( applause )
generous and kind words. >> Thank you, Frank, for your
thanks very much for coming And lto listen to me.men,
Please if you can't understand
stop me. anything that I'm saying,
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
in Africa. to talk about 25 years of AIDS
that have taken place And thosover the years.he events
AIDS was first discovered or diagnosed around 1980
here in the United States,
What I would like you to see and events have taken place.
The two lines all going up. froThe top is the numbersse.
of people who have been infected
And the bottom is the line with HIV in the world.
parallel to the numbers. of offense that have risen
is the deaths, which have taken place all over the world.
Now symptomatic AIDS
at the same time was first diagnosed in Uganda
That was early 1980s. And in Uganda, it was first seen
in a place called Rakai,
part of the country. that is in the south western
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
and studying the impact of AIDS. going across the continent
was to try and define Othe epidemic involvement,dy
to measure the magnitude
to find out of the current and impact of the epidemic,
on the continent, intespecially the gaps,ted
to document any successes,
and constraints. if any,
country and regional priorities, And also to determine
some research priorities, and as well.mine
And, above all, to make recommendations.
In brief, we found a continent
and ignored by the world. tAnd it was a very, veryDS
depressing findings.
ranging from a high of about 30%, downwards.
At about the same time
in the world, Africa was the continent
most affected by HIV AIDS;
were living with AIDS. almost about 30 million people
were not so badly affected. AThese are some of the microt
details that we found.
disease in Africa, AIDS was a sexually transmitted
the heterosexuals. and it affected
from blood transfusion. OIt was a disease of the youth.S
The young generation
by HIV/AIDS. were the ones most affected
Previously, just about in 1992, And this less than 15%,ppening.
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
In some western African countries, we had some
low rates, but overall
I want to talk to you it what happened in Uganda.se.
By 1990s, Uganda had the highest
In fact, if you talked about rates of HIV/AIDS in the world.
people's mind was either AIDS Uganda, whor Idi Amin.e to most
( laughter )
in Uganda started coming down. Now, from 1995, the rates
they reached about And they came down until
And this was remarkable, because the current level of 6.4.
any other intervention this was done without
communication and information oto 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.
which I have seen as a pattern The first phase,
in Sub-Saharan Africa, in virtually all countries
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
That is an epidemic under effective control.
And then we get out a bottoming effect.
Now, that is demonstrating
And currently, a lot of African a countries are in this phase,.
because most interventions
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,
is in the declining phase. while the epidemic itself
that comes down, Now, it's not only epidemic
come up, I mean that the AIDS patients
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.
Without interventions, Take an example of South Africa.
suffer a decline in growth it was estimated
and loss of about $22 billion. and production of about 20%
was greatly deficient. We found care and support
there was absence, But most remarkably,
of antiretroviral drugs. almost total absence
in human resources There were other deficiencies
But by far the biggest concern and epidemic monitoring.
of antiretroviral drugs. was a lack
activities were concentrated We found that all of the donor
But the prevention itself was grossly deficient.
We also learned that
control the epidemic. it wIf you took measureslly
that were robust in prevention
you could actually bring topped by treatment,
under control. the African runaway epidemic
desperate need for treatment. But eAs I said earlier on,re was
all the donors chose to handle
For example, in prevention, they didn't tackle expensive
diseases like toxoplasmosis,
that affects mainly the brain, which is an infection
because those or care very expensive.tis,
They concentrated on septrin prophylaxis.
It didn't cost much,
to reduce only a few diseases. and it controlled, it helped
at the time, that treatment was impossible in Africa.
As for prevention of mother-to-child,
it was only restricted
Most importantly, as far as tprevention was concerned,y.
we found some of the best practices that had helped
to reduce the Ugandan epidemic
And this was to a controllable level.
and multi-sectorial approach. By multi-sectorial approach,
we mean all the departments of government, in education,
in agricultural,
were involved to some extent in all kind of sectors
And then there was some investment in capacity building,
which was taking place
and then networking. but this was sufficient,
in our research was Soan epidemic in South Africa,d
an estimated 500 people were dying on a daily basis.
In Kenya, Uganda, Tanzania
at least 200 people every day. each country was losing
were dying. LitAnd what was regrettable,ans
almost all of these deaths
This was a remarkable finding. were preventable.
from 1955, were achieving some growth in healthcare
and treatment.
had grown steadily. And we're realizing a continuing
rise in the life expectancy.
life expectancy plummeted. Now from 1985,
is Zambia, And of particular interest
to have a life expectancy wof only 30 years.d
And then, to put it into perspective,
life expectancy in Japan
So this is the kind of picture is about 81 years.
of what has happened I wanted to paint for you
Now, all of that red line in is showing a periodrs.
where most people in Africa died of AIDS.
