This Lancet 'interview' is really an infomercial for WHO's global HIV strategy. It makes more interesting reading than the strategy documents themselves.
[him] moderator
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Interview
Kevin De Cock: guiding HIV/AIDS policy at WHO
Priya Shetty
Kevin De Cock is director of WHO's HIV/AIDS department. Formerly director of the US Centers for Disease Control and Prevention in Kenya, he is an infectious disease specialist, with expertise in HIV/AIDS, tuberculosis, liver disease, and tropical diseases such as yellow fever and viral haemorrhagic fevers.
TLID: How has your time as WHO's HIV/AIDS director been?
KDC: It has been extremely interesting. AIDS policy is always challenging and changing. WHO's HIV efforts up to 2005 were very much oriented around the 3 by 5 initiative. The G8 in 2005 made an announcement about working towards universal access, which became an AIDS rallying cry. So we've had to reorganise ourselves around that as a theme. Some internal reorganisation was necessary to focus not only on treatment, but also on broader issues. We now have five key strategic directions: increasing access to HIV testing and counselling, maximising prevention, accelerating treatment scale-up, strengthening health systems, and investing in strategic information. We have also been working on some important technical areas. One is the issuing of guidance on both provider-initiated testing and male circumcision. In April, 2007, we also issued a report, in response to a request from the World Health Assembly, on the health sector's progress towards universal access.
TLID: People working on so-called neglected diseases sometimes complain that the big three diseases unfairly grab the lion's share of funding and global attention---is that a fair comment?
KDC: I don't think it's an accurate comment, although it's something I can sympathise with. Some major, particularly parasitic, diseases---ones that I've worked on in the past such as schistosomiasis---have definitely been overshadowed by emerging global infectious diseases, such as the AIDS pandemic, new and exotic infections such as haemorraghic fever viruses, and concerns around pandemic influenza. With all these problems, treatment for diseases such as schistosomiasis hasn't really got any better. However, that doesn't mean that malaria, tuberculosis, and HIV/AIDS get too much money---they don't. Especially in Africa, there's no question that these three are the major infectious diseases that cause an incredible amount of morbidity and mortality.
TLID: The link between tuberculosis and HIV is really starting to get people's attention now---is this dual epidemic being properly tackled?
KDC: The recognition at the global level that these diseases are linked is a double-edged sword. On the one hand, the recognition is absolutely necessary; on the other hand, we must not forget that 89% of the world's tuberculosis is not HIV-related. But in Africa, the link between HIV and tuberculosis is particularly strong, especially in southern Africa, and a coordinated response to both is absolutely essential. When you add multidrug-resistant and extensively drug-resistant tuberculosis into that mix, it emphasises the need for HIV and tuberculosis sectors to work together better.
Achieving this integration will be very challenging; there is not necessarily one model that works. Some parts of South Africa have done well in tackling the disease together, other parts considerably less well. As is often the case, individuals can make a big difference through their leadership, their own technical capacity, and so on. The HIV community has a lot of work do to. We are not doing particularly well, for example, in the screening of HIV-infected people for tuberculosis or in the implementation of preventive therapy for tuberculosis.
TLID: In relation to South Africa, the health ministry seem finally to be advocating proper HIV programmes rather than their nutritional "cure" of garlic and lemons, but is the commitment really there?
KDC: Last year, I spoke at South Africa's third national AIDS conference. An encouraging spirit of consensus between civil society and government about what needs to be done on AIDS seems to have emerged in the past year or so. The South African government's commitment to tackling AIDS was evident when the Deputy President spoke in a very robust way at the national conference about implementing their new national AIDS plan. And a new national council to oversee implementation is jointly chaired by the Deputy President and a member of a leading civil society group. The rate of treatment scale-up seems to be improving.
However, they still have an enormous job to do. The problems of tuberculosis and HIV in South Africa, individually and combined, are so great---South Africa's HIV epidemic is the biggest of any country in the world. About one in six or one in seven people with HIV worldwide is living in South Africa. It dawned on me while I was there that what happens in South Africa is more important for the future of the HIV/AIDS epidemic than what happens anywhere else in the world. It's also so different from the other African countries; it has such resources available---financial, human, and infrastructural---that you think if they don't manage to get it right there, what is the likelihood of us doing it elsewhere in Africa?
TLID: How important is women's empowerment in fighting the HIV epidemic, especially in Africa?
