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INTERVIEW - Dr. Helene Gayle,
MD, MPH, Director, HIV, TB and Reproductive Health programme,
Bill & Melinda Gates Foundation |
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| "Treatment and prevention must go hand-in-hand" |
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| Which current global initiatives
combating HIV/AIDS do you believe are most important for policymakers
worldwide to know about? |
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| This is an exciting and critical time in the global AIDS
epidemic. I think there are a few areas in urgent need of attention: |
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| Adapting prevention approaches in the context of treatment:
Greater access to antiretroviral therapy will have a major impact
on HIV prevention programmes, and programmes must anticipate
and adapt to such changes. HIV-positive people will need special
prevention interventions tailored to helping them protect others
from infection, and HIV-negative people will need to maintain
safe behaviour and understand that anti-retroviral therapy is
not a "cure" and that people on AIDS treatment are
still infectious. |
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Integrating prevention into treatment programmes:
AIDS treatment initiatives will also provide important new opportunities
to deliver HIV prevention interventions. Treatment programmes
will bring many thousands of people into health care clinics
and testing sites. We need to make sure that the clinical and
non-clinical staff at treatment sites are trained to deliver
HIV prevention interventions - counseling about risk reduction,
offering condoms, and referring to other prevention services.
Unless the number of new infections is substantially reduced
as treatment efforts are expanded, treatment will not be able
to keep pace with the growing number of people in need. For
example, while WHO and UNAIDS have set a global goal of 3 million
people on treatment by 2005, 5 million new infections occur
every year. |
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| Fully funding the response to AIDS: Policymakers also
need to understand the scope of the challenges we face in fighting
HIV/AIDS, and commit to sustained funding increases for programmes
addressing the epidemic. Overall spending on HIV/AIDS in 2003
was $4.7 billion - far short of the $10.5 billion that UNAIDS
estimates will be required by 2005. Closing this gap will require
significant increases in funding through bilateral initiatives
like the President's AIDS initiative and multilateral channels
like the Global Fund to Fight AIDS, Tuberculosis and Malaria.
The Fund has already established itself as a flexible, efficient
mechanism to direct funds to programmes in the hardest-hit countries,
but it will require substantially increased, multi-year commitments
in order to ensure that the progress made is sustainable. |
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| Greater private sector resources are also needed - not just
donations, but also funding by employers for HIV prevention
and care in the workplace, and investment in research on microbicides,
vaccines, and other urgently needed technologies. |
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| In developing countries that now have a
low prevalence of HIV, what are the most important prevention
measures to take? |
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| HIV prevention programmes delivered early in an epidemic can
avert a major AIDS catastrophe down the road. In low-prevalence
epidemics, HIV infections are usually concentrated in higher
risk groups, such as sex workers, men who have sex with men,
and injection drug users. Targeted, evidence-based HIV prevention
must reach these groups quickly, accompanied by broader efforts
to fight stigma, discrimination, gender inequality, and other
factors that foster risk behaviour and hinder HIV prevention.
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| Political leaders can play a decisive role in a country's
response to HIV by discussing the epidemic openly, and by supporting
HIV prevention and treatment initiatives for the populations
at highest risk. This is not easy - there are powerful taboos
in almost all countries against talking about sex and drug use
- but it is essential to protect the health and well-being of
every nation's population. |
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| India, where overall HIV prevalence is still relatively low
but rising, provides a good example. There is now a window of
opportunity to avoid a widespread HIV/AIDS epidemic in India.
Over 5 million people were living with HIV in India in 2004,
and projections suggest that number could rise to 20 million
or more by the end of the decade. Avahan, the India AIDS initiative
of the Gates Foundation, is working with partners in India to
slow the epidemic by targeting groups that are at highest risk
of infection, and are most likely to spread HIV to the general
population. For example, one programme will provide prevention
services to truck drivers and commercial sex workers along 7,000
kilometers of the country's major highways. |
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| There is considerable new funding for HIV/AIDS
from the Global Fund, World Bank, US Government, and others.
Where do you see the biggest mis-match between what is getting
funding and what should be getting funding? |
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| Despite recent increases, funding for global HIV/AIDS still
falls short across the board. Overall spending in 2003 on HIV/AIDS
for prevention, treatment and care was $4.7 billion - far short
of the $10.5 billion that UNAIDS estimates will be required
by 2005, and the $15 billion that will be required by 2007.
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| Increased funding for current prevention and care interventions
is only part of the long-term solution - significantly more
resources are necessary for research too. Vaccines and microbicides
against HIV offer the best long-term prospect of bringing the
HIV/AIDS epidemic under control, but less than 1% of global
spending on health and pharmaceutical research and development
is devoted to AIDS vaccines, and even less is dedicated to microbicide
research. |
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| In past years there has been concern about
"treatment programmes" out- competing "prevention
programmes" for funding. The current refrain is "treatment
and prevention go hand in hand". Do you believe that treatment
programmes may occur at the expense of prevention programmes?
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| We do not gain anything by pitting treatment and prevention
against each other; the two must go hand-in-hand. Policymakers
must recognize the unique opportunity to expand HIV prevention
as ARV delivery is scaled up in countries around the world.
Widespread ARV therapy may enhance HIV prevention by lowering
the viral loads of people on treatment and making them less
infectious. At the same time, unless treatment scale-up is coupled
with a revitalized prevention effort, it is possible that the
number of new infections will actually increase over time if
treatment leads people to perceive HIV as less of a threat and
risk behaviour increases - as has happened in the industrialized
world. Unless we do a better job of preventing new HIV infections,
there is little hope HIV treatment can ever reach everyone who
will need it. |
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| How can a private foundation most effectively
complement inter-governmental assistance for HIV/AIDS in developing
countries? |
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| We spend a lot of time thinking about how to make our grant-making
as strategic as possible and complement the work of governments
and other funders. One approach we take is to support programmes
that can demonstrate success and attract funding over the long-term
from other donors. |
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| The Global Alliance for Vaccines and Immunization (GAVI) and
The Vaccine Fund - sister organizations created to expand childhood
immunization in the world's poorest countries - are great examples
of how grant-making has leveraged increased investments from
public and private funders. With support from the foundation,
these organizations have helped deliver millions of vaccines
to children in the last several years. A recent study found
that these results are encouraging other funders and developing
country governments to step up their investments in immunization.
In 10 countries studied, GAVI/Vaccine Fund support led to a
significant increase in funding from other sources, particularly
multilateral donors like UNICEF and WHO. |
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| Of course, there is a long road ahead to get governments and
others to increase their funding to the levels needed to match
the scale of global health problems. Our goal is to act as a
catalyst - by drawing attention and resources to health problems
that have largely been neglected. |
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| This interview is sourced with permission from
International AIDS Economics Network (IAEN) and may not necessarily
reflect the views of the United Nations or its agencies. The
copyright is with International AIDS Economics Network (IAEN). |
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| International AIDS Economics Network (IAEN) focuses
on the economics of HIV/AIDS prevention and treatment, providing
data, tools, and analysis for researchers and policymakers working
to define and implement effective AIDS policy for HIV/AIDS prevention
and treatment. |
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| About
Helen Gayle |
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