous and kind words. And ladies and gentlemen,
thanks very much for coming to listen to me.
Please if you can't understand anything that I'm saying,
stop me. I'll try to go through this
as fast as I can. It's an easy and relaxed talk.
Not so much that I need telling you the story of AIDS.
Basically, my topic is to talk about 25 years of AIDS
in Africa. And those are some of the events
that have taken place over the years.
AIDS was first discovered or diagnosed around 1980
here in the United States, and events have taken place.
What I would like you to see from this graph is the rise.
The two lines all going up. The top is the numbers
of people who have been infected with HIV in the world.
And the bottom is the line of offense that have risen
parallel to the numbers. And somewhere in the middle
is the deaths, which have taken place all over the world.
Now symptomatic AIDS was first diagnosed in Uganda
at the same time as it was in the United States.
That was early 1980s. And in Uganda, it was first seen
in a place called Rakai, that is in the south western
part of the country. And it has since
devastated the country. I'd like to take you back
to 2000, when I got a grant from Rockefeller Foundation
to study the impact of HIV/AIDS in Africa.
And I spent about a year going across the continent
and studying the impact of AIDS. Our objectives in this study
was to try and define the epidemic involvement,
to measure the magnitude and impact of the epidemic,
to find out of the current interventions that existed
on the continent, especially the gaps,
to document any successes, if any,
and constraints. And also to determine
country and regional priorities, and to determine
some research priorities, as well.
And, above all, to make recommendations.
In brief, we found a continent totally devastated by AIDS
and ignored by the world. And it was a very, very
depressing findings. We found the rates
ranging from a high of about 30%, downwards.
At about the same time that was the picture
in the world, Africa was the continent
most affected by HIV AIDS; almost about 30 million people
were living with AIDS. And the rest of the continent
were not so badly affected. These are some of the micro
details that we found. AIDS was a sexually transmitted
disease in Africa, and it affected
the heterosexuals. Only a small proportion got AIDS
from blood transfusion. It was a disease of the youth.
The young generation were the ones most affected
by HIV/AIDS. And this is what was happening.
Previously, just about in 1992, less than 15%,
on or about 15% of the hospital beds
were occupied by AIDS patients. And by the year 2000, more than
half of the hospital beds were occupied by AIDS patients.
And everything was on the rise. The epidemic was rising
in both east and southern Africa and western Africa.
In some western African countries, we had some
low rates, but overall it was everything on the rise.
I want to talk to you what happened in Uganda.
By 1990s, Uganda had the highest rates of HIV/AIDS in the world.
In fact, if you talked about Uganda, what would come to most
people's mind was either AIDS or Idi Amin.
( laughter ) Now, from 1995, the rates
in Uganda started coming down. And they came down until
they reached about the current level of 6.4.
And this was remarkable, because this was done without
any other intervention other than education,
communication and information to the populations.
It made us study the epidemic a little bit more closely
in other countries. And overall, I defined
three phases of the epidemic, which I give some special
identifications. The first phase,
which I have seen as a pattern in virtually all countries
in Sub-Saharan Africa, is what I call an epidemic
out of control. It first goes up, because it
normally happens insidiously. Nobody knows they have it
until they find it on the rise. And then the second phase
is what I called a declining phase.
That is an epidemic under effective control.
And then we get out a bottoming effect.
Now, that is demonstrating a second phase of the epidemic.
And currently, a lot of African countries are in this phase,
because most interventions are taking place
bringing the epidemic down, the risks of the epidemic.
And the country that, for a long time has been in a
bottoming out phase is Senegal, because it took effective
measures. And the epidemic
is in that phase. But what happens
as the epidemic becomes under control?
All of those people who got infected turn up with AIDS.
So the patients tend to go up, while the epidemic itself
is in the declining phase. Now, it's not only epidemic
that comes down, I mean that the AIDS patients
come up, it is many complications
of AIDS that come up. You get rising opportunistic
infections, rising deaths and rising numbers of offense.
In our findings, we looked at the social economic impact
and we found it was devastating. Take an example of South Africa.
