Katherine Marshall
World Bank, USA
  

I am honored to be part of the remarkable spirit and tradition of Sant�Egidio�s international gathering for peace. This meeting promises to be, once again, an intellectual as well as a spiritual fest, a place for dialogue and contemplation about the most critical issues facing humanity.

This year�s overarching theme is �Religions and Cultures: the Courage of A New Humanism.� Surely any �new humanism� must entail a central and dynamic focus on HIV/AIDS. Among the countless urgent global problems today, none is so demanding, yet also so elusive and complex, as the HIV/AIDS pandemic. Treacherous and difficult technical and ethical issues abound around HIV/AIDS, but at the center is the issue of priority: this is a calamity for the global community without rival, yet its treatment in many if not most global fora too rarely reflects this urgency and centrality.

Bombarded by HIV statistics, many leaders and institutions often appear numb to the ever-higher numbers that tell of people infected and dying. Are the horrific realities of HIV/AIDS becoming mundane and acceptable? Earlier this summer at the Parliament of World Religions meeting in Barcelona, it was disheartening how few leaders, who represented so many faith institutions, attended the handful of sessions dedicated to HIV/AIDS and how seldom the issue came up in plenary discussions. Hopefully, those gathered here, who are so committed to social justice, can bring new vigor and focus to this epic battle.

Let us never forget that:

� AIDS is a human crisis of unimaginable proportions. Over 20 million people have already died of AIDS. Over 40 million more are infected. Each day brings over 18,000 new infections, more than 95% of them in developing countries. It is estimated that 75 million people will be infected worldwide by 2010 and 100 million by 2020�if there is no effective intervention. Millions of children have lost parents to AIDS.

� AIDS is a major development problem. HIV/AIDS turns back the clock on social progress by undermining social infrastructure and ravaging productive individuals (nurses, teachers, and farmers included) and communities. The AIDS pandemic presents the greatest test of the new millennium, eroding the social fabric of so many communities. It challenges the hope that must lie at the heart of efforts to build better lives.

� HIV/AIDS fosters instability and threatens peace and security, with repercussions at community, national, regional and global levels.

Statistics and human stories paint a grim picture and underpin the sense of urgency which we must bring to our partnerships to combat this pandemic. Notwithstanding action and rhetoric about partnerships, collaboration, and AIDS education, though, we need to recognize squarely the unfortunate reality that an accelerating number of people each day are newly infected with HIV, and too few of those already infected have access to the medicines and holistic treatment they need to live productive lives. The pandemic challenges us all to put our best selves, resources, and creativity forward to find ways to halt the spread of HIV and to provide to sick people the life-saving medicines they desperately need.

My remarks today focus on success factors in confronting HIV/AIDS, the central importance and demands of partnerships and the roles of faith communities; access and treatment issues; gender dimensions of HIV/AIDS; and some of the ethical challenges that this pandemic presents. I hope to leave you with a sense of the critical importance of public, private, and civil society partnerships, and what we need to do if we are to make these partnerships work well.

Looking to Success � Three Country Stories

The story of HIV/AIDS holds some important beacons of hope, prominent among them the quite different stories of how three countries have succeeded, at a national level, in changing the grim path of the pandemic. In Uganda, Senegal and Thailand, multi-sector alliances have mobilized formidable responses against HIV/AIDS. It is useful to probe deeper to understand why these countries stand out and what we can learn from their experience.

Uganda�s response to HIV/AIDS is almost unique in its bold, consistent and high level support for multi-constituency efforts. Uganda was the first African country to reverse the AIDS epidemic by reducing the number of new infections. The ingredients of success turn centrally on courageous leadership, of Uganda�s President but also champions and leaders throughout the society. Leadership allowed open discussion of sensitive subjects without confrontations between different groups around differing values, forthright examination of unexpected realities, appreciation of complexity and differences, creativity in trying new solutions, and new kinds of partnerships and alliances, often among unlikely fellows. The role of faith communities has had special importance: from the start, the Ugandan government sought a partnership with religious communities in response to AIDS, with a special appeal to church leaders.

