Clinton Presidential Center "Transcript: Press Conference with President Clinton and Stephen Lewis at the XVI International AIDS Conference"

Denise Lawdy: This question is for President Clinton. Today you talked about leadership.

Helene Gayle, MD: Could you just say who you are and who you are representing?

Denise Lawdy: Okay, sorry. Denise Lawdy representing One Hundred Humpney Street. I just wanted to ask you about leadership. That is what your topic was today and you have been a leader in so many capacities, but what has AIDS taught you about leadership that you didn’t know?

President Clinton: I think that it has taught me, more than I once knew, to persist in the face of frustration and failure and it has taught me that leadership is more a state of mind than a place in a hierarchy.

You know, I mentioned a young woman who works for us in advocating that people know their status in Lesotho and if I were to describe to you this person and say she is a very young woman who is a rape victim and she is HIV-positive, living in a poor country with the third highest or fourth highest infection rate in the world, you wouldn’t think of her as a leader. But she will have a bigger impact on that country’s willingness to know their status than I will.

And so actually all of you, the media, the presence of a global media, for all of its frustrations, it has been incredibly empowering. It can be negatively empowering, right, and now we are arguing about whether the Lebanese cease-fire is a good or bad thing, not based on the movement of people on the ground and destruction of missiles or whatever, but based on how people perceive the words that were uttered at the beginning of this by people on both sides. They are frustrated, but what it means is that an ordinary person with a deep conviction can have an incredible impact. And we need more of that insofar as, one of the things that I have learned is that I need to try to find more people like those advocates in Lisutu Forest and use my foundation and my position to lift them up because they can have a bigger impact, I think, in many ways than I can.

Helene Gayle, MD: Next question? Yes right there.

Sasha Wallack: Hi, Sasha Wallack with CNN. President Clinton, you said earlier today that those who advocate for abstinence-based prevention programs, since they don’t understand what women are up against in certain parts of the world, PEPFAR currently allocates a third of all of its funding to abstinence based prevention programs. You also said yesterday that PEPFAR on balance does a tremendous amount of good. Is your foundation currently lobbying U.S. Congress to get that policy reversed?

President Clinton: Well, let me state specifically what my position is, first of all. I am not against, if someone - for religious, philosophical, or practical reasons - who wants to join this fight, believes that abstinence is a critical part of their prevention efforts, I have no problem with that. I think the evidence is that abstinence-only programs are ultimately unsuccessful, even when the most generous reading of the evidence is that aggressive and comprehensive actions programs delay the onset of initial sexual activity and, therefore, at-risk behavior by young people. But if they are abstinence-only, then when the young people do - as eventually they will - engage in sexual activity, they become more likely to be infected than they would have been in a program that had a more comprehensive approach, so that is my position.

I think that abstinence-only is an error. Our experience working with PEPFAR is that actually it operates differently in different countries, maybe depending on who is running it, maybe depending on what the country itself wishes to do. Our experience on balance has been quite positive and I do believe if you take out the 30-percent of the money that has to be spent on that, whether it is good or bad, as I said that varies from country to country, in my experience. The other 70-percent is still a whopping amount of money and more money in bilateral [inaudible] I think than anybody else is giving. And that is why I say I believe they have done on balance more good than harm and most of the people with whom we deal are not unlike people who would be doing this work for any country anywhere at any time.

Now, there have been some particular problems and I think those need to be addressed and I think the more likely thing to happen is that the administration might be persuaded to interpret the guidelines in a way that promote abstinence in the context of more comprehensive prevention policies. That is what I would like to see happen. I have no problem with their fulfilling their convictions, but it shouldn’t be operating in places, for example, where the overwhelming number of girls under 16 that have sex do it because they were forced to.

Helene Gayle, MD: Next question?

Simon [INAUDIBLE]: My name is Simon [Inaudible] for the [Inaudible] in Uganda. To use your own words, President Clinton, you said earlier today that for every dollar we spend, it puts a life at danger. In many African countries which have been a huge beneficiary of the Global Fund which you support greatly, that money has not been used to do exactly as it was meant to do. Many African leaders have used it to fund their campaigns and all that, but you would think your proponents and funders of the Global Fund need to put up more stringent measures to put the mechanism of following the money right from your pocket to go down to exactly do what it was meant to do, rather than ending in the hands of disappointed regimes which use it to entrench themselves while in power. Thank you.