Without interventions, it was estimated
suffer a decline in growth and production of about 20%
and loss of about $22 billion. We found care and support
was greatly deficient. But most remarkably,
there was absence, almost total absence
of antiretroviral drugs. There were other deficiencies
in human resources and epidemic monitoring.
But by far the biggest concern was a lack
of antiretroviral drugs. We found that all of the donor
activities were concentrated on prevention.
But the prevention itself was grossly deficient.
We also learned that it was possible to actually
control the epidemic. If you took measures
that were robust in prevention topped by treatment,
you could actually bring the African runaway epidemic
under control. But everywhere we went there was
desperate need for treatment. As I said earlier on,
all the donors chose to handle only the easy options.
For example, in prevention, they didn't tackle expensive
diseases like toxoplasmosis, which is an infection
that affects mainly the brain, or cryptococcal meningitis,
because those are very expensive.
They concentrated on septrin prophylaxis.
It didn't cost much, and it controlled, it helped
to reduce only a few diseases. And it was generally said
at the time, that treatment was impossible in Africa.
As for prevention of mother-to-child,
it was only restricted to developing immunotherapy.
Most importantly, as far as prevention was concerned,
we found some of the best practices that had helped
to reduce the Ugandan epidemic to a controllable level.
And this was committed leadership
and multi-sectorial approach. By multi-sectorial approach,
we mean all the departments of government, in education,
in agricultural, in all kind of sectors
were involved to some extent in AIDS control.
And then there was some investment in capacity building,
which was taking place but this was sufficient,
and then networking. So the summary of what we found
in our research was an epidemic in South Africa,
an estimated 500 people were dying on a daily basis.
In Kenya, Uganda, Tanzania each country was losing
at least 200 people every day. Literally, millions of Africans
were dying. And what was regrettable,
almost all of these deaths were preventable.
This was a remarkable finding. All the African countries
from 1955, were achieving some growth in healthcare
and treatment. And the health facilities
had grown steadily. And we're realizing a continuing
rise in the life expectancy. Now from 1985,
life expectancy plummeted. And of particular interest
is Zambia, which was projected
to have a life expectancy of only 30 years.
And then, to put it into perspective,
life expectancy in Japan is about 81 years.
So this is the kind of picture I wanted to paint for you
of what has happened in Africa over the years.
Now, all of that red line is showing a period
where most people in Africa died of AIDS.
And this is the period when effective treatment
in form of antiretroviral drugs was available.
So obviously there was a moral imperative
to make AIDS treatment accessible to Africa.
And in some cultures, there was growing outrage
that so many people were allowed to die,
when treatment that could stop the carnage was available
and easy to administer. So while the world
was not so affected, this is the grim picture
of high prevalence of HIV on the continent,
most of it in Southern Africa. And after that,
other things were taking place. The African continent
is a boiling pot of so many of the HIV virus types.
All the types, all ten of them, can be found on the continent.
And what I want to show on this is the march of the most
aggressive type, type C. It has taken over
the whole Southern Africa and is marching northward.
It is not so vicious in affectivity.
But patients don't die soon, and, as a result,
it has time to infect more people.
And that's why it is successful in taking over
most parts of the world. Now, I'd like to talk to you
about the campaign that I've been involved in
to make AIDS treatment in Africa.
I think I have made a case of how desperately needed
treatment was, because it was the only one
that would put a stop to the carnage.
The talk around the year 2000, was that Africa cannot use
antiretroviral drugs. There were so many statements,
which I don't want to pronounce, trying to emphasize
that it was futile to try and use antiretroviral drugs
in Africa. However, there were
some concerns. And some of these concerns
were quite general. They related
to drug affordability. It was extremely expensive
and unaffordable, by any of the African continent.
The monitoring tests were also equally expensive.
Care providers were not so many.