President Museveni also appreciated well the power and importance of communication and information, employing both traditional and modern tools. He called for an assault-like public information campaign on HIV/AIDS, aimed at building consensus on a national response. The National AIDS Prevention and Control Committee�a precursor to the Uganda AIDS Commission established several years later�included government, non governmental organizations, and faith leaders, and was charged with launching the public debate on HIV/AIDS. It targeted NGOs and faith-based organizations as creative and respected change agents, sensitive to local conditions and able to engage a wide range of stakeholders not traditionally involved in health issues, including politicians, community leaders, educators, students, administrators, commercial traders, and sex workers. The media was enlisted as an important partner in the fight against HIV/AIDS, as part of a broader national process of opening up public debate and transparency.

Religious leaders and faith communities have played a central role in Uganda�s efforts to combat HIV/AIDS. In the epidemic�s early days, when the government focused on prevention, faith-based health services recognized that patient care and counseling were woefully neglected. In the intervening years, faith-based groups and a host of volunteers, many trained by religious organizations, have provided counseling, home-based care, care of orphans and vulnerable children and, increasingly, antiretroviral (ARV) drug therapy. Partnerships with faith-based organizations have permeated virtually every aspect of Uganda�s HIV/AIDS program since its inception. Moreover, many of Uganda�s key HIV/AIDS organizations, while not directly faith based, have long-standing and deeply rooted partnerships with faith-based organizations, both Ugandan and international.

Uganda�s examples of leadership and partnership are straightforward and exemplary. Other dimensions of the Uganda experience demand a more sober appraisal, as active international debates around Uganda�s approaches to HIV/AIDS illustrate the complexity and interplay of technical and ethical issues where HIV/AIDS is concerned. Where preconceptions dominate programs and action, all lose out.

Uganda�s approach to HIV/AIDS is commonly described in terms of its cornerstone �ABC program�: promote abstinence, be faithful, and use condoms responsibly. There are important differences, however, between �sound bytes� about the significance of this program and the realities lived on the ground. Uganda�s experience gets very different treatment in different quarters. Some would argue that experience comes down squarely on the side of behavioral change�towards abstinence and monogamy�as the critical success factor. The abstinence message has indeed had important benefits especially for younger people who have delayed the onset of sexual activity, yet there is evidence that the effects are tapering off somewhat. Others ascribe success to quite different sources, including forthright discussions of sexual behavior and promotion of condom use. There is conflicting evidence on how far the �be faithful� message can address the central problem of multiple sexual partners, and it may not help women who are in practice often infected within marriage. Meanwhile, condom distribution rose dramatically�from 300,000 in 1991 to over 20 million in 2000, as did general awareness about condoms, suggesting that they do play an important part. In short, all three elements of the ABC approach have been vital; they are not a progression from virtue nor separate �choices� but an intricately interrelated set of social and personal issues.

Our conclusions from this complex experience underscore how far the full range of interventions was critically needed and how far they were complementary rather than competitive. First, different approaches work for different situations and groups, second, situations change over time demanding constant adaptation, and third, the role of stigma and stigmatizing behavior, often inadvertent, is a thread woven through both debates and intervention. In sum, there is no �silver bullet� � no ready or single path to success. Thus, another important lesson from Uganda is the extent to which her leaders and policymakers took care to avoid pitting the moral precepts of one partner against another. This was particularly important for faith communities and the issues around the role of condoms.

Senegal is considered the other HIV/AIDS �success story� in Africa. With one of the lowest HIV/AIDS prevalence levels in Sub-Saharan Africa, it did not reverse the course of HIV/AIDS but instead kept the rate from ever going up, keeping its total infection rate near 1 percent. Senegal also presents a story of a broad based coalition working to coordinate HIV/AIDS prevention country-wide. As in Uganda, government leadership was instrumental in inviting the partnership of many constituencies, including faith communities. In particular, Muslim leaders sought actively to engage in the dialogue on condom use. Political leaders and faith leaders collaborated to come up with prevention programs in the epidemic�s early stages; these prevention mechanisms included the creation of the National AIDS Control Program in 1987, a body responsible for coordinating HIV/AIDS prevention activities nationwide.