President Clinton: Do you know?

Stephen Lewis: Maybe I can just take a first crack at this. Increasingly, in my observation, the Global Fund follows the money very, very carefully and where there is evidence of inappropriate use of the money, the Global Fund suspends the grants or indeed eliminates the grants. And in your own country of Uganda, the Global Fund suspended the grant when it was felt that there was malfeasance.

I remind you that there was a commission of inquiry. The commission has reported. Cabinet ministers have lost their jobs. Criminal proceedings will probably follow and the Global Fund has been responsible for tracking that money very carefully and then renewing it when they are competent that can be done. The Global Fund has done more on monitoring money than I have seen in many other international organizations, quite frankly. There are other questions about the money getting to people on the ground, but they are monitoring abuse very carefully.

President Clinton: So let me just answer that. First of all, I agree with everything Stephen said. I think that if somebody is stealing the money, they ought to be fired from their government post and they ought to be prosecuted, because even if there is a culture of corruption in a country, they ought to steal somewhere else. You know, we can’t reinvent everything that happens everywhere, but this ought to be off-limits. That is the deal I have where we work, you know, I only go places, we sell this medicine in about 60 countries. We work in 25. The governments ask us to come in, and that is the deal I have.

You know, I haven’t been out of office so long that I don’t actually know personally most of these leaders, and we have good personal relationships. But there is another country I won’t mention where we were asked to come in and I personally called the president because they were paying seven or eight times too much for generic drugs and I said look, you know we can’t do this. This is like every time, if I come in there and work, then every time we buy drugs, I’ll know there are six people dying for every one person I am saving. I can’t do it and nobody will respect me anywhere else in the world. We won’t have integrity. I cannot do it. Whoever is getting this money, can they get it in concrete? I mean, you know, can’t you do something else? I mean, this is ridiculous.

So I think we have to be very hard about this. On the other hand, sir, I would bet that notwithstanding your personal experience, the bigger problem with wasted money or less efficiently spent money is in the absence of effective systems, which we can do something about. I believe most people want to do something about this and most people want to be honest in the expenditure of the money. The question is, can they also be effective? That is why we announced this operations research project here in Toronto, because we not only want the people to be honest. We want them to be effective.

Helene Gayle, MD: A question over here?

Marilyn Chase: A question for President Clinton.

Helene Gayle, MD: Name?

Marilyn Chase: Marilyn Chase from the Wall Street Journal. I would like to ask, with a program heavy on prevention, on remedies for brain drain, and on boosting infrastructure, what have you learned at the conference that may inform future initiatives by your foundation?

President Clinton: Well, I think first of all, a lot of the advocates here are really concerned about what is going to happen to these countries when people need the second-line drugs. That is one thing I learned. We thought we were doing a pretty good job in lowering prices for second line drugs, but we have got to get more drugs in the agreement. We don’t have enough now to really treat people adequately and we have got to find a funding source so I learned that.

Secondly, I learned just how important it was to other people that we try to do something about this resource problem and that at least the NGO community not be a part of it. That is why I devoted so much of it, so much talk in my speech today about it, and frankly what we have done in Kenya was brought to us by the Kenyans. It wasn’t something we just stumbled on. When they asked us to help, they said this is a problem we have. And I think now I want to be more active or, I guess the government word is “pro-active,” in going around and looking at all the countries in which we operate and seeing if there is something else we can do on this front.

I think that all of us who are here - and I talked to Bill and Melinda Gates about this yesterday - we were all sort of hypersensitized to it, not only by the people standing up with the little placards on their shirts saying they needed nurses, but just everybody we have talked to. We want to be part of the solution, not the problem here. I think that is the number one thing that I personally learned that relates directly to the work we do.

Helene Gayle, MD: Thank you. Question there?

Maureen Taylor: Maureen Taylor from the Canadian Broadcasting Corporation. President Clinton and then, perhaps, Mr. Lewis, we have heard a lot about new prevention tools and strategies here this week and I just wonder from each of you, which of those strategies or tools you find hold the most promise and perhaps the most immediate promise?

President Clinton: Okay, I think the most promise of the prevention tools is not the most immediate. That is microbicides. If you have microbicides, particularly those that are undetectable by male sex partners, you are going to empower women to save their own lives and to stop from being infected, and you will then not have to worry about whether they get the drugs preventing mother-to-child transmission if they become pregnant, and anything we can do to empower women in this context is important. They won’t have to have somebody’s permission like you do with a condom, so I think that holds the most promise, but it also is probably five years away from mass distribution.