Logistics for drugs, storage and distribution
was a challenge. And compliance for use of these
were also a challenge. And then, most of the Africans
are not found in cities. They actually live
in rural areas, so treatment needed to be taken
to the districts, where facilities were even bleaker
than in towns. And, of course, the widespread
poverty among the communities and systems that needed
to be put in place. All of these
were some of the challenges. But our view was that
all of these could be overcome. My center, the Joint Clinical
Research Center, which started in 1991,
had some experience in use of antiretroviral drugs.
And this experience had proved to us that
we could use antiretroviral, not only in Uganda,
but in any part of Africa, if only of the costs
of the drugs and some of those challenges
could be addressed. And this is the effect
that we saw with regard to the cost of the drugs.
The decline in the cost of the drugs
corresponded very closely with the increase in the numbers
of people accessing treatment in the center.
So the number one constraint, the smaller graph
is showing the increase in a number
which corresponds with decrease in the cost of various drugs.
So this was obviously the main constraint
that we're meeting in the country.
So our job was to overcome the constraints associated
with the HIV treatment. What we did at my center,
we started importing the drugs. The rich could access them.
Meanwhile, we would charge them overheads, which would go
to helping the poor patients. We ignored the red herrings,
infrastructure deficiencies and all of that stuff,
and concentrated on finding solutions
around those problems, because it was imperative
that at any cost we had to provide
life-saving treatment. And we introduced what we
called cost recovery system, whereby the rich would pay
and then give something to the poor.
And we kept increasing the numbers.
The is a busy slide, but it is quite simple to understand.
This is what we called the network model that we developed,
tested out and found it worked, and could apply in any country.
Basically, the principal of it is that you cannot have
all the facilities all at once. So if you have facilities
in the capital city, you can use a referral system
so that only those who need the high-tech kind of facilities
come to the city. And others can be managed
in their respective areas. So we had the levels
of healthcare defined. We had where
they were positioned. We defined what kind of
infrastructure was needed. The personnel
that would be there, we are talking about
minimal personnel, and what kind of facilities
that would be available. And we put it in action.
And by 1998, we had established three centers
that worked very well. By 2001, we had over ten
centers. And we are ready scale up,
but we are constrained by funds. Now in the year 2002,
we presented, I was called to the U.S. Congress
to present the network model. There was a group
of policymakers of U.S. government.
They were exploring how AIDS treatment
could work in Africa and many other poor societies.
The majority opinion was that it was impossible
to use this treatment in Africa.
So we presented the network model and demonstrated
that it would work, and also showed them physically
how we are running it. And at the end of the day,
this convinced the policymakers that it was worthwhile
considering AIDS treatment support for Africa.
And in January 2003, President Bush announced
$15 billion for aid to Africa and some Caribbean countries
for treatment of HIV in those countries.
My center got the grant in November 2003.
And when we got the grant, we hit the ground running.
By May, the president, I think, had woken up to find that
actually there was a emergency in Africa but, in fact,
the emergency had been there for more than ten years.
And he became an avid fighter for AIDS treatment in Africa.
So what will follow is a description
of the program that we set up to take AIDS treatment
to the people of Uganda through my center.
We called it Time Table for Regional Expansion
of Antiretroviral Therapy. Under this program,
we have successfully established AIDS treatment centers
in all regions of the country, and we have established
a network of public-private centers, including
faith-based organizations. And we have a nucleus
of expertise to build capacity for quality and sustainable
program. So we have been
fanning everywhere. We know the science
of antiretroviral therapy. We know how to monitor
the drugs, very well drugs treatment.
We know how to change treatment, and all of the scientific needs
for modern management of antiretroviral therapy.
But we realized that this was not going to make it work.
It took much more than that. One of our greatest needs
was to get a big number of our people trained.
And this is where Wisconsin has come in very strongly.
We had to train them in all kinds of ways,
on the premises, on the job, in their various areas.
And Dr. Graziano and his team have been going to all parts
of the countries doing training with us.
We decided to train while we're working on treatment
at the same time. People who'd get treatment
would immediately be sent in the field to treat,
because it was critical. Start of treatment
was equal to saving lives. We had a drill
which we followed. We didn't care
what we found there, but whichever infrastructure
we found, we used it. We had low cost renovations
and we had improvisations where necessary.
