Interesting Stephen Lewis speech on the new AIDS stats - and where we stand..

Excerpt from a speech by Stephen Lewis, Co-Director, AIDS-Free World
to the World Health Editors Network, Imperial College, London, UK
Friday, November 23, 2007, 11:00 am
For Immediate Delivery

It's fair to say that any speech designed to address leadership and AIDS
must start with the events of this week: the publication of the UNAIDS
Epidemic Update, 2007.

Let me get two matters out of the way at the outset. I think the new set of
numbers is much closer to the truth of the pandemic, although I'm inclined
to believe that they're still too high and that another awkward revision
lies ahead. Second, I don't believe for a moment that UNAIDS inflated the
figures for the purpose of extracting money. That seems to me too
conspiratorial by half. If by some bizarre happenstance, Machiavelli's
apprentices were involved, they make lousy fund-raisers: we're billions of
dollars short of where we should be, old estimates or new.

I take issue with the report on different grounds. For years, knowledgeable
epidemiologists have been telling the UN that the figures were too high.
They didn't whisper their criticisms: they wrote books and articles. They
lobbied behind the scenes. No one paid them heed. It doesn't take a Nobel
prize statistician to guess that prevalence rates based on urban antenatal
clinics should not be extrapolated to the entire country and presented as
holy writ. That became compellingly clear when the spate of population-based
household surveys, country after country, invariably showed lower
prevalence.

But the UN chose a course of delay and dithering. It can never admit that
it's
wrong. So finally, and predictably, came the moment of truth: the result is
an overall prevalence rate that is lower by almost seven million than last
year's estimate.

Sure, it can be rationalized by arguing that it's just a methodological
adjustment, rooted in superior statistical-gathering techniques. And that
might even be persuasive if there hadn't been academicians and
epidemiologists clamouring for revision for years. The UNAIDS explanation
sounds good; the fine print has the ring of arcane scientific authority. But
down here, in the mortal universe, where people aren't easily taken in, it
doesn't wash.

The UN was stubborn and it was sloppy. In the process, it undermined public
confidence in the reliability of the figures, introducing completely
unnecessary levels of doubt, contention and confusion.

Where HIV/AIDS is concerned, there is no room for the jolting of confidence.
The new estimates confirm a continuing apocalypse for sub-Saharan Africa:
22.5 million infections, 61% of them women, 68% of world-wide infections,
76% of all deaths, 11.4 million orphans . this is where the focus must be,
this is where it should always have been; not a report cluttered by
mathematical adjustments so that virtually every story that's written begins
with the news of a statistical volte-face. If the recording of data had been
more scrupulous all along, we could have welcomed this report as the latest
instalment in a record of declining numbers, showing some strong hints of
progress, and plausibly leading to universal access for treatment,
prevention and care by 2010.

Instead, all of us have to run to the trenches to remind the world that more
money is still desperately needed and that the situation, in many places,
remains grim, bleak, funereal.

As a matter of fact, at the risk of knocking the nail through the wall,
allow me to add that I earlier used the word 'sloppy' advisedly. For a
number of years in the 1990's, I was the Deputy at UNICEF and oversaw a raft
of publications. I would never have permitted this Update to go out as is.

Let me explain by way of example.

In one of the dense explanatory notes, there's a statistical adjustment
described that attracted little notice, but seems to me to be of enormous
import. If I may attempt a straightforward simplification, the report seems
to be saying that, on average, the population-based random household surveys
in countries with generalized HIV epidemics produced estimates that were 20%
lower than the estimates produced by antenatal surveys. Therefore, says the
report, for all those countries with generalized epidemics that have not yet
done random surveys, we're applying a reduction factor of .8 . that is to
say, the new figures will be 80 % of the old figures.

That's quite a reduction! Don't you think it might have been useful to
produce a table (there were, after all, tables galore) to show what it might
mean, in practice, country by affected country? No such luck.

Instead, the report notes that \"Of the total difference in the estimates
published in 2006 and 2007, 70% are due to changes in six countries: Angola,
India, Kenya, Mozambique, Nigeria and Zimbabwe.\" I was stumped by Angola
because its prevalence rate is so low, it's hard to imagine that it could
make a great difference to the numbers. India everyone knows about. Kenya
and Zimbabwe have oft been talked about (although the alleged decline in
Zimbabwe seems to me to be complicated by the numbers of deaths, the
out-migration, and the difficulty of reliable surveys in a sociological
wasteland). Nigeria was clearly possible. But Mozambique was a mystery
because I remembered from my last visit that the most recent data had shown
an increase in prevalence.