Behavior change has contributed to the low HIV rate in Senegal. Both the reduction of sexual partners and increased condom usage have been key messages promoted by the cross-constituency coalition. Messages were and are particularly focused on young people, pushing for them to delay their first sexual experiences or to use condoms. Senegal�s regulation of the commercial sex market, launched well before HIV/AIDS was even known, demonstrates how far Senegal has been able to confront taboo topics. From 1968, Senegal began to require its commercial sex workers to register and to come in for regular medical appointments. If they are healthy, they receive a stamp on their ID cards indicating as much. When police visit prostitutes in their workplaces, sex workers are required to show their ID cards, indicating the regularity of medical visits. The system is not 100% effective�there are unregistered sex workers, particularly in rural areas, but it has helped to keep the HIV infection rate steady, and low, since the early 1990s.

Senegal�s success also owes much to Senegal�s community and religious leaders. In the 1990s, the religious community joined together with the government to declare AIDS prevention a national priority. Spiritual and religious leaders in Senegal are thought to be among the most open in discussing the threat of HIV/AIDS in the context of their religious teachings.

In July of this year, Thailand hosted the Fifteenth International AIDS Conference, the largest gathering ever of AIDS experts and activists. It was fitting that this event was held in Thailand, another of the all too few HIV/AIDS �success stories.� Thailand has experienced a major drop in HIV/AIDS prevalence rates, which is most often attributed to Thailand�s strong condom program as well as the strong involvement of religious communities, including Buddhist monks, in HIV/AIDS prevention; According to the Thai government, the number of people testing positive for HIV fell last year to 23,676, down 83% from a peak in 1991 of 142, 819.

In Thailand, as in Uganda and Senegal, a comprehensive mobilization of all stakeholders drew on strong political commitment from the King and Prime Minister. A nationwide initiative launched early in the 1990s emphasized condom usage and behavioral change. The �100% condom program� has official sanction and support, and provides free condoms in sex establishments and regular screening of sex workers to ensure that they are using condoms. This aspect of the program has not been without criticism. Human Rights Watch, for instance, makes a case that penalizing sex workers who do not use condoms perhaps will result in pushing sex workers underground. Seemingly as a direct result, however, there has been a dramatic increase in condom use. There has also been, according to Human Rights Watch, a corresponding drop in demand for commercial sex.

Thailand is remarkable for the great extent to which diverse religious communities are involved in providing direct services to people with HIV/AIDS. Images of Buddhist monks providing HIV/AIDS education training are powerful. In fact, both Buddhist and Christian groups have mobilized to combat HIV/AIDS. Religious groups provide home based care services. Buddhist monks have been involved in creating AIDS-education programs in local school, and providing support and counseling to HIV-positive individuals. Through this open commitment of religious communities to be involved with HIV/AIDS advocacy and treatment, the stigma of HIV/AIDS is reportedly less pronounced in Thailand than in many other countries.

Thailand is emerging as something of a learning center on HIV prevention for developing countries in Asia. At Thailand�s Chiang Mai University, training courses for AIDS prevention have attracted healthcare workers from around the region, including from Afghanistan, East Timor, and Sri Lanka. Afghanistan�s Minister of Health, while visiting Thailand to learn about HIV prevention, was quoted in the Christian Science Monitor as reporting �zero percent condom use� in Afghanistan and �large numbers of drug users sharing needles.� Thailand�s sharp focus on the sex worker industry, promotion of 100% condom usage, and involvement of the religious community offer valuable lessons.

While Senegal, Thailand, Uganda present distinct stories, some common threads run through their success in responding to HIV/AIDS.

(a) Commitment of public leaders, including the government apparatus: In the three countries, public officials early on recognized the problem of HIV/AIDS, and were intent on preventing people from becoming infected. Courageous groups of leaders worked to build cross-constituency coalitions to tackle the problem head on. Governments acknowledged that HIV/AIDS was a public health problem and needed to be dealt with publicly, even when sensitive and previously taboo issues had to be addressed, i.e. condoms, legal and illegal sex worker markets, and personal sexual choices related to numbers of partners. Squeamishness in all these areas is all too common, so the contrasting forthrightness of Thailand, Senegal, and Uganda is remarkable.

(b) It is vitally important both to remain open to different explanations of the pandemic (we are learning all the time) and to different approaches. Neither the �condom� nor the �behavior� schools have all the answers. The importance of both factors � condoms and behavior change, needs to be recognized, as do new and different factors that may become more evident with time. Closing minds and spirits is dangerous. In both Thailand and Senegal, a risky public policy initiative (legislation regulating sex workers) by all accounts has contributed to lower infection rates. The growing potential and importance of treatment as part of HIV/AIDS programs has and will continue to change many previously accepted assumptions. Strategies that work with compassion and creativity to address particularly high risk communities and their partners are in order.