I think for men, the most promise is in the circumcision study and we just need to follow up on it and then, as I said, it is going to be a total headache trying to figure out how to sell people and do it in a sterile and large-scale way. But although I don’t want it to be a false front either, if you reduce the likelihood of transmission by 60-percent, you’ve still got a 40-percent likelihood from what was left over. So it doesn’t mean you can just go out and behave irresponsibly, but it will save more lives if it works.

And then the third thing that I would say is the prospect that medication can be taken orally in a preventive way, that some of this medication that was developed for treatment can be used for prevention is to me very, very exciting. Now, in the long run, the most promising thing to me, I didn’t personally hear anybody talk about because I’ve only been here for part of the conference, is the collection of 1,000 people, more or less, in that by the Harvard folks who have never lowered their T-cell count and have never needed medication to stay alive, either because their general immune system or their specific immune response to the virus has kept them healthy. That is less than 1-percent of the total people ever infected, considerably less than 1-percent, but given the sequency in the human genome, and our capacity to study that, this to me offers hope, maybe even for a cure, and certainly for a vaccine.

That is a way long way away, but the fact that we now have 1,000 people in two different groups should be enough to actually do some serious science here and get to the bottom of this.

Stephen Lewis: I agree with everything the president says. I would add only the footnote that the search for a vaccine as such must continue to be followed with tremendous devotion and the increased amount of money and the numbers of vaccine products in the pipeline and the sense of momentum building is really important. It is probably at least 10 years off, but ultimately, as things now stand, it is the only cure for the epidemic.

Helene Gayle, MD: I will just take the moderator’s prerogative to remember that only one in five people have access to the things that we have available today, so I think we also have to remember that while we are continuing to look for new approaches, there is a lot more that we could do today. I will take this question over there.

Joe Decapo: Joe Decapo of Voice of America. This question for Mr. Clinton and if Mr. Lewis would like to comment, what more do you feel the U.S. government should or could be doing in the fight against HIV/AIDS?

President Clinton: I actually believe, as you know, I said yesterday my personal experience with the PEPFAR people with whom we work on the ground in the countries where we both work has been good. For the last couple of years, the Congress has appropriated more money than the administration has asked for, for the Global Fund. That is good, and a departure and I hope that will continue on a bipartisan basis.

I think because we know when we kick in more money to the Global Fund, it leverages funds. People give more. Second thing is, I would like to see - I don’t ask them to give up their commitment to abstinence but I think that it ought to be part of a more comprehensive prevention strategy and not abstinence-only so it doesn’t necessarily trip over or undermine other good works that are being done, particularly with people in difficult populations in the country.

The third thing I think we need to take another look at based on my experience with Our Neighborhood Clinic in Harlem is that we have some discrete populations in the United States, including young women of color, where the infection rates are creeping up again because of the unique circumstances of their lives and I think we need to highlight that. I noticed we had some African-American leaders here, Julian Bond and Jesse Jackson among others came, and they talked about this. We need to not forget that we have to set a good example in the United States to keep lowering our incidence.

Sabin Russell: Sabin Russell with the San Francisco Chronicle. Mr. President, I was wondering, with your experience now with AIDS in the last several years, have you had any regrets about the policy of forbidding federal funding for needle exchange, and if your views have changed on needle exchange and what would they be now?

President Clinton: Yeah, I think I was wrong. I mean, I think the evidence shows that it doesn’t lead to increased drug use and what I advocated was that we allow basically local option so we didn’t mandate it, but we didn’t forbid it altogether but we permitted local option. And as you know, you probably remember giving the prevailing political climate in the United States in the 1990s which a lot of people conveniently forget when they ask me why I didn’t do this, that or the other thing, I was excoriated for allowing local option.

But I don’t think, you know, this is to me, it is easy to say when you get out of office that political consideration should never play a role and you should never give an inch to your opponent and all that, but that is not the way the world works. But the fact is we need to create a climate here in which policymakers in the United States and elsewhere are free to act upon the evidence, whether it is AIDS, global warming, or whatever. Whenever people are prohibited from acting on the evidence in any major area, you are almost certainly going to get bad decisions with bad consequences.

Helene Gayle, MD: We have one more question there.

