July19,2010PreparedRemarksbyBillGates,Co-chairandTrusteeWatchavideoofthespeechThankyou,Vuyiseka,forthatkindintroduction.IalsowanttothankPresidentClintonfortheinspiringmessagehedeliveredthismorning.Itsanhonortospeakwithallofyoutoday.Asyousawinthevideo,theworldhasmadeamazingprogressinthefightagainstHIV.Yetwealsohavetorecognizethatthesearetoughtimesforallofuswhoarepassionateaboutthiscause.Economicturbulencehasdrivenupgovernmentdeficits,andsomecountrieshaverespondedbyfreezingorevenreducingtheirinvestmentsinglobalhealth.Thisisachallengeweallface.Butitdoesnotneedtodefineourtime.Iamheretodaybecause,whenitcomestothefightagainstAIDS,Iamstillanoptimist.Thepast10yearsareatimeofremarkableprogress.Todaymorethan5millionpeoplearereceivingantiretroviraltreatment,upfromfewerthanhalfamillionjustsixyearsago.Since2001,therateofnewHIVinfectionshasfallen17percent.Thoseofyouinthisroomhelpedmakethisprogresspossible.Thescientistsmadeprogressonnewtoolstofightthedisease.Thecommunityworkersandcliniciansdrovepreventioncampaigns.Theadvocatesarguedformorefundingandtheworldrespondedbyaddingmoneyforthiscausefasterthananyotherhealthprobleminhistory.TheGlobalFundhasbeenafantasticvehicleformakingsurethisfundinghelpsthepeoplewhohavethegreatestneed.Allofyoucametogethertoovercomehugeobstacles.Twodecadesago,theskepticssaid:“Wecantmakedrugstotreatavirus.”Butyoupersistedandnowtheycan.Thentheskepticssaid:“Wecanmakethedrugs,butwecantmakethemcheapenough.”Butyoukeptpushingandnowtheydo.Thentheskepticssaid:“Wecanmakethedrugscheaply,butwedontknowwhetherpeoplewillsticktotheregimen.”Butyouinsistedandnowtheyknow.Todaytheskepticslookatthestrugglingeconomyandsay:“WecantbeatAIDSunlesswecantreatmorepeople.Andwecanttreatmorepeoplewithoutmoremoney.Soifwedontraisemoremoneyfortreatment,welllosethefightagainstAIDS.Itshopeless.”Theskepticshaveapoint.Thisisatougheconomicenvironment.Rightnowthereisntenoughmoneytosimplytreatourwayoutofthisepidemic.Ifwekeepspendingourresourcesinexactlythesamewaywedotoday,wewillfallfurtherbehindinourabilitytotreateveryone.ThatswhyIwanttomakethecasetodaythat,evenasweadvocateformorefunding,wecandomoretogetthemostbenefitfromeachdollaroffundingandeveryounceofeffort.Ifyoupushforanewfocusonefficiencyintreatmentandpreventionandalsopushtocreatenewpreventiontools,wecandrivedownthenumberofnewinfectionsdramaticallyandstartwritingthestoryoftheendofAIDS.ScalingupexistingtoolsMalecircumcisionOurfirsttaskistoscaleupthepreventioneffortsthatarecheap,effective,andeasytoapply.Someoftheseespeciallymalecircumcisionandpreventingmother-to-childtransmissionaresocheap,andsoeffective,thatinendemiccountriesitismoreexpensivenottopursuethem.Inasinglemonthlastyear,36,000meninKenyawerecircumcised,atatotalcosttothegovernmentof$1.4million.Ifthesemenhadnotbeencircumcised,andeventuallybecameinfectedwithHIVattheprevailingrateforuncircumcisedmalesinKenya,treatingthemwouldhavecostthegovernmentnearly10timesasmuch.Thatsanastonishingfinancialreturnbutitsnotjustsavingmoney；itssavinglives.Ihavetoadmit:Whenitcomestocircumcision,Iusedtobeoneoftheskeptics.Ithought:“Sure,itreducestransmissionbynearly60percent.Buttheresnowaythatlargenumbersofmenwillsignupforit.”Imgladtosay:Iwaswrong.Whereverthereareclinicsavailable,menarevolunteeringtobecircumcisedinfargreaternumbersthanIeverexpected.Iwouldliketoshowyouashortvideoaboutoneofthem,ayoungmanfromSwaziland.LastDecember,IwenttoSouthAfricatoseeformyselfhowenthusiasticallymenareembracingcircumcision.IvisitedaclinicinthetownshipofOrangeFarmthatservesmorethan750meneverymonth.Imetafewofthem,andtheywereallthrilledaboutgettingcircumcised.Theoneswhohadalreadyundergonetheproceduresaiditmadeiteasierforthemtouseacondom.IalsometasurgeonatirelessyoungwomannamedJosephineOtchere-Darko.Shetoldmeshehadperformed67circumcisionsthatday.Iaskedher,“Whendoyoustop?”Shesaid:“Whenwearedone.”RightinterventionfortherightpopulationMalecircumcisionisanamazingadvanceinprevention.Ifwehadavaccinethatwasaseffective,wewoulddoeverythinginourpowertodeliverittoeverypersonwhocouldbenefitfromit.Anditisreachingmanymenbutnotnearlyenoughofthem.Inthefouryearssincewelearnedaboutitsbenefits,only150,000meninsub-SaharanAfricahavebeencircumcisedoutof41millionwhoneedit.Thatsinexcusable.Countriesneedtomakethisapriorityintheirpoliciesandintheirfunding.Wehavetodoafarbetterjobofscalingupinterventionsthatareproventowork,assoonastheyareproventowork.Wehaveseensimilargapswithotherpreventionefforts,includingcounselingsexworkersandofferingdrugtreatmentandneedleexchangesfordrugusers.Therearemanyreasonsforthesefailures.Forinstance,moreaidfromdonorcountriesneedstoreachthepeopleitsintendedtohelp.Butthereisonereasonthatespeciallydeservesourattention:Manypreventioneffortsarenottargetingthecommunitieswheretransmissionisthehighest.AccordingtotheKnowYourEpidemicreportpublishedthisyearbyUNAIDS,10percentofHIVinfectionsinKenyaareduetosexbetweenmen.Insomecoastalregions,itcouldbeashighas20percent.YetmostdistrictsinKenyahavenopreventionprogramsforthesemen.InRussia,theepidemicisconcentratedamonginjectingdrugusers.Inareaswheretheyreceivedcleanneedles,testing,andotherservices,theinfectionraterose15percentoverfiveyears.Wheretheydidnt,itskyrocketed105percent.Clearly,theseserviceswork.YetRussiahasguttedthemcutthebudgettozeroandshiftedthemoneyintoprogramsforthegeneralpopulation.Why?Theproblemisnotalackofdata.UNAIDScanhelpanyendemiccountryanalyzeinformationtounderstandwhichpopulationsareatthegreatestrisk.Theproblemisthatmanycountriesarenotusingthisdatatomaketheirfundingdecisions.Instead,politiciansaremakingthembasedonfearandstigma.Theydontwanttoassociatethemselveswithpeoplewhoengageinbehaviorthatmakesthemuncomfortable.AsPresidentClintonsaidthismorning,everydollarwastedputsalifeatrisk.Ifyoureafraidtomatchyourpreventioneffortstotherightpopulations,thenyourewastingmoneyandthatcostslives.TreatmentaspreventionThereisoneotherpreventiontechniquewheregreaterefficiencywillmakeabigimpact:antiretroviral(ARV)treatment.WenowknowthatputtingpeopleonARVsmakesthemfarlesslikelytopassthevirusontoothers.Treatmentisprevention.Butthisraisesacrucialquestion:Howcanwegetthemostpreventionbenefitfromthetreatmentwereproviding?WhenyouhaveahigherCD4countandyourviralloadislow,youfeelhealthyandaremoresexuallyactive