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2010 International AIDS conference(2010年国际艾滋病会议英文版).doc

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2010 International AIDS conference(2010年国际艾滋病会议英文版).doc

July19,2010PreparedRemarksbyBillGates,CochairandTrusteeWatchavideoofthespeechThankyou,Vuyiseka,forthatkindintroduction.IalsowanttothankPresidentClintonfortheinspiringmessagehedeliveredthismorning.Itsanhonortospeakwithallofyoutoday.Asyousawinthevideo,theworldhasmadeamazingprogressinthefightagainstHIV.Yetwealsohavetorecognizethatthesearetoughtimesforallofuswhoarepassionateaboutthiscause.Economicturbulencehasdrivenupgovernmentdeficits,andsomecountrieshaverespondedbyfreezingorevenreducingtheirinvestmentsinglobalhealth.Thisisachallengeweallface.Butitdoesnotneedtodefineourtime.Iamheretodaybecause,whenitcomestothefightagainstAIDS,Iamstillanoptimist.Thepast10yearsareatimeofremarkableprogress.Todaymorethan5millionpeoplearereceivingantiretroviraltreatment,upfromfewerthanhalfamillionjustsixyearsago.Since2001,therateofnewHIVinfectionshasfallen17percent.Thoseofyouinthisroomhelpedmakethisprogresspossible.Thescientistsmadeprogressonnewtoolstofightthedisease.Thecommunityworkersandcliniciansdrovepreventioncampaigns.Theadvocatesarguedformorefunding–andtheworldrespondedbyaddingmoneyforthiscausefasterthananyotherhealthprobleminhistory.TheGlobalFundhasbeenafantasticvehicleformakingsurethisfundinghelpsthepeoplewhohavethegreatestneed.Allofyoucametogethertoovercomehugeobstacles.Twodecadesago,theskepticssaidWecantmakedrugstotreatavirus.Butyoupersisted–andnowtheycan.ThentheskepticssaidWecanmakethedrugs,butwecantmakethemcheapenough.Butyoukeptpushing–andnowtheydo.ThentheskepticssaidWecanmakethedrugscheaply,butwedontknowwhetherpeoplewillsticktotheregimen.Butyouinsisted–andnowtheyknow.TodaytheskepticslookatthestrugglingeconomyandsayWecantbeatAIDSunlesswecantreatmorepeople.Andwecanttreatmorepeoplewithoutmoremoney.Soifwedontraisemoremoneyfortreatment,welllosethefightagainstAIDS.Itshopeless.Theskepticshaveapoint.Thisisatougheconomicenvironment.Rightnowthereisntenoughmoneytosimplytreatourwayoutofthisepidemic.Ifwekeepspendingourresourcesinexactlythesamewaywedotoday,wewillfallfurtherbehindinourabilitytotreateveryone.ThatswhyIwanttomakethecasetodaythat,evenasweadvocateformorefunding,wecandomoretogetthemostbenefitfromeachdollaroffundingandeveryounceofeffort.Ifyoupushforanewfocusonefficiency–intreatmentandprevention–andalsopushtocreatenewpreventiontools,wecandrivedownthenumberofnewinfectionsdramaticallyandstartwritingthestoryoftheendofAIDS.ScalingupexistingtoolsMalecircumcisionOurfirsttaskistoscaleupthepreventioneffortsthatarecheap,effective,andeasytoapply.Someofthese–especiallymalecircumcisionandpreventingmothertochildtransmission–aresocheap,andsoeffective,thatinendemiccountriesitismoreexpensivenottopursuethem.Inasinglemonthlastyear,36,000meninKenyawerecircumcised,atatotalcosttothegovernmentof1.4million.Ifthesemenhadnotbeencircumcised,andeventuallybecameinfectedwithHIVattheprevailingrateforuncircumcisedmalesinKenya,treatingthemwouldhavecostthegovernmentnearly10timesasmuch.Thatsanastonishingfinancialreturn–butitsnotjustsavingmoneyitssavinglives.IhavetoadmitWhenitcomestocircumcision,Iusedtobeoneoftheskeptics.IthoughtSure,itreducestransmissionbynearly60percent.Buttheresnowaythatlargenumbersofmenwillsignupforit.ImgladtosayIwaswrong.Whereverthereareclinicsavailable,menarevolunteeringtobecircumcisedinfargreaternumbersthanIeverexpected.Iwouldliketoshowyouashortvideoaboutoneofthem,ayoungmanfromSwaziland.LastDecember,IwenttoSouthAfricatoseeformyselfhowenthusiasticallymenareembracingcircumcision.IvisitedaclinicinthetownshipofOrangeFarmthatservesmorethan750meneverymonth.Imetafewofthem,andtheywereallthrilledaboutgettingcircumcised.Theoneswhohadalreadyundergonetheproceduresaiditmadeiteasierforthemtouseacondom.Ialsometasurgeon–atirelessyoungwomannamedJosephineOtchereDarko.Shetoldmeshehadperformed67circumcisionsthatday.Iaskedher,WhendoyoustopShesaidWhenwearedone.RightinterventionfortherightpopulationMalecircumcisionisanamazingadvanceinprevention.Ifwehadavaccinethatwasaseffective,wewoulddoeverythinginourpowertodeliverittoeverypersonwhocouldbenefitfromit.Anditisreachingmanymen–butnotnearlyenoughofthem.Inthefouryearssincewelearnedaboutitsbenefits,only150,000meninsubSaharanAfricahavebeencircumcised–outof41millionwhoneedit.Thatsinexcusable.Countriesneedtomakethisapriorityintheirpoliciesandintheirfunding.Wehavetodoafarbetterjobofscalingupinterventionsthatareproventowork,assoonastheyareproventowork.Wehaveseensimilargapswithotherpreventionefforts,includingcounselingsexworkersandofferingdrugtreatmentandneedleexchangesfordrugusers.Therearemanyreasonsforthesefailures.Forinstance,moreaidfromdonorcountriesneedstoreachthepeopleitsintendedtohelp.ButthereisonereasonthatespeciallydeservesourattentionManypreventioneffortsarenottargetingthecommunitieswheretransmissionisthehighest.AccordingtotheKnowYourEpidemicreportpublishedthisyearbyUNAIDS,10percentofHIVinfectionsinKenyaareduetosexbetweenmen.Insomecoastalregions,itcouldbeashighas20percent.YetmostdistrictsinKenyahavenopreventionprogramsforthesemen.InRussia,theepidemicisconcentratedamonginjectingdrugusers.Inareaswheretheyreceivedcleanneedles,testing,andotherservices,theinfectionraterose15percentoverfiveyears.Wheretheydidnt,itskyrocketed105percent.Clearly,theseserviceswork.YetRussiahasguttedthem–cutthebudgettozero–andshiftedthemoneyintoprogramsforthegeneralpopulation.WhyTheproblemisnotalackofdata.UNAIDScanhelpanyendemiccountryanalyzeinformationtounderstandwhichpopulationsareatthegreatestrisk.Theproblemisthatmanycountriesarenotusingthisdatatomaketheirfundingdecisions.Instead,politiciansaremakingthembasedonfearandstigma.Theydontwanttoassociatethemselveswithpeoplewhoengageinbehaviorthatmakesthemuncomfortable.AsPresidentClintonsaidthismorning,everydollarwastedputsalifeatrisk.Ifyoureafraidtomatchyourpreventioneffortstotherightpopulations,thenyourewastingmoney–andthatcostslives.TreatmentaspreventionThereisoneotherpreventiontechniquewheregreaterefficiencywillmakeabigimpactantiretroviralARVtreatment.WenowknowthatputtingpeopleonARVsmakesthemfarlesslikelytopassthevirusontoothers.Treatmentisprevention.ButthisraisesacrucialquestionHowcanwegetthemostpreventionbenefitfromthetreatmentwereprovidingWhenyouhaveahigherCD4countandyourviralloadislow,youfeelhealthyandaremoresexuallyactive.AsyourCD4countdrops,yourviralloadspikes,andyoubecomelessactive,butyoumaybemoreinfectious.WhenshouldyoustarttreatmentArecentstudyinvolvingsevenAfricancountriesfoundanintriguinganswerPeoplewithCD4countsbelow200weresixtimesmorelikelythanhealthierpeopletotransmitthevirus.Thiswastrueevenafteraccountingforthefactthattheywerelesssexuallyactive.Sowhetheryourgoalistomaximizethepreventivebenefitsoftreatmentortosaveasmanylivesaspossible,youshouldfocusfirstontreatingeveryonewithaCD4countbelow200.ThisgivesusvitalinformationforthefightagainstHIV.Ithelpsusseewhereourtreatmenteffortscanbetargetedsotheymakethebiggestimpactforprevention.Atthesametime,wehavetofaceaharshtruthBecauseofthevirusslonglatencyperiod,expandingourpreventioneffortswontdrivedownthenumberofdeathsforadecadeormore.Evenasweactnowtopreventfutureinfections,theonlywaytosavemorelivesimmediatelyistoexpandthenumberofpeoplereceivingtreatment.Unfortunately,thecurrenthighcostoftreatmentmeanswecannottreateveryonewhoneedsit.IfyouhaveAIDS,andyougotoahealthclinic,youshouldneverhavetohearsomeonesayImsorry.Youcanthavethedrugsthatwouldsaveyourlife.Wedonthavethemoney.Whenfundingislimited,therearetwowaystostopturningpeopleawayandstartexpandingtreatmentYoucanreducethecostofthedrugsoryoucanreducethecostofdeliveringthemtopatients.Thecheapestfirstlinedrugsnowcostlessthan100peryear.Weneedtokeepworkingtoreducethecostoftheseandothertreatmentdrugs,especiallythemoreeffectiveregimesthatcontaintenofovir.Butunfortunately,noneofthedrugsarelikelytogetalotcheaperinthenextfewyears.Thatleavesoneoptionforexpandingtreatmentnowdrivingdownthecostofdelivery.Weareseeingexcitingevidencethatthisispossible.In2006,PEPFARstudiedanumberofitssitesinBotswanaandreporteddeliverycostsofnearly1,000perpatientperyear.Twoyearslater,thecostwasdownto245.InNigeria,itdroppedfrom2,000to280–areductionofnearly90percent.Someofthesesavingscomefromminimizingpersonnelcosts.Asasiteseesmorepatients,thestaffneedslesstraining.Sometaskscanbeshiftedfromdoctorstonurses,orfromnursestoassistants.Someclinicsalsocutcostsbysimplifyingtheirtestingregimes.TheymayrunfewerCD4countsorchecklessoftenfortoxicity.Todrivedownthecostofdeliveringtreatment,weneedtodobothminimizepersonnelcostsandsimplifythetestingregimes.Butthebestpracticesarentbeingmeasuredorshared.Isthereamoreexpensivedrugthatactuallysavesmoney,becauseitrequireslessmonitoringorcanbedeliveredbylowerpaidstaffWedontknow.Weneedtoidentifythemostefficientmodelsandthenmakesureeveryclinicfollowsthem.Ifwecouldlimitthedeliveryandadministrativecoststonomorethantwicethecostofthedrugsthemselves,thenthetotalcostoftreatmentwouldbeabout300perpatientperyear.Forthesameamountofmoneywespendtoday,wecouldtreatmorethantwiceasmanypeople.ARVtreatmentandmalecircumcisionaretwopowerful,proventoolsforprevention,andweshouldscalethemupasquicklyaspossible.Anothersetofinterventions–thosedesignedtopersuadepeopletochangeriskybehavior–havehadsuccessincertainregionswithcertainpopulations.Forinstance,ourfoundationsupportseffortsinIndiatoencouragesexworkersandtheirclientstousecondoms,andtheresultshavebeenimpressive.Now,aswescaleupvariousmethodsofbehaviorchangeinAfrica,weneedtomeasuretheirimpactsoweknowwhichonesmakethebiggestdifference.Thepayoffofscalingupexistingtoolscouldbehuge.Ifweidentifythemosteffectivepreventionefforts,andthenexpandaccesstothem,wecanpreventmillionsofdeaths.Thisisgoodnews–butitisnotgoodenough.Evenifwedideverythingpossiblewiththetoolswehavetoday,themostoptimisticpredictionssuggestthattheywouldonlyreducenewinfectionsbyhalf.Millionsofpeoplewouldcontinuetotransmitthevirus,andwewouldneverhaveenoughmoneytotreateveryonewhoneededit.DevelopingnewtoolsFortunately,thereisnoreasontoassumethatinthefuturewewillbelimitedtofightingHIVwiththetoolswehavetoday.Wecandobetter.Innovationsinbasicscience,diagnostics,computermodeling,andourunderstandingofthevirusitselfwillmakeitpossibletocreatenewweaponsforthefightagainstAIDS,preventevenmoreinfections,andsaveevenmorelives.LetmedescribesomeoftheworkthatImespeciallyexcitedabout.ARVbasedpreventionOnepromisingareaisARVbasedpreventionpills,injections,andgelsthatcontainthedrugsnowusedfortreatment.Fouryearsago,whenMelindaandIspokeattheInternationalAIDSConferenceinToronto,wecalledARVbasedmicrobicidesthenextbigadvanceinthefightagainstHIV.TheearlytrialresultsofgelsthatdidnotcontainARVingredientsfailed.ButwearestillveryoptimisticaboutthelongtermpotentialofmicrobicidesandotherformsofARVbasedprevention.ThenewgenerationofmicrobicidescurrentlybeingtestedismorelikelytosucceedbecausetheycontainARVs.Theresultsfromthefirstofthesetrials,CAPRISA,willbeannouncedtomorrow.Researchersarealsobuildingonimportantlessonsfromtheearlymicrobicidetrials.Theynowunderstandthatweneedawiderangeofproducts,becausepeoplehaveawiderangeofneeds.Forinstance,somewomencantorwontuseageleveryday.Soresearchersarestudyinglongactingproductsthatcanbedeliveredbyvaginalringsthatstayinplaceforamonthormore.Efficacytrialsononeringarescheduledtobeginnextyear.Ifitworks,itcouldhelpovercomesomeoftheadherenceproblemsweveseeninearlymicrobicidetrials.Anotherpromisingareaofresearchispreexposureprophylaxis,orPrEP–adailypilloralonglastinginjection.Thiswouldputthepowerofpreventionintothehandsofwomenwhocantusemicrobicides,andpeopleathighrisk,suchasinjectingdrugusersandmenwhohavesexwithmen.Laterthisyear,researchersinLondonwillbeginanewstudyoftheoraltreatmentdrugrilpivirine,toseeifitcanbeusedasalonglastinginjectionforPrEP.Whenwegetresultsfromthesestudies,weshouldbereadytoactrightaway.Butrightnow,werenotready.SupposewegotpositiveresultsonanARVbasedpreventiontooltoday.Betweengainingregulatoryapprovals,raisingmoney,trainingthestaff,andotheractivities,usingthenormalapproachwouldlikelytakeatleastsixyearstoscaleitup.Thatisunacceptable.Whentherearepositiveresults,weneedtobereadytolaunchalargecommunitytrialalmostimmediately.Wemadethismistakewithmalecircumcision.IhopewewontmakeitagainwithARVbasedprevention.VaccinesEffectiveARVbasedpreventionwouldbeabigadvance,buttheultimatepreventiontoolwouldbeavaccine.Foryears,somequestionedwhetheritwasevenpossibletopreventacquisitionofHIVwithavaccine.TheresultsfromthetrialinThailandlastyeargaveustheanswerItispossible.