(c) The single most important lesson we take from these country histories is that a very different kind of broad partnership (not fitting earlier experience and stereotypes) works best in dealing with HIV/AIDS. In each country, coalitions of government and non-governmental groups came together to develop comprehensive responses to HIV/AIDS. It is partnerships, particularly, whether initiated by or with strong support from governments, that have largely accounted for success. Close and on-going collaboration from a broad spectrum of actors is imperative� in Uganda, Senegal, and Thailand, governments, external donors, private sector players, secular civil society, and faith communities all came together. We need significantly more dialogue, partnerships, and cross fertilization across cultures, faith traditions, and development practices to be able to formulate a more comprehensive global AIDS strategy. We need to better understand and to deal with the stigma associated with HIV/AIDS and, crucially, to ensure that the organizations, faith based and otherwise, that are doing effective HIV/AIDS work are able to access funds to continue that work.

As we know all too well, building strong partnerships is much more difficult than it sounds: tellingly, a Business Times of Singapore editorial last week likened the search for workable forms of public and private sector partnership to the elusive quest for the Holy Grail. Partnership is difficult and time-consuming. It takes active listening; openness to learning and change, being open to what others have to say about the lessons they have learned; it takes looking at each other and challenging each other to do more, be better and more efficient. The task facing the global community in building strong global, national and community partnerships that address both prevention and treatment issues illustrate these challenges well.

(d) These three country stories illustrate that it is open dialogue, where government and religious authorities were frank about the ramifications of HIV/AIDS at an early stage, that changed the trajectory of the pandemic and reduced the stigma associated with it. Dialogue and cooperation have great power in developing and delivering an effective response. There are, however, other and more sobering messages, including the still formidable challenges in all three countries (In Senegal alone, an estimated 79,000 people are HIV infected, and there are 42,000 AIDS orphans; in Uganda, a newspaper reported last week that half the children rescued from the Lord�s Resistance Army (LRA) rebels in northern Uganda are HIV-positive) and the many countries which have yet to achieve bold leadership and forthright discussion of HIV/AIDS.

�Success� to date is a distant goal for many countries � the lesson is that success is possible but the battle to stop the spread of HIV is nowhere near over, and too many people (by moral and/or public health measures) continue to get sick.

Role of Faith Communities in the War against HIV/AIDS

The prominent role for faith institutions has been central to success in all countries which are showing success in combating HIV/AIDS, including prominently Uganda, Senegal and Thailand. This underscores powerfully the importance of partnerships with faith communities. Faith group participation is of course not sufficient to address the pandemic but it was, and continues to be, a critical factor in each of these countries, and demonstrates how far faith leaders of many faith traditions can be effective agents for change, successful in mobilizing communities in the areas of prevention and treatment. These three countries run the gamut of the three major religions: Senegal is largely Muslim, Thailand largely Buddhist, and Uganda largely Christian. In each country, nonetheless, a variety of faith groups, often working together, have been involved and instrumental in dealing with HIV/AIDS.

Among the lessons to draw are the tremendous potential of faith organizations to provide and exploit effective communication channels, given their influence in most cultural and social environments. They have wide geographical reach, respect they have earned in their local communities, and a staying power they have attained over centuries. They hold a unique position to advocate for open dialogue, particularly when addressing what are often considered the religiously rooted taboos that tie to behaviors that are root causes of HIV/AIDS.

The clich� runs that religion is �part of the problem� in the HIV/AIDS pandemic, contributing to denial, stunting open discussion, impeding some programs, but also that it is �part of the solution�: essential for precisely this open public discussion and a critical part of the community response which is vital to successful efforts to combat HIV/AIDS. We need to focus on the positive action-oriented, moral, and compassionate force of faith in fighting this terrible disease. There is a continuing, tragic pattern of believing that HIV/AIDS will not affect a given society until the pandemic is deeply established. Looking positively, we are seeing today in faith after faith, parish by parish and denomination by denomination a rise in concern and compassion. What is most needed in the fight against HIV/AIDS is action at the community level, and this demands the full engagement of faith institutions. The challenges to these institutions are enormous and a common effort is urgently needed to ensure that funds are well and honestly used and that lessons of experience are shared across communities and countries. This is classic story of partnership, and the good news is that, in a jerky fashion and with considerable difficulty, these are taking shape quite rapidly in many countries.