And this is the period
in form of antiretroviral drugs when was available.tment
So obviously there was
to make AIDS treatment a moral imperative
And in some cultures, there was growing outrage
that so many people were allowed to die,
when treatment that could stop
and easy to administer. the So while the worldble
was not so affected,
of high prevalence of HIV thion the continent,ture
most of it in Southern Africa.
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.
the whole Southern Africa and is marching northward.
It is not so vicious
But patients don't die soon, in affectivity.
it has time to infect andmore people.t,
And that's why it is successful in taking over
most parts of the world.
about the campaign Now, I'd like to talk to you
to make AIDS that I've been involved in
I think I have made a case treatment in Africa.
treatment was, of how desperately needed
that would put a stop becausto the carnage.ly one
The talk around the year 2000,
antiretroviral drugs. There were so many statements,
which I don't want to pronounce,
that it was futile to try and use antiretroviral drugs
in Africa.
some concerns. However, there were
were quite general. And somThey relatedoncerns
to drug affordability.
and unaffordable, by any of the African continent.
The monitoring tests
Care providers were also equally expensive.
Logistics for drugs, storage were not so many.
was a challenge. and distribution
were also a challenge. And compliance for use of these
are not found in cities. And then, most of the Africans
in rural areas, so treatment needed to be taken
to the districts, where facilities were even bleaker
than in towns.
poverty among the communities Andand systems that neededread
to be put in place. All of these
were some of the challenges.
all of these could be overcome. My center, the Joint Clinical
Research Center,
had some experience in use of antiretroviral drugs.
And this experience had proved to us that
we could use antiretroviral,
but in any part of Africa, not only in Uganda,
of the drugs if only of the costs
could be addressed. andAnd this is the effectges
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
So our job was to overcome in the country.
with the HIV treatment. What we did at my center,d
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
around those problems, on finding solutions
that at any cost because it was imperative
life-saving treatment. we had to provide
called cost recovery system, And we introduced what we
and then give something wherebyto the poor.uld pay
And we kept increasing the numbers.
The is a busy slide, but it is
This is what we called the quite simple to understand.
tested out and found it worked, and could apply in any country.,
Basically, the principal of it
all the facilities all at once. So if you have facilities
in the capital city,
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.
of healthcare defined. So we had the levels
they were positioned. We defined what kind of
infrastructure was needed.
that would be there, The personnel
minimal personnel, we are talking about
that would be available. and what kind of facilities
And by 1998, And we put it in action.
that worked very well. we had established three centers
centers. By 2001, we had over ten
but we are constrained by funds. And we are ready scale up,
we presented, I was called Now in the year 2002,
to present the network model. tThere was a groupss
of policymakers of U.S. government.
They were exploring how AIDS treatment
could work in Africa
The majority opinion and many other poor societies.
to use this treatment was thatin Africa.possible
So we presented the network model and demonstrated
that it would work, and also showed them physically
how we are running it.
this convinced the policymakers Anthat it was worthwhiley,
considering AIDS treatment
And in January 2003, support for Africa.
$15 billion for aid to Africa and some Caribbean countries
for treatment of HIV
My center got the grant iin November 2003..
And when we got the grant,
By May, the president, I think, had woken up to find that.
actually there was a emergency
the emergency had been there in Africa but, in fact,
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.
we have successfully established Under this program,
in all regions of the country, AIDS treatment centers
a network of public-private andcenters, includinged
faith-based organizations.
of expertise to build capacity And we have a nucleus
program. for quality and sustainable
fanning everywhere. We know the science
of antiretroviral therapy.
the drugs, We know how to monitor
We know how to change treatment, very well drugs treatment.
for modern management andof antiretroviral therapy.ds
But we realized that this was not going to make it work.
It took much more than that.
was to get a big number Onof our people trained.s
And this is where Wisconsin has come in very strongly.
We had to train them
on the premises, on the job, in all kinds of ways,
And Dr. Graziano and his team have been going to all parts
of the countries
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.
was equal to saving lives. Start of treatment
which we followed. We had a drill
what we found there, but We didn't care
we found, we used it. We had low cost renovations
and we had improvisations where necessary.
And I'll show you some examples.
working toward sustainability by addressing infrastructure,
by addressing human resource
for longer time. and discussing with donors
for a lifetime disease. It's not going to go awayn
next year or within next ten years.
