As the United Nations' special envoy for HIV/AIDS in Africa, Stephen Lewis is Canada's public face in the global fight against AIDS. The 68-year-old is no stranger to controversy, and his performance at the 16th annual International AIDS Conference in Toronto–held August 13 to 18–was no exception. At the conference, which attracted some 31,000 delegates and journalists from around the world, Lewis pointed out that not one pill has made its way to Africa since Canada promised to make cheap generic drugs available (where needed) through its Access to Medicines Regime, passed in 2004. We caught up with Lewis recently to discuss Canada's contribution–or lack thereof–to the fight against HIV/AIDS.
CB: Why aren't Canada's generic HIV/AIDS drugs getting to Africa?
Lewis: Brand-name pharmaceutical companies are making the generic company (Apotex, in this instance), jump through endless hoops, stalling while Apotex tries to negotiate a voluntary license. Apotex doesn't want to have to force the Canadian government to issue a compulsory license, because thatÂ¹s an invitation for brand name companies to fight them all the way.
CB: What needs to happen to get the drugs moving?
Lewis: There are already drugs stockpiled under the agreement between Apotex and Doctors Without Borders. It's the question of getting the drugs released for shipment, and of course, the generics won't get orders of purchase until they say the drugs are available. The Canadian promise has received tremendous publicity, and African nations are bewildered why there haven't been drugs for sale. It'll depend on [federal Health Minister Tony] Clement's review of the legislation. If the review is done within the next three months, drugs could be sent in six months.
CB: Big Pharma tends to get a bad rap when it comes to providing low cost drugs. Is it deserved?
Lewis: It's warranted. I watched 43 pharmaceutical companies endeavor to back the South African government down in its effort to produce generic HIV/AIDS drugs. They ended up with egg on their faces.
CB: Do Canada's brand-name drug compnies need incentives to justify their multi-million-dollar R&D costs?
Lewis: You've got to have enough money to do the research. But it's a bit much to say that selling drugs at low cost to Africa is so going to prejudice a company's financial integrity that they can't do it. The market in Africa is at most 3% of their world market. The impact on their balance sheet is modest, to put it mildly.
CB: What was the most promising scientific development to come out of the conference?
Lewis: One was the very strong concentration on [vaginal] microbicides and the hope that within five to seven years there might be a microbicide that is at least partially effective. The second was the discussion, which was mentioned by [Microsoft chairman] Bill Gates, on pre-exposure prophylaxis, or the possibility that there are some combinations of antiretrovirals, which, if taken by high-risk groups, might stall infection. The third, also the most controversial yet intriguing, was [president-elect of the International AIDS Society] Julio Montaner's proposition that if you had all 40 million people on antiretrovirals, if you could encourage worldwide testing, then the viral load in the blood would be so depleted it would drop to undetectable levels, which means the transmission would be similarly reduced.
CB: How much will it cost globally to fight HIV/AIDS in the future?
Lewis: We spent US$8.3 billion in 2005. According to the financial studies done by UNAIDS and the World Health Organization, we'll need US$15 billion for 2006, US$18 billion for 2007, US$22 billion for 2008 and it's generally agreed that that will rise to US$30 billion a year by 2010, which is when the G8 agreed it would provide universal access, treatment, care and prevention. They committed themselves to an annual expenditure of somewhere between US$22 billion and US$30 billion a year, and we were at US$8.3 billion last year. The shortfall is clearly in the billions, as evidenced by the fact that even the Global Fund to Fight AIDS is short this year and next year, let alone overall. It speaks to the frailty of the commitments which were made at the G8 Summit last year, which are already unravelling.
CB: Why is HIV/AIDS much more than just a health issue?
Lewis: At the moment, AIDS has become the premier development issue internationally. It's not just a health issue. Social and economic indicators are being rolled back in country after country, and whole systems are being thrown into fractured status. There are whole countries fighting for survival. This is an investment in poverty and disease reduction. If you explain that it's the productive generation–the people between the ages of 15 and 49 who are losing their lives and therefore affecting all of the occupations, whether it's nursing, or civil servants or farmers of teachers, it becomes easier to see how entire populations are being ravaged. Inevitably, the help they require will be a huge additional cost for the international community. It's so much more worthwhile to intervene now while the costs can still be absorbed rather than intervene later when the costs will be monumental.
CB: The importance of gender parity in the fight against HIV/AIDS was a major theme at this year's conference. Why is this so important?
Lewis: A number of us are calling for the creation of an international agency for women through the United Nations. It's women in their late teens and twenties and thirties who are infected and die in such disproportionately huge numbers. The need to respond with a sense of overwhelming urgency to the question of gender inequality is paramount. That means laws against sexual violence, coping with property and inheritance rights, economic empowerment and political representation. It's a whole canopy of rights for women.
CB: Your term as UN special envoy is up this December. What's next?
Lewis: I don't know. I'll tell you what I'd like to happen after December 31. I work with a team of four other wonderful people. We've worked as a useful team for the last couple of years and more. I'd love to be able to keep us all together and have some kind of independent entity that can continue to act as an advocacy voice maybe on HIV/AIDS, maybe extending beyond Africa. That would be the best of all possible worlds, but that means raising a significant amount of money, presumably through a foundation somewhere. If that doesn't happen, we'll go our separate ways. I'm also writing a book, and I'll be doing some teaching at McMaster University. Of course, there's the foundation [Lewis's own–established to raise money for community-level treatment and assistance initiatives]. It's become quite a force on its own.