Joan Yarber-Gray: Joan Yarber-Gray, I’m with the Intense Victory in Irvine, California. Mr. President, those of us who have HIV are very encouraged about your taking a stand with us, and we thank you for that. Can you assure us that you are in this cause for the long haul?

President Clinton: Yes ma’am. You know, even my worst critics never accused me of being a quitter. I tend to be a sticker. That is when, you know, sometimes it is a fault but nonetheless it was the way I was raised. I can’t conceive of anything that would divert me from this commitment short of a life-threatening illness or success, so if Father Time doesn’t get me, I’ll stay here until we turn it around.

Helene Gayle, MD: Thank you. I was going to take a couple of more questions, first here.

Female Speaker: President Clinton, my name is [Inaudible]. I am also from Nigeria. I want to know what PEPFAR is going to do to save millions of children infected and affected by HIV. It appears there isn’t any sign or effective of pediatric care [inaudible].

President Clinton: Of what?

Helene Gayle, MD: Pediatric antiretrovirals.

President Clinton: Yes, first of all, I think you asked about PEPFAR. I don’t know. I can’t say what they are going to do but I can say what I am going to do. I am committed to working with others who are coming up with funds for this to do whatever is necessary to get the pediatric medicine to every child who needs it. And in Nigeria, we should actually be able to do it in fairly short order, at least in the urban centers.

Now, I have been despairing of this. I literally raised, I understood why the governments didn’t spend money on pediatric AIDS medicine in the beginning. It was more expensive and wide swaths of young adults were dying but now we have got the price down under $200 dollars and now we have this unitary commitment, you know, from France, Chile, Norway, and others, to do something about it. So now it is just going to be question of going out and training people and putting the systems in place and executing. Pediatric treatment has lagged behind other treatment woefully for the last few years. Given the change in funding priorities, it might actually jump ahead in the next two years if we can set up the system to do it, and that is one of the commitments that I have.

Mark Hayward: President Clinton, my name is Mark Hayward from the Treatment Action Campaign in South Africa. In South Africa, 800 people are dying a day. I just wonder of HIV, whether you think the South African government is providing enough leadership on HIV and what it should be doing, and what people like yourselves can do to help people like us to make sure that the response meets the need that exists in South Africa? Thank you.

President Clinton: You know, we helped the South African government to develop its plan and they didn’t really need us on the drugs because one of our drug partners is South African, so they can get the same prices we can. That is the deal we made both for South Africa and India when we went to work with those companies. But you have several urban areas where the treatment has scaled up a lot in recent years.

My impression is that in the high-incidence rural areas, you still don’t have the delivery networks out there necessary to make the medicine work and do the care and treatment that is needed to be done. So that, I think, is most necessary now is to reemphasize that and you know, I would be glad to do whatever I could if asked by either the - Now, the federal government, as you know, has allowed the states, the provincial governments, to actually do some of this work on their own and to me, that is the next big frontier there. We have got to have same sort of network of availability for care and treatment. In rural South Africa, we do in those big urban centers that are so impressive. Then, you have got another problem which is that South Africa keeps filling up with people from other places who are HIV positive because of political upheavals elsewhere.

I don’t know what the answer to that is but I would be glad to do whatever I can to help.

Chris Norwood: Mr. President, even in the United States, we have hundreds of thousands of AIDS orphans and HIV affected children. In New York City now, a total of 245,000 children are living with their grandparents, about a third of them who are AIDS orphans. We have no national policy in our own country. Even until Title I, which is the main support program, you are not allowed to counsel the uninfected children. We don’t have regular support services for them.

We don’t have foundations behind them. They are not a cause in our own nation and I would like you to comment on that and how this has happened. Oh, I should say Chris Norwood, the Bronx.

President Clinton: I think it happened more by accident than anything else. I think it happened because those kids fell through the cracks because most policymakers thought that the AIDS problem was over in America and I think that you and others, and I would be glad to advocate for a more adequate policy.

Let me just mention something else that has become a really big problem in America. As people with HIV in America live instead of die, we have more and more people. We pay $10,000 dollars a person a year for the medicine. For the same medicine, Canada and Europe pay about $3,500 dollars for and I won’t go into that policy and what I think of it, but anyway it is there and I did it, too, because I wanted the people to get a life.