.AsyourCD4countdrops,yourviralloadspikes,andyoubecomelessactive,butyoumaybemoreinfectious.Whenshouldyoustarttreatment?ArecentstudyinvolvingsevenAfricancountriesfoundanintriguinganswer:PeoplewithCD4countsbelow200weresixtimesmorelikelythanhealthierpeopletotransmitthevirus.Thiswastrueevenafteraccountingforthefactthattheywerelesssexuallyactive.Sowhetheryourgoalistomaximizethepreventivebenefitsoftreatmentortosaveasmanylivesaspossible,youshouldfocusfirstontreatingeveryonewithaCD4countbelow200.ThisgivesusvitalinformationforthefightagainstHIV.Ithelpsusseewhereourtreatmenteffortscanbetargetedsotheymakethebiggestimpactforprevention.Atthesametime,wehavetofaceaharshtruth:Becauseofthevirusslonglatencyperiod,expandingourpreventioneffortswontdrivedownthenumberofdeathsforadecadeormore.Evenasweactnowtopreventfutureinfections,theonlywaytosavemorelivesimmediatelyistoexpandthenumberofpeoplereceivingtreatment.Unfortunately,thecurrenthighcostoftreatmentmeanswecannottreateveryonewhoneedsit.IfyouhaveAIDS,andyougotoahealthclinic,youshouldneverhavetohearsomeonesay:“Imsorry.Youcanthavethedrugsthatwouldsaveyourlife.Wedonthavethemoney.”Whenfundingislimited,therearetwowaystostopturningpeopleawayandstartexpandingtreatment:Youcanreducethecostofthedrugs；oryoucanreducethecostofdeliveringthemtopatients.Thecheapestfirst-linedrugsnowcostlessthan$100peryear.Weneedtokeepworkingtoreducethecostoftheseandothertreatmentdrugs,especiallythemoreeffectiveregimesthatcontaintenofovir.Butunfortunately,noneofthedrugsarelikelytogetalotcheaperinthenextfewyears.Thatleavesoneoptionforexpandingtreatmentnow:drivingdownthecostofdelivery.Weareseeingexcitingevidencethatthisispossible.In2006,PEPFARstudiedanumberofitssitesinBotswanaandreporteddeliverycostsofnearly$1,000perpatientperyear.Twoyearslater,thecostwasdownto$245.InNigeria,itdroppedfrom$2,000to$280areductionofnearly90percent.Someofthesesavingscomefromminimizingpersonnelcosts.Asasiteseesmorepatients,thestaffneedslesstraining.Sometaskscanbeshiftedfromdoctorstonurses,orfromnursestoassistants.Someclinicsalsocutcostsbysimplifyingtheirtestingregimes.TheymayrunfewerCD4countsorchecklessoftenfortoxicity.Todrivedownthecostofdeliveringtreatment,weneedtodoboth:minimizepersonnelcostsandsimplifythetestingregimes.Butthebestpracticesarentbeingmeasuredorshared.Isthereamore-expensivedrugthatactuallysavesmoney,becauseitrequireslessmonitoringorcanbedeliveredbylower-paidstaff?Wedontknow.Weneedtoidentifythemostefficientmodelsandthenmakesureeveryclinicfollowsthem.Ifwecouldlimitthedeliveryandadministrativecoststonomorethantwicethecostofthedrugsthemselves,thenthetotalcostoftreatmentwouldbeabout$300perpatientperyear.Forthesameamountofmoneywespendtoday,wecouldtreatmorethantwiceasmanypeople.ARVtreatmentandmalecircumcisionaretwopowerful,proventoolsforprevention,andweshouldscalethemupasquicklyaspossible.Anothersetofinterventionsthosedesignedtopersuadepeopletochangeriskybehaviorhavehadsuccessincertainregionswithcertainpopulations.Forinstance,ourfoundationsupportseffortsinIndiatoencouragesexworkersandtheirclientstousecondoms,andtheresultshavebeenimpressive.Now,aswescaleupvariousmethodsofbehaviorchangeinAfrica,weneedtomeasuretheirimpactsoweknowwhichonesmakethebiggestdifference.Thepayoffofscalingupexistingtoolscouldbehuge.Ifweidentifythemosteffectivepreventionefforts,andthenexpandaccesstothem,wecanpreventmillionsofdeaths.Thisisgoodnewsbutitisnotgoodenough.Evenifwedideverythingpossiblewiththetoolswehavetoday,themostoptimisticpredictionssuggestthattheywouldonlyreducenewinfectionsbyhalf.Millionsofpeoplewouldcontinuetotransmitthevirus,andwewouldneverhaveenoughmoneytotreateveryonewhoneededit.DevelopingnewtoolsFortunately,thereisnoreasontoassumethatinthefuturewewillbelimitedtofightingHIVwiththetoolswehavetoday.Wecandobetter.Innovationsinbasicscience,diagnostics,computermodeling,andourunderstandingofthevirusitselfwillmakeitpossibletocreatenewweaponsforthefightagainstAIDS,preventevenmoreinfections,andsaveevenmorelives.LetmedescribesomeoftheworkthatImespeciallyexcitedabout.ARV-basedpreventionOnepromisingareaisARV-basedprevention:pills,injections,andgelsthatcontainthedrugsnowusedfortreatment.Fouryearsago,whenMelindaandIspokeattheInternationalAIDSConferenceinToronto,wecalledARV-basedmicrobicides“thenextbigadvanceinthefightagainstHIV.”TheearlytrialresultsofgelsthatdidnotcontainARVingredientsfailed.Butwearestillveryoptimisticaboutthelong-termpotentialofmicrobicidesandotherformsofARV-basedprevention.ThenewgenerationofmicrobicidescurrentlybeingtestedismorelikelytosucceedbecausetheycontainARVs.Theresultsfromthefirstofthesetrials,CAPRISA,willbeannouncedtomorrow.Researchersarealsobuildingonimportantlessonsfromtheearlymicrobicidetrials.Theynowunderstandthatweneedawiderangeofproducts,becausepeoplehaveawiderangeofneeds.Forinstance,somewomencantorwontuseageleveryday.Soresearchersarestudyinglong-actingproductsthatcanbedeliveredbyvaginalringsthatstayinplaceforamonthormore.Efficacytrialsononeringarescheduledtobeginnextyear.Ifitworks,itcouldhelpovercomesomeoftheadherenceproblemsweveseeninearlymicrobicidetrials.Anotherpromisingareaofresearchispre-exposureprophylaxis,orPrEPadailypilloralong-lastinginjection.Thiswouldputthepowerofpreventionintothehandsofwomenwhocantusemicrobicides,andpeopleathighrisk,suchasinjectingdrugusersandmenwhohavesexwithmen.Laterthisyear,researchersinLondonwillbeginanewstudyoftheoraltreatmentdrugrilpivirine,toseeifitcanbeusedasalong-lastinginjectionforPrEP.Whenwegetresultsfromthesestudies,weshouldbereadytoactrightaway.Butrightnow,werenotready.SupposewegotpositiveresultsonanARV-basedpreventiontooltoday.Betweengainingregulatoryapprovals,raisingmoney,trainingthestaff,andotheractivities,usingthenormalapproachwouldlikelytakeatleastsixyearstoscaleitup.Thatisunacceptable.Whentherearepositiveresults,weneedtobereadytolaunchalargecommunitytrialalmostimmediately.Wemadethismistakewithmalecircumcision.IhopewewontmakeitagainwithARV-basedprevention.VaccinesEffectiveARV-basedpreventionwouldbeabigadvance,buttheultimatepreventiontoolwouldbeavaccine.Foryears,somequestionedwhetheritwasevenpossibletopreventacquisitionofHIVwithavaccine.TheresultsfromthetrialinThailandlastyeargaveustheanswer:Itispossible.Weveneverhadthiskindofevidencebefore.ResearchersarenowstudyingtheThaisamplestolookforacorrelateofprotection.Iftheyfoundone,itwouldbeamajorbreakthrough,becauseitwouldhelpusselectthemostpromisingcandidatesforfuturetrials.Thereareotherexcitingdevelopments.Inthepastyear,boththeNIHVaccineResearchCenterandtheInternationalAIDSVaccineInitiativehaveisolatedverypotentantibodiesthatcanneutralizealmosteverystrainofthevirus.Thisisthefirststepinmakingavaccinethatcanstimulatethebodytoproducetheseantibodies.Thesearepromisingideas.Butrightnow,ittakesmuchtoolongtoturnideasintoproducts.Sofar,onlythreevaccineconceptshaveundergoneclinicalefficacytesting.Thefirstwasin2003.ThemostrecentwastheThaitrial,in2009.Inthatspanoftime,nearly17millionpeoplewereinfectedwithHIV.Thatswhyweneedtospeedupthedevelopmentprocessforallnewtools,withoutcompromisingsafetyorthepotentialtogetproductslicensed.Researcherscanhelpbydesigningtrialsthatrequirefewerparticipants,involveearlierreviewsofthedata,andtargetthepopulationswiththehighestincidence.Atthesametime,theagenciesthatregulatetrialscanbemorereceptivetotheseideas,andpharmaceuticalcompaniescandomoretoallowdirectcomparisonsoftheirproducts.SeeingtheImpactVaccines,newdiagnostics,andARV-basedpreventionaresomeofthenewtoolsImexcitedabout.Ofcourse,itsimpossibletoknowwhichofthesemightbreakthrough.Butifwegotjustafewofthem,theimpactwouldbephenomenal.Tounderstandtheimpact,ourfoundationworkedwithresearchersatImperialCollegeinLondon.TheyrancomputermodelsfortwopartsofAfricawheretheepidemiclooksverydifferent.Inbothcases,wefoundthatnewtoolscouldleadtodramaticresults.RuralZimbabweThefirstisruralZimbabwe,wheretheepidemicisgeneralizedacrossalargepartofthepopulation.Wellstartwiththestatusquowhatcouldhappenifwedontdoanymorethanwedotoday.NowIlladdalinetoshowwhatcouldhappenifwescaleupsomeexistinginterventionsthatworkinageneralizedepidemicsuchasmalecircumcision,ARVtreatment,andpreventingmother-to-childtransmission.Asyoucansee,annualnewinfectionscouldbereducedby38percentin2031.Nowletslookatsomenewtools.FirstIlladdARV-basedPrEPandmicrobicides.Thesecouldbringannualnewinfectionsdownbyatotalof53percent.Ifwealsogotapartiallyeffectivevaccineanddeliveredittomostofthepopulation,itcouldcutannualnewinfectionsby90percent.Thesefiguressuggestthatwecouldstopnearly400,000infectionsbetweennowand2031,justinruralZimbabwe.Thatwouldbefantastic.Butthewaywefightageneralizedepidemicisverydifferentfromthewaywefightonethatsconcentratedinaparticularpopulation.Theepidemicisdifferent,soyouneedtoapplythetoolsindifferentways.Thisraisesaquestion:Canwemakeasmuchprogressinplaceswheretheepidemicisconcentrated?UrbanBeninTofindout,letslookaturbanBenin,wheretheepidemicisconcentratedamongsexworkersandtheirclients.AgainIllstartwithwhatcouldhappenifwedontdoanythingnew.NextIlladdafewexistingtoolsthataretargetedforthispopulation,suchaspromotingcondomsamongsexworkers.Scalingtheseupcouldcutannualnewinfectionsby46percentin2031.NowletsseewhathappensifweaddPrEPandmicrobicidesdeliveredtomostsexworkersinthearea.Thatcouldcutannualnewtransmissionsbyatotalof64percent.Finally,letsaddapartiallyeffectivevaccinethatsdeliveredtoa