And I'll show you some examples. But all the time, we are
working toward sustainability by addressing infrastructure,
by addressing human resource and discussing with donors
for longer time. Because this is a donation
for a lifetime disease. It's not going to go away
next year or within next ten years.
When we open a center up country,
it is time of great celebration. We actually do
very big parades within towns. It's grand.
We get students putting up spectacular concerts.
We get very big marches. And by the time we leave town
everybody knows we have been in town.
( laughter ) And the question
they ask themselves, "What are these guys
doing here?" They look around,
they find religious leaders, politicians, villagers,
everybody talking about AIDS and that helps
to decrease stigma. You can do as much as you like,
but nothing decreases stigma like the way we open our centers
with such a bang and getting people participating
and organized. And this has served us
very well. We get on tracks and start
driving around the villages. Those who remained
in the villages, making as much noise and
making a nuisance of ourselves as much as we can.
And by the end of the day, everybody gets to know
that a clinic to treat AIDS has been opened.
What happened the next day, we are swamped.
People come. And we always make sure
that we are ready not to disappoint them.
In some places, when you go over there
and you find that the ambulance that is the only one available,
you just don't say, "It can't be done."
Patients can still be brought to hospital, to the clinics, and
you can actually treat them. If your treatment is good,
it doesn't matter how they came in.
In fact, this is an example of one of the places
that we went to and found they had
absolutely no infrastructure. And it has since become one
of our most successful centers. When we found they had
no infrastructure, but they had so many patients,
we just put up a tent. And when we put up a tent,
by next week, we are doing health education in it.
It became one of the busiest spots.
We had a small room enclosed, where we did counseling,
and another one where we did HIV testing,
and another one where we treated those who needed treatment.
And we started operating. Meanwhile, we started building.
We don't have money to build such complex structures
like you have here. And even some of us occasionally
volunteer some labor, and right now, this is
what we have in that place. We have a neat, small laboratory
which works very well. And we have a clean clinic
where patients are treated. But at no time while we were
getting these facilities, did we stop for these facilities
to be established. We continued treating people.
And when the facility came, it made it easier for our staff
and for some of the patients. But at least lives were saved.
When our program started, we started by addressing
the poorest of the poor. We started with orphans
and vulnerable children, until we got more funds.
Then we went to look after orphan caretakers.
And when we got funds we progressively addressed
more and more of the poor. I'm very glad to say
that before I came here we looked in the kitty,
and our program is able to give everybody who comes
to our centers treatment. So this is what has happened
in our place. From six centers,
which grew to ten, these were six big centers,
but we're taking care of about 12 sub-satellites.
We have grown to 50 centers countrywide,
with 25 outreaches. So we have got 75 places
where we give treatment as Joint Clinical Research Center.
This is not government or other organization.
This is just our center, which I head.
We have numbers accessing antiretroviral therapy
increased from 10,000 in 2004 to 47,000.
Actually, the latest data is over 50,000.
And most of them are females in our country.
It's a heterosexual disease which effects mainly females.
And we are taking care of over 39 districts in Uganda.
So we have had, in addition, a big number in care.
Because those who go on antiretroviral therapy--
For one patient who goes on antiretroviral therapy,
there is two to three others who don't need treatment as yet,
but whom we continue to look after.
So we have over 65,000 in continuous care
in some of our centers. So our treatment program
have been increasing almost in a linear manner
as we extend treatments to various parts of the country.
And one of the most pleasing things to me, because
my background is in pediatrics, is that we now have the capacity
to treat children. And the children are coming up,
and right from the beginning, all children access treatment
free all over. More recently, we have
introduced advanced tests like DNA PCR for early
childhood diagnosis of HIV. With the Clinton Foundation,
we've been able now to get some pediatric dosages
of all of these, which you know are quite difficult to get.
So this is the network of the centers that I run.
Which, as I said, the main one is about 50.