When we open a center up country,
it is time of great celebration.
very big parades within towns. We actually do
We get students putting up It's grand.
We get very big marches. spectacular concerts.
everybody knows And we have been in town.town
( laughter )
they ask themselves, And the question
doing here?" "What are these guys
they find religious leaders, They look around,
everybody talking about AIDS politicians, villagers,
to decrease stigma. You can do as much as you like,
but nothing decreases stigma
with such a bang like the way we open our centers
and organized. and getting people participating
very well. And this has served us
driving around the villages. We get on tracks and start
in the villages, Those who remained
making a nuisance of ourselves making as much noise and
And by the end of the day, as much as we can.
that a clinic to treat AIDS evehas been opened.now
What happened the next day, we are swamped.
People come.
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.
it doesn't matter If yhow they came in.good,
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,
we just put up a tent. but they had so many patients,
by next week, we are doing And when we put up a tent,
It became one of the busiest spots.
We had a small room enclosed, where we did counseling,
and another one where we did
and another one where we treated HIV testing,
And we started operating. Meanwhile, we started building.
We don't have money to build
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.
where patients are treated. But at no time while we were
getting these facilities, did we stop for these facilities
to be established.
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.
and vulnerable children, We started with orphans
Then we went to look after until we got more funds.
And when we got funds we progressively addressed
more and more of the poor.
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,
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
This is not government Joint Clinical Research Center.
This is just our center, or other organization.
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
It's a heterosexual disease which effects mainly females.
And we are taking care
So we have had, in addition, of over 39 districts in Uganda.
Because those who go on antiretroviral therapy--
For one patient who goes
there is two to three others on antiretroviral therapy,
but whom we continue who don't need treatment as yet,
So we have over 65,000 to look after.
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
my background is in pediatrics, is that we now have the capacity
to treat children.
and right from the beginning, Aall children access treatment,
free all over.
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
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,
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
advanced tests like CD4s, viraloids, both PCR and DNA,
full chemistries and others,
by public transport from a company that we hired.
And in this way, each area
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
that you can see over there. infrastructures
regional centers of excellence, and also as training centers.
In fact, this is where
Dr. Graziano and his team will be conducting a course.
This is in the east,
they conducted courses near Kenya border, previously
which is a teaching hospital. in tAnd they have also beenaroa,
in extreme south at Congo border
People they teach tquickly 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
where we are working of the country,
providing care and treatment. So these are the critical areas
which we have concentrated on,
so that together and we are developing
Training. We have got laboratories,
because laboratories define the quality of the services
that you give.
explained, not necessary But they were, as I have
We could use classifications. We could use CDC classification
to determine
and start treatment based on those criteria.
All we needed was an HIV test to confirm that patients
were indeed infected with HIV.
in our area, where we've got And this is important
But subsequently, we have come to a stage
where quality of the program
And of course, is very, very important.
is measured by good ideas. treatment success
you have to get good logistics. so that drugs reach people
where they are. And this,
we have been setting up.
is very important, because And finally, sustainability
that relies on donors you canperpetually.rogram
You must have a strategy
within the country for eventual take over of the program.
And we have been giving this--
some attention. WeLastly, we gatheredhis
a lot of experience, because
And therefore, we have been we sharing our experiencea.
with other parts of Africa. The Joint Clinical Research
Center is now serving as
knowledge hub tfor East and Central Africa.
We share those experiences
in scaling up treatment with and skills
And we have got a secretariat many and a team, which isies.
going around the continent, exchanging knowledge
with other colleagues where they have not advanced
that much.
two other programs. One is called
African Dialog on AIDS. And this one is where we bring
African experts to share
and treatment of AIDS. African experience in the care
Research Center, And at the Joint Clinical
And we were also lucky we have reached many countries.
to provide African to get a grant from Doris Duke
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
And in this, we have been fhighly successful, because.
at least five of our members
applied for international grants have already successfully
So with that, to cI'd like to thank youarch.
for listening to me and to invite any questions
that you might have about the outline of our program
that we have carried out
to try and reverse the carnage in our country
I'd like to say that in 2000, at least a relative or a friend
would die every day.
treatment that has happened, With proper program and this
a couple of months you can now spend
dying of HIV/AIDS. without hearing of somebody
something tremendous, Areversing human horrorn
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
about 20 million Africans on antiretroviral therapy
within the next five
And when you have such massive numbers,
you have got to get people
We can get or colleagues, like mthe nurses,stants.
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 )