Access and Treatment Issues

Growing experience, like that of Sant�Egidio�s DREAM Program, shows ever more clearly how far we must view prevention and treatment as intricately linked elements of strategies to combat HIV/AIDS. This applies for technical, financial, medical and social issues, yet even more when viewed from an ethical perspective. Earlier arguments ran that in poor countries and communities the best strategy was to focus solely on prevention, primarily because poor countries simply could not afford treatment. Indeed, prevention efforts need to remain at the heart of any effort to halt HIV/AIDS, but access to life saving medication has been shown to motivate people to undergo voluntary testing and subsequent preventative measures. We should not highlight a largely false choice between prevention and treatment. We need to do both.

We also need to focus more on the many complementary issues around treatment�it is well known and recognized that a holistic treatment program is best, one which stresses the importance of good nutrition and treatment of overall physical, mental and spiritual life. Treatment of opportunistic infections can prolong life and extend the period before which drug therapy is appropriate. These complementary issues need to be at the core of any treatment program. They will extend lives and can vastly improve their quality.

A central component of dealing with the pandemic is to make antiretroviral treatment readily accessible, which has posed a challenge for many African countries who cannot afford the prices of this treatment even after accounting for recent prices declines of branded drugs and increasing supplies of generics. Notably, the Clinton Foundation this year has made great strides in this area by negotiating down the cost of branded drugs for a number of countries in Africa. It is a different world in light of recent price declines and availability of generics, but the problem of access is still daunting.

Significant expansion of treatment calls into question health sector infrastructure in Africa, and whether many countries are capable of responding by providing sufficient monitoring and diagnostic facilities as well as training of health sector staff. A number of alternative distribution models are being tested for their effectiveness and applicability to specific African environments involving a combination of public/private/community based partnerships. Sant�Egidio, of course, is among the pioneer organizations in this area.

After drugs are available, adherence becomes a major issue. Experience with adherence is different in different settings. Cultural and practical reasons abound for this, and need to be taken into account in planning treatment programs. We really do not know enough about this area. In some settings, Uganda for example, there are community level models for facilitating adherence, with �buddy systems� and report cards set up to ensure people take their medications on time. The organization Partners in Health, which works primarily in Haiti, Peru, and Boston, has ensured that people comply with TB drug treatments by actually taking medicines directly to people who need them. This kind of vigilance, while seemingly impractical, might just be what is necessary to ensure the kind of compliance that is necessary for people taking HIV/AIDS drugs.

Some particularly troubling ethical questions cannot be avoided, especially where resources are scarce. Should certain categories of people have privileged access to treatment, say the medical profession or teachers? Or should we work for an equitable treatment dissemination program? Government policies need to be developed and refined to address these questions, and international leaders need to take a stand here. We need to insist that treatment coverage be as equitable and comprehensive as possible, and we need to help provide governments ways to make this possible.

HIV/AIDS treatment raises a whole host of issues that have to do with stigma, moral, and legal issues. We need to focus on the next so-called �flashpoints� of HIV/AIDS: Eastern Europe and the Subcontinent, where the issues and challenges are likely to be very different than those which have confronted us thus far. In these contexts, the vector of transmission is much more likely to be injection drug use. An ABC message will obviously be only part of the story here. Much more thought will have to be given to how to control the spread of HIV through injection drug use. Issues of stigma are likely to be more complicated when HIV affected populations are engaged in illegal drug use, and, by implication, supporting global drug use and crime. How will drug users be targeted for education campaigns? Will education be tied with policing in this instance? Again, faith communities and leaders can play vital roles here, in helping to construct effective and humane approaches to curbing the spread of HIV through drug use.

Focus on Women

Among all the complex challenges raised by the HIV/AIDS pandemic, far too little attention has been paid to the particular situations facing women. Too often, programs of prevention, treatment, and drug development are developed with men in mind. Women are physiologically more vulnerable to contracting HIV, and socially more likely to contract it unknowingly from a partner. Women�s bodies and voices need to be respected and protected.