The outreach is about 25. And in total, we are looking at
75 centers countrywide. Now, what we did in our program
was to divide the country in two regions.
And in each of the region, we established
a center of excellence. This center of excellence
provided tests that could not quickly be established
in all of the centers where we give treatment.
What's happening in those places that we are able to do
advanced tests like CD4s, viraloids, both PCR and DNA,
full chemistries and others, and samples are brought
by public transport from a company that we hired.
And in this way, each area is able to provide
some diagnostic treatment for all of the centers
by referral system. And those centers,
we also use the same method that I've already explained.
We found, usually no infrastructure.
And we built these various infrastructures
that you can see over there. And these are serving as the
regional centers of excellence, and also as training centers.
In fact, this is where within a few weeks,
Dr. Graziano and his team will be conducting a course.
This is in the east, near Kenya border, previously
they conducted courses in the west, southwest in Paroa,
which is a teaching hospital. And they have also been
in extreme south at Congo border to teach in this place.
People they teach quickly go to provide
antiretroviral therapy. And I think they have also been
foot patrol, as well. So this is the collaboration
in the different parts of the country,
where we are working with University of Wisconsin
providing care and treatment. So these are the critical areas
which we have concentrated on, and we are developing
so that together we get a quality program.
Training. We have got laboratories,
because laboratories define the quality of the services
that you give. But they were, as I have
explained, not necessary for saving lives initially.
We could use classifications. We could use CDC classification
to determine the disease severity
and start treatment based on those criteria.
All we needed was an HIV test to confirm that patients
were indeed infected with HIV. And this is important
in our area, where we've got many tropical diseases.
But subsequently, we have come to a stage
where quality of the program is very, very important.
And of course, treatment success
is measured by good ideas. And to have good ideas
you have to get good logistics. so that drugs reach people
where they are. And this,
we have been setting up. And finally, sustainability
is very important, because you cannot have a program
that relies on donors perpetually.
You must have a strategy that builds capacity
within the country for eventual take over of the program.
And we have been giving this-- We have been giving this
some attention. Lastly, we gathered
a lot of experience, because we started early in Uganda.
And therefore, we have been sharing our experience
with other parts of Africa. The Joint Clinical Research
Center is now serving as the World Health Organization
knowledge hub for East and Central Africa.
We share those experiences and skills
in scaling up treatment with many other various countries.
And we have got a secretariat and a team, which is
going around the continent, exchanging knowledge
with other colleagues where they have not advanced
that much. We also host
two other programs. One is called
African Dialog on AIDS. And this one is where we bring
African experts to share African experience in the care
and treatment of AIDS. And at the Joint Clinical
Research Center, we have reached many countries.
And we were also lucky to get a grant from Doris Duke
to provide African young scientists to carry out
research on HIV/AIDS or TB, and be able to develop skills
while they are actually doing research
that would contribute towards the care of patients
in their own countries, so that in the future
they are able to compete for the likes of NIH grants.
And in this, we have been highly successful, because
at least five of our members have already successfully
applied for international grants to carry out various research.
So with that, I'd like to thank you
for listening to me and to invite any questions
that you might have about the outline of our program
that we have carried out in our country
to try and reverse the carnage of AIDS.
I'd like to say that in 2000, at least a relative or a friend
would die every day. With proper program and this
treatment that has happened, you can now spend
a couple of months without hearing of somebody
dying of HIV/AIDS. And to us, this has been
something tremendous, reversing human horror
and suffering to a current position of hope.
I don't like anybody to believe that we are on top
of the situation. There is much more to be done.
We need much more help. Lots of people
need to be trained. And we need also
to shift some of the tasks, because we cannot have
physicians being solely responsible for treatment
of HIV/AIDS, because we are going to be having
about 20 million Africans on antiretroviral therapy
within the next five to ten years.
And when you have such massive numbers,
you have got to get people like medical assistants.
We can get or colleagues, the nurses,
to do some of the work, to be able to prescribe
and treat patients, and get the community
more involved in care and treatment of AIDS.
Thank you very much. ( applause )