This is no small matter. This is a report that is telling the world that the
dramatic revision in the figures, and the figures themselves, are now the
best that science has to offer.
Naturally, therefore, I looked at all the entries in the report dealing with
Mozambique. On page 12, there is a section on \"Recent HIV and sexual
behaviour trends among young people\" that chronicles reductions in HIV
prevalence in various countries from Kenya to Malawi to Zimbabwe to rural
Botswana. However the paragraph ends with these words: \"There was no
evidence of a decrease in HIV infection levels among young people in
Mozambique .\" (emphasis mine).

On page 13, there's an elaborate table titled, in part, \"2006/2007 analysis
of trends among 15 to 24-year-olds in high prevalence countries: HIV
prevalence among pregnant women, 2000-2006 in sentinel surveillance
systems .\" Mozambique is in the table. Below the list of countries, there's
an asterisk which reads: \"Analyses of countries with more than three years
of data based in the following number of consistent urban and rural sites .\"
For Mozambique there are 20 sites listed, South, North and Central. Beside
Mozambique is another legend symbol which reads: \"No evidence of decrease\"
(emphasis mine).

On page 15 we encounter the critical \"Regional Overview\", leading with the
section on \"Southern Africa\". It indicates that this sub-region includes the
eight countries with prevalence rates over 15%: Botswana, Lesotho,
Mozambique, Namibia, South Africa, Swaziland, Zambia and Zimbabwe. The
narrative then points out, with some gratification, that in Zimbabwe there
is an actual decline in national HIV prevalence, and that \"the epidemics in
most of the rest of the sub-region have either reached or are approaching a
plateau\" The next sentence reads: \"Only in Mozambique latest HIV data (in
2005) have shown an increase in prevalence over the previous surveillance
period.\" (emphasis mine).

Finally, on page 17, Mozambique is dealt with separately, as are all the
countries of the sub-region. The opening paragraph reads \"In the other
lusophone country of this sub-region, Mozambique, the epidemic has again
started to increase in all three zones after appearing to have stabilized in
the early 2000s.\" (emphasis mine . the three zones are south, central and
north, and the other lusophone country is of course Angola.)

If I was in the Ministry of Health in Mozambique, I would want to know why
all of the narrative evidence of the report seems to contradict the
assertion that Mozambique is one of the six countries in the world that has
most significantly contributed to the reduced numbers, 2007 over 2006. And
if the explanation is --- as it must be --- the application of the new 80%
rule applied to countries, ie Mozambique, that haven't yet done
population-based surveys, then those figures should be set out conclusively.
Otherwise this report does what so many other reports have done: it slides
casually over critical information. It confuses where it ought to be
clarifying. It's blurred where it should be coherent.

For me, the Epidemic Update, 2007, is simply a symbol, a symbol of
insufficient leadership, within the United Nations, against the pandemic of
AIDS. The time has come --- we're just a week away from another World AIDS
Day --- for the new Secretary-General to throw the full weight of his office
behind a campaign to subdue the pandemic, with a particular consuming focus
on Africa.
The agenda lies in the UNAIDS report.
For example, one of the most startling statistics is the revelation that
women now constitute 61% of the infections in Africa . close to 14 million
women infected. There are no words. It's a catastrophe rooted in gender
inequality, and everyone in the highest citadels of the United Nations knows
it, but virtually nothing changes.

We have a report from a High-Level Panel on UN Reform, pointing out the
lamentable UN record on women, and recommending the creation of a new
international agency for women. The proposal lies dormant on the order paper
of the General Assembly, crying out for leadership from the Secretary
General. The Deputy Secretary General has spoken, strongly and bravely
although, given the inevitable and nasty internal rivalries, her words are
too often given to rhetorical sleight-of-tongue.

Where is the UN Secretary General when the AIDS pandemic rages, and the
women of Africa need him most? No one pretends that the women's agency is
the sole answer, but you can bet that things would not be so excruciatingly
horrendous if women had an international vehicle to draw upon, with
resources and voice.