One of the most contentious and divisive issues among and within faith communities and between the worlds of faith and development is the role of women in society and particularly women�s reproductive health issues and rights. These issues have both practical and symbolic importance, lying at the core of issues of identity, cultural heritage, individual versus community rights, and pitting tradition versus modernity. No other set of issues seems to have so colored the relations between faith and development institutions over the past decades, generally in a negative light (on both sides). Yet few issues have such vital importance for social welfare and stability � whether in education policy, child health and nutrition, small business development, and achievement of human rights. We need to find ways to engage in dialogue on these sensitive issues in ways that promise to advance understanding, build on such common ground as concern for maternal health, violence against women, and HIV/AIDS, and address the areas where there is real disagreement. Leaving this issue as a �sleeping dog� is both unproductive and damaging to the broader objectives that we share.

Access continues to be a huge issue. Women enter care later than men and, as a group, adhere less well to treatment than men. Today, it is not so much that providers will not or do not treat women; it is that women have real trouble with the basics of regularly accessing health care�they can be unreliable in making and keeping appointments, most often as a result of domestic and childcare responsibilities. Women face even more stigma and thus may delay seeking treatment and wind up with suboptimal care. Care systems and programs need to be better tailored to women�s needs, reaching out especially to marginalized women.

Drug toxicity and side effects in relation to HIV/AIDS are issues we are only beginning to understand. Research on new drugs and trials is almost always conducted within a male cohort. We need more research on women and women�s issues in particular. There are huge issues for men, too, but men and women may have different susceptibilities to many side effects. These questions, if answered, could improve routine monitoring�for instance, by informing better ways to use glucose and liver tests.

Another issue is how little research has been done about how HIV/AIDS drugs interact with women�s hormones depending on what stage in life medicine is taken. Studies have shown that HIV itself can affect the body�s ability to produce or maintain hormone levels. Changes in the balance of estrogen, progesterone, or testosterone can affect HIV-positive women in many ways. There is conflicting evidence about whether HIV itself and antiretroviral drugs used to treat HIV can also lead to estrogen deficiency and/or health conditions associated with low estrogen such as early menopause or bone loss. While men with HIV have been offered testosterone for years to treat HIV-related weight loss, there is limited experience with hormone replacement in HIV-positive women. This may be an especially important option for women showing signs of wasting or low weight, body composition changes, and/or bone density problems.

Antiretroviral dosing, and possibly overdosing, of women present troubling issues also. Approval of anti-HIV drugs has essentially been based on dosing data gathered in male adults. There also have been a myriad of research observations, including published data, on differential initial viral loads and CD4 cell counts in women, and there are different patterns of drug toxicity in women as well. The most important issue here is probably the fact that we need studies focused on women. If we want answers to questions about women, we cannot get the data we need from men. This is true whether you�re talking about antiretroviral treatments or side effects.

A critical issue for women, and one that affects access, is the amount of violence, both psychological and physical threats, that so many women experience, especially at the hands of intimate partners. Violence affects women�s entry into care and adherence to care. HIV/AIDS, drug use, and violence against women are often, though not always, intimately linked. In treating women with multiple major issues, ARV drug distribution alone is not the answer. These women need and deserve more comprehensive, holistic programs that address their underlying insecurities and particular needs.

World Bank Role and HIV/AIDS

There is much to say about the World Bank�s role in combating HIV/AIDS. Briefly, the President of the World Bank, Jim Wolfensohn, has committed the institution to support HIV/AIDS programs at whatever financial level it takes, and we are involved in a rich array of partnerships. The Bank has pledged that no country with an effective strategy for fighting the disease will go without funding. The Bank has committed US$1.7 billion in grants, loans and credits for HIV/AIDS programs worldwide, and is especially engaged in Sub-Saharan Africa. The core approach is support for multi-sector, multi-actor strategies, providing funding and strengthening national HIV/AIDS strategies and supporting a wide range of interventions at the level of community based organizations. The World Bank works actively in all regions in the developing world that are affected by HIV/AIDS.

In partnership with African countries, a series of Multi-Country HIV/AIDS Programs (MAPs) have been launched and it is here that most active partnership initiatives with faith organizations are focused. The common approach of these projects is to place HIV/AIDS in the context of a multi-sectoral development challenge. Working through national HIV/AIDS groups, these projects are supporting a full range of interventions�prevention, care, treatment and capacity building. Within the funding allocated to each country�s program, on average, about half is meant to be channeled to community level interventions�there is widespread consensus within the Bank that it is in these communities that the question of sustainability will be addressed.