KDC: Gender equity is extremely important for public health and for social justice. I think one needs to be careful before saying that there are macro-level explanations for the AIDS epidemic and that if we could only change that aspect it would all be fine. Botswana, for example, is a fair country in terms of the role of women and the respect for their rights, but it has one of the worst HIV/AIDS epidemics in the world. Some of the factors fuelling its high rate include rates of sexual partner change, lack of male circumcision, and high frequency of genital herpes. So you need to work on all these levels: behaviour change, biomedical interventions, human rights, and structural change.
However, for women's health in general, the issues of equity, economic empowerment, and human rights are all immensely important. And helping women to gain power over their sexual and reproductive choices is a key strategy to tackling the AIDS epidemic.
TLID: Male circumcision has been incorporated into HIV prevention strategies, but is there a danger that circumcised men might take fewer precautions during sex, believing themselves to be protected?
KDC: The recommendations issued last March by WHO and UNAIDS were carefully worded to say that male circumcision is only partly preventive (its efficacy is 50--60%) against heterosexual acquisition of HIV. However, it's not every day that we are offered an intervention with a protective efficacy of up to 60%. Yes, I wish it were a vaccine rather than a surgical procedure that has cultural connotations, but it is what it is. The recommendations are careful in pointing out that it is not a replacement strategy, rather it is an additional strategy that must be added to the other advice of partner reduction, correct and consistent condom use, and so on.
There is obviously the danger that men may feel they are protected and will not use other prevention measures---although the guidelines strongly warn about this---but there is the same danger with any intervention that is not 100% protective.
TLID: WHO and UNAIDS recently issued guidelines on provider-initiated testing---why is it so important to scale this up?
KDC: First, knowledge of HIV serostatus is extremely low worldwide. Several studies in sub-Saharan Africa suggest that only about 12% of men and 10% of women had actually been tested for HIV and knew their HIV status. In mother-to-child transmission prevention programmes, only 10% of all women actually got tested for HIV. Tuberculosis patients are not being tested, so those who are HIV-infected are not accessing antiretroviral therapy or co-trimoxazole prophylaxis and have a mortality rate of 25% in 2 years. This lack of knowledge translates into direct adverse effects---people won't get treatment early enough, they will present late with advanced disease, and the outcome is worse. Testing is the essential entry point to timely treatment. And from a prevention perspective, people who know their HIV-positive status tend to adapt their behaviour to avoid transmitting the infection. We are also aware that practice in health-care settings has been diverse. Many countries asked for guidelines for testing in health-care settings.
TLID: The 3 by 5 initiative didn't meet its goals, and even by December, 2006, only 2 million of the 7 million people who needed it were receiving treatment. What are the biggest obstacles to providing treatment for all?
KDC: Although the 3 by 5 goals were not met, recent trends have been encouraging. In the past 3 years, the number of people receiving antiretroviral treatment in low-income and middle-income countries has increased from around 400000 to over 2 million. The biggest obstacle, however, remains the weakness of health systems, not only in terms of human resources, but also quality of infrastructure, laboratory capacity, procurement and supply management, and financial management.
TLID:New datahave been published showing that the number of people infected with HIV in India is about 3?5 million rather than 5?7 million (the highest worldwide) as previously thought. Will this affect HIV programmes there?
KDC: The estimates of the size of epidemics in various countries have changed over time because of new data, better methodology, and so on. In African countries, household surveys have lower estimates of the size of the epidemic compared with estimates based on data from antenatal clinics. This has happened for several countries, and WHO and UNAIDS have been transparent about these revised estimates. Some people, however, have made the accusation that UNAIDS and partner organisations have intentionally inflated the figures for advocacy. That's simply not true. Some of the best minds in this business have worked on these estimates and the quality of measurement of the HIV/AIDS epidemic is superior to measurement of any other global infectious disease.
There is, however, a communications challenge in explaining to people that the change in India's prevalence doesn't mean the epidemic has gone away. This new information needs to be seen in the context of efforts to be more precise in quantifying the epidemic. But it doesn't alter the fact that this is still a severe epidemic, nor the fact that the response to it is still under-resourced.
http://www.thelancet.com/journals/laninf/article/PIIS147330990870015X/fulltext
The Lancet Infectious Diseases 2008; 8:98-100
DOI:10.1016/S1473-3099(08)70015-X