So, too, women in conflict zones. My colleagues and I carefully watched the
Security Council debate on Resolution 1325 just a couple of weeks ago, and
have read carefully the proceedings of the Security Council debate this week
on the protection of civilians in armed conflict. The speeches are getting
better: more feeling, more informed, more urgent (that is particularly true
of the Undersecretary General for Humanitarian Affairs; on the other hand,
the Secretary General's speech last Tuesday on the protection of civilians
in armed conflict was so pro forma as to make one weep. He managed to
mention Sudan, Somalia, Afghanistan, Iraq and a passing aside to Darfur. Not
a syllable on the Democratic Republic of the Congo). When you have a savage
war on women, as in the DRC, with huge implications for transmission of the
AIDS virus, speeches are the road to hell. When will the United Nations
actually take hold? There are suggestions cited of the Secretary General
leading a new campaign to eliminate violence against women. I recently saw
an early draft of this potential Secretary General initiative, and I can
categorically say that in more than twenty years of association with
multilateralism, I've rarely seen anything more vapid, fatuous and
insubstantial. It was as if the illusion of progress, dressed up in the
Byzantine underworld of United Nations processes was sufficient unto itself.
Public relations for inconsolable grief.

The Epidemic Update report acknowledges that only in a few instances has
behaviour change played a serious role in the reduction of the numbers. In
fact it says that the differences in estimates \"result largely from
refinements in methodology rather than in trends in the pandemic itself.\"
There is no question that a small proportion of the decline stems from
changes in behaviour, but there is equally no doubt that the vast majority
of the difference lies in the methodological adjustment.

Now, then, is the perfect time to rally the UN community to the side of
prevention, with much greater focus on high-risk groups; on the increasingly
persuasive thesis of concurrent partners; on the roll-out of male
circumcision (which should have been pursued vigorously much more quickly,
but like so much else in the response to the pandemic got caught up in the
overweaning proclivity for excessive scientific inquiry when the case is
already clear, not to mention the faint hearts in the face of potential
controversy); on harm reduction around which there has been inexcusable
ambivalence; on the Prevention of Mother to Child Transmission, possibly the
easiest preventive intervention of all, and therefore the most grievous
emblem of multilateral negligence; on the absolute, resolute need to pursue,
with unflinching tenacity the continued quest for a microbicide and a
vaccine, regardless the setbacks. This is the time for a crescendo of United
Nations voices.

The Epidemic Update is also shocking in the information that 76% of the
overall deaths lie in Africa: one million, six hundred thousand adults and
children. It tells you everything you didn't want to know about the
painfully slow rollout of treatment, and how vital it is that keeping people
alive not get lost in some senseless, artificial tension between treatment
and prevention. Nor should we ever forget where so many of the deaths come
from, and how silent were the voices of the United Nations leadership while
President Mbeki pursued his fatal denialism. South Africa has far and away
the highest number of HIV infections in the world: five and a half million.
There are eight hundred to a thousand deaths a day. No one has ever been
held to account. Talk about impunity.

And as always, there's the question of resources. It's hard to know how the
donors will react to the new numbers published by UNAIDS. They may simply
yawn, and give whatever they intended. They may feel bamboozled, and want to
cut back. They may see possibilities in the reduced numbers, possibilities
of greater progress because fewer people are involved. Whatever the
reaction, we must somehow persuade the world that we're way behind, billions
and billions of dollars behind, when it comes to funding all the components
of the pandemic, from orphans to second-line drugs.

All of these elements, so many of them flowing generically from the Epidemic
Update, are the stuff of the United Nations. UNAIDS, the Joint UN Programme
on HIV/AIDS, oversees or coordinates ten co-sponsors: UNHCR, UNDP, UNICEF,
WFP, UNFPA, UNODC, ILO, UNESCO, WHO and the World Bank. That's a compendium
of multilateral aristocracy and power rivaled in influence only by the G8
and the International Financial Institutions. And yet, members of the UN
family, in the face of the AIDS pandemic, have sometimes acted with a kind
of catatonic passivity. There is no excuse for it.

More than twenty-five years into the pandemic, we have an epidemic update
that is --- let's face it --- horrifying in its implications. Whether it's
40 million or 33 million, this plague continues to ravage humankind. I
simply do not believe that the United Nations has done everything it can
possibly do to turn the tide. And I don't mean just the member states, I
mean the agencies and the secretariat.

I'm a multilateralist to the core of my being. But that doesn't mean that
the UN is above criticism. And it most emphatically doesn't mean acting as
an apologist for those who are chosen to lead and who have failed to lead.