World Bank efforts to work with religious leaders on HIV/AIDS have been growing in importance and have already yielded some important lessons. The participation of faith groups in the MAP projects, while uneven, is strategic. Faith groups are represented on national councils, review boards, and among the approved projects. In Ethiopia, for example, a country where the importance of religious ties cannot be overstated, experience has demonstrated the importance of engaging in outreach efforts to religious communities. In Kenya, faith groups have been actively engaged in testing out the operational manual for the MAP project and there are numerous and very diverse subproject proposals. In Cameroon, more than 30 subprojects under that country�s project are being implemented by faith groups. In Ghana, an active outreach campaign is planned for all of the country�s major faith traditions, to ensure they participate in the MAP to the fullest possible extent. In Uganda, Senegal, and Thailand, as I have detailed, members of religious communities have been vital players in shaping messages as well as implementing projects.

Sant�Egidio and the World Bank: Dialogue, Debate and Partnership

The Community of Sant�Egidio and the World Bank, though they are two very different organizations, are working together in widely flung regions of the world and on a wide range of issues. The essence of the partnership here is the powerful common passion to fight poverty and an appreciation of the different perspectives that each institution brings. Within this broad partnership, one aspect has particular relevance: Sant�Egidio�s AIDS treatment program. It is now moving to a new stage, and has already helped to prompt new thinking in both organizations.

The aim of the Treatment Acceleration Program (in which Sant�Egidio is a central partner) is to address the very practical problems involved in moving from relatively small pilot projects for holistic treatment to much larger programs that offer the potential of scale to serve significant numbers of AIDS affected people, even in the poorest countries. The program will explore different models for treatment activities supported by NGOs and/or by a public/civil society/private partnership to test their efficacy in a decentralized, cost-effective and equitable manner. It also assists participating country governments in refining their national treatment policies and adapting WHO recommended treatment protocols to their individual situations. The program offers opportunities and methodologies to train staff on the job and better target poor urban and rural neighborhoods, the youth, women of childbearing age and professional and technical staff at high risk. The program is above all founded on the vision of a cross country learning process in the selected countries.

Sant�Egidio�s Drug Resource Enhancement Against AIDS and Malnutrition in Mozambique (or DREAM program), launched with great vision and a passion for people against many odds, is a pioneering venture for Africa and other regions. The program�s support for people affected by HIV/AIDS focuses on providing high standards of care, using the best technologies and drugs available. The DREAM project models an integrated approach, with multiple partnerships, to combat the HIV/AIDS pandemic. Sant�Egidio is a partner of the government of Mozambique, and also works with universities in Italy and Mozambique, pharmaceutical companies, communities, other NGOs, and international development agencies (including, of course, the World Bank). As many of you know, the DREAM project has grown rapidly, adapting to lessons learned, and with ever bolder objectives.

The World Bank�s partnership with Sant�Egidio has pushed both of our organizations to challenge our ways of working and assumptions�about who we should partner with, and how practically we can work together when we operate with different fiduciary management and organizational structures; about the most effective ways of reaching communities, and about concentrating focus on small projects in the hopes that they will be effective enough to expand.

One crucial question we need to ask is how the work of our partnership on HIV/AIDS will be measured and evaluated. We need to challenge ourselves and all of our partners to engage in diligent monitoring of our efforts, measuring success in terms of both the infections that are prevented and the lives that are prolonged. These indeed are the ultimate measures of success. At the same time, there are several other issues that we must pay close attention. How well have our efforts supported locally designed programs rather than supplanted them? To what extent has the response to HIV/AIDS helped to improve the number and skills of technical and managerial staff at all levels? How sustainable are our efforts, taking into account local and international sources? We must engage in collective learning, supporting operational and basic research, learning from our strengths and weaknesses, and continually striving to do better work.