We have an increasing number of people in America who are HIV-positive, who have AIDS, who need the medicine, who have gone above the income line necessary to get covered by medicaid and don’t have health insurance on the job so this is a related matter. I think one of the things for the Americans that are here is that we should advocate that Medicaid cover people in the work force who are not eligible who don’t have other sources of health insurance and the same way we did for disabled people in 2000.

We had a dramatic impact on the ability of people with disabilities to go into the work force by saying they could keep their Medicaid coverage and take a job, even a part-time job, once we have proved, first of all, the taxpayers are always better off, people that are working on Medicaid. But this is a terrible disabling problem for people with HIV and I think it is just like the orphans problem.

I think somewhere along the way, Congress turned its attention to the overseas problem, which I applaud because it is so much greater, but they sort of assumed everything at home was all right. It is not all right, and for some populations it is getting worse. So if you could give me what you think ought to be done, I would be glad to try to see what I could do.

Helene Gayle, MD: All right, one last, really, last question, up front, and President Clinton has stretched his time a little already.

Rehan Hussein: Hello, Mr. President. I am Rehan Hussein from [Inaudible] from Pakistan. We have our, we actually promote peace and universal brotherhood and the fight against IV use. What are the resources we can utilize from in your foundation in Pakistan to increase the education level so the IV use could be reduced and the AIDS could becontrolled in that third part of the world? I appreciate. Thank you.

President Clinton: Well, sir, I can give you a very brief answer and then if you want to take one more, you can. I signed an agreement with the Pakistani government recently. You may know I came over there actually while the demonstrations were going on in the aftermath of the Danish cartoon controversy. I flew in to another hornet’s nest and signed an AIDS agreement and Pakistan was the first non-African Muslim country to sign a public agreement with me saying, and that in itself was a big step forward on national television, you know. We are out of the denial business. We are out of the stigma business. We are dealing with this so I think that we are off to a decent start. And I would like to urge you to, before you leave, you come out here, do you have a card or some way our people can get in touch with you? We would like to work with you, because we are going to do education, prevention, medicine, the whole nine yards. We are going to be a good partner for Pakistan because they deserve a big pat on the back for saying that Islam does not require denial in dealing with AIDS.

Helene Gayle, MD: Okay, I think this is really the last question.

Anne-Marie Christensen: Anne-Marie Christensen from the Global Health Counsel AIDS Link. Both of you, Stephen Lewis and President Clinton, your feelings on the U.S. anti-prostitution pledge and what would your foundation or what would you do to try to overturn that?

Stephen Lewis: I am not sure what I could possibly do to try to overturn it, but obviously those who are working with the high-risk groups, and working with prostitutes, commercial sex workers, find the requirement offensive and inappropriate and you will know that some governments have even turned back money. The government of Brazil turned back $40 million dollars rather than submit to the requirement.

These gag orders, these presumptions on the part of the administration to impose policies on other countries which must flow from within their own prevention apparatus, from their own priorities around HIV and AIDS, I think that has to come to an end. These conditionalities simply never work. They are usually more destructive than they are in any way effective, and this is particularly the case.

President Clinton: You know, I’m not so sure this anti-prostitution provision hasn’t caused more practical trouble than set aside of money for abstinence, because I just don’t see how you can go to a country that has a substantial number of sex workers and not deal with the sex workers. And you know, I understand, you know, I wish they would just amend the law and say we disapprove of prostitution but here is the money, go save lives.

I know that probably won’t happen but that is what I wish would happen. I just don’t see how we can have a practically effective program if we say we are disapproving of prostitution. What does that got to do with the fact that this is one of the main transfers of this virus? And they are people too, and they deserve a chance to be empowered to save their lives and to keep from infecting others.

I just think, you know, to me it is a no-brainer. I don’t know whether we can change this but if I were, like on your side, just being primarily an advocate, particularly in America, America’s policy here, I think this is a real problem. You can say, well, I’m morally bound to advocate for abstinence, but I don’t think you can morally justify if say you are pro-life, discounting the lives of people who have made decisions before they ever met you or got a hold of your checkbook to be sex workers because that is the way they live and for some of them the only way they can make a life. And I just think it needs to change and I am going to do what I can to change it. We can’t be effective if we don’t deal with it in places where it is a problem. We can’t.

Helene Gayle, MD: Thank you very much and thanks for extending your time. Thanks to both of these gentlemen for their leadership and for their time. Thank you.
[Applause]