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,andARVbasedpreventionaresomeofthenewtoolsImexcitedabout.Ofcourse,itsimpossibletoknowwhichofthesemightbreakthrough.Butifwegotjustafewofthem,theimpactwouldbephenomenal.Tounderstandtheimpact,ourfoundationworkedwithresearchersatImperialCollegeinLondon.TheyrancomputermodelsfortwopartsofAfricawheretheepidemiclooksverydifferent.Inbothcases,wefoundthatnewtoolscouldleadtodramaticresults.RuralZimbabweThefirstisruralZimbabwe,wheretheepidemicisgeneralizedacrossalargepartofthepopulation.Wellstartwiththestatusquo–whatcouldhappenifwedontdoanymorethanwedotoday.NowIlladdalinetoshowwhatcouldhappenifwescaleupsomeexistinginterventionsthatworkinageneralizedepidemic–suchasmalecircumcision,ARVtreatment,andpreventingmothertochildtransmission.Asyoucansee,annualnewinfectionscouldbereducedby38percentin2031.Nowletslookatsomenewtools.FirstIlladdARVbasedPrEPandmicrobicides.Thesecouldbringannualnewinfectionsdownbyatotalof53percent.Ifwealsogotapartiallyeffectivevaccineanddeliveredittomostofthepopulation,itcouldcutannualnewinfectionsby90percent.Thesefiguressuggestthatwecouldstopnearly400,000infectionsbetweennowand2031,justinruralZimbabwe.Thatwouldbefantastic.Butthewaywefightageneralizedepidemicisverydifferentfromthewaywefightonethatsconcentratedinaparticularpopulation.Theepidemicisdifferent,soyouneedtoapplythetoolsindifferentways.ThisraisesaquestionCanwemakeasmuchprogressinplaceswheretheepidemicisconcentratedUrbanBeninTofindout,letslookaturbanBenin,wheretheepidemicisconcentratedamongsexworkersandtheirclients.AgainIllstartwithwhatcouldhappenifwedontdoanythingnew.NextIlladdafewexistingtoolsthataretargetedforthispopulation,suchaspromotingcondomsamongsexworkers.Scalingtheseupcouldcutannualnewinfectionsby46percentin2031.NowletsseewhathappensifweaddPrEPandmicrobicidesdeliveredtomostsexworkersinthearea.Thatcouldcutannualnewtransmissionsbyatotalof64percent.Finally,letsaddapartiallyeffectivevaccinethatsdeliveredtoabouthalfofthepopulation.Thatcouldreduceannualnewinfectionsby90percent,avertingnearly66,000newinfectionsbetweennowand2031.Thesefindingsmakemeveryoptimistic.Inbothcountries,whethertheepidemicisconcentratedorgeneralized,currentandnewtoolstogethercouldcutannualnewinfectionsby90percentin20years.Othercountriesmightneeddifferentinterventionstoachievesuchdramaticresults.Butthesenumbersshowuswhatspossible.ConclusionIfthenumbersfellthisfarinthehardesthitcountries,itwouldchangethefaceofAIDS.Newcaseswouldplummet.Everypersonwhoissickcouldbetreated.ThecontrolofHIVwouldstandalongsidetheeradicationofsmallpoxasoneofthegreatpublichealthvictoriesinhistory.Thisistheopportunitywehave.Weareataturningpoint.Wecankeepdoingthingstheoldway,andkeepgettingthesameresult.Orwecanchange.Wecanpushourselvestomakethemostofeverydollaroffundingandeveryounceofefforttoidentifythemosteffectivewaystosavelives,andtosharewhatwelearnaswidelyaspossible.Ifwedothat,wewillhavematchedourcompassionwiththegrowingcapacitiesofscience,andwewillstarttowritethestoryoftheendofAIDS.Thankyou.http//www.gatesfoundation.org/speechescommentary/Pages/billgates2010internationalaidsconference.aspxBillMelindaGatesFoundationGuidedbythebeliefthateverylifehasequalvalue,theBillMelindaGatesFoundationworkstohelpallpeopleleadhealthy,productivelives.Indevelopingcountries,itfocusesonimprovingpeopleshealthandgivingthemthechancetoliftthemselvesoutofhungerandextremepoverty.IntheUnitedStates,itseekstoensurethatallpeopleespeciallythosewiththefewestresourceshaveaccesstotheopportunitiestheyneedtosucceedinschoolandlife.BasedinSeattle,Washington,thefoundationisledbyCEOJeffRaikesandCochairWilliamH.GatesSr.,underthedirectionofBillandMelindaGatesandWarrenBuffett.

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