Some Ethical Challenges

As we build partnerships around HIV-AIDS, important ethical problems come to the fore. A prominent example is the very pragmatic challenge of corruption. With large numbers of stakeholders involved in a complex new venture, many in quite new roles, there are many places where corruption may take place�no member of the alliances and partnerships can be exempt from concern. The topic of corruption is one that we simply must address with frankness. Corruption in the form of stealing funding or resources is always wrong; in the situation of HIV/AIDS, it amounts to murder. Illegal trafficking and resale for profit of medicines needed by poor people is abominable as is the production and sale of counterfeit drugs, an issue of great concern. It must not be tolerated at any level. We must be creative and effective at coming up with ways to uncover corruption, name it, and stop it.

There are many other equally important if less tangible ethical issues around HIV/AIDS�places of deep discussion and disagreement�where the best course of action is not always self-evident. Two issues strike me as falling into this category: (1) ideas on reproductive health rights and (2) challenges around gender. The debates around issues of reproductive health rights, and more broadly, the rights of women have colored dialogue and action in many parts of the world. These issues are moral and political. While we development practitioners at the World Bank view our analysis of reproductive and gender issues as holistic and perhaps even definitive, we are aware that others have very different perspectives.

An example is our hope for dialogue about these issues with Catholic Church organizations. Working with these institutions on reproductive health issues has been, it will come as no surprise, notably challenging. The wide-ranging role and extraordinary importance of Catholic Church health policies and institutions, as well as the broader Church role in helping to shape the course of development work, are well recognized. Catholic social justice traditions have also served to inspire secular social justice movements in powerful ways. Developing better partnerships with these institutions is thus critical, as is learning from the tremendous history of peace and justice at the center of the Catholic Church. Differences of opinion on birth control, the use of condoms, and the rights of women to take up roles in society are where partnerships become challenging. How do we reconcile pro-contraceptive positions with the strong conflicting position of many Catholics worldwide? There does not seem to be a universal answer to this dilemma, but rather I believe that we must address this issue as we tackle development problems together.

Another area of discussion about HIV/AIDS is the relationship between violent conflict and sexually transmitted diseases. There are several aspects of this relationship. To begin, rape and sexual abuse are used as weapons of war, making it impossible to talk about the full problem of HIV/AIDS without dealing with violence and conflict. There is no �just war� where women�s (and men�s and children�s) bodies are violated. This happens too often in conflict. It is unethical, dishonorable, a public health threat, and something that reflects poorly on all of humanity. Furthermore, in a case like Angola, which has been engaged in conflict for over thirty years, refugees from high sero-prevalence countries will be returning home. How will post-conflict society deal with the pressure of many more HIV-infected people? So many questions remain.

The central message, the lesson I take from the cases of Uganda, Senegal, and Thailand; from the work of the Bank in engaging with faith communities these last several years; and from confronting difference in philosophy and approach; from dealing on the �frontlines� of development with issues of gender, reproductive health, conflict and violence, and corruption is that we must work together. We must have dialogue, even and perhaps especially where deep disagreement exists. Often by working together in practical situations, we can find common ground. On HIV/AIDS, we must.

Concluding Thoughts

My remarks have aimed to convey my sense of urgency about AIDS, a sense of hope�the cases of Senegal, Thailand, and Uganda provide important evidence that HIV/AIDS can be fought with effect - and a sobering reminder of the complexity of the issues we face and the demands these entail for dialogue, partnership, humility, and a willingness to learn constantly from each other. Where countries are succeeding in combating this terrible scourge, leadership is the crucial lynchpin, drawing together multi-constituency groups, including faith groups, to deal head on with the HIV/AIDS crisis. We need to share their strategies, helping to support dialogue and alliances wherever we can.

The AIDS pandemic is in many senses a parable of our times, with its fast pace and constantly changing and expanding demands. Twenty-three years ago, none of us had any inkling that HIV/AIDS would so dominate the global scene. The pandemic overwhelmed the development community, always with surprises and new demands, and that is likely to continue into the future. It forces us constantly to look at basic development issues � the very essence of humanism - in different ways. AIDS may be the greatest test of our lives: how will future generations view how we, as individuals, communities, institutions, organizations, and governments, have responded to this pandemic?

Both the World Bank and Sant�Egidio have remarkable convening power�this Meeting powerfully brings together leaders who are deeply invested in dealing with social problems. We have a responsibility to help bring together the right people and institutions to help stamp out HIV/AIDS� we must help foster and model a �new humanism� that focuses on bringing together institutions and individuals, secular and religious, to save our sisters and brothers from sickness and death by a preventable, treatable disease.