ACW Interview: Dr Charles Gilks
At the recently concluded 14th International Conference on AIDS and STIs in Africa (ICASA) in Abuja, Nigeria, ACW caught up with Dr Charles Gilks, Professor of International Health at Imperial College London and Director Co-ordinator of the Treatment and Prevention Scale-up team in the HIV Department of the World Health Organization (WHO) Headquarters in Geneva.
Dr. Gilks has been working in the HIV/AIDS field since 1988, largely in Africa, and has seen first hand how the epidemic has grown out of control, with the suffering and untimely death of hundreds of his patients, and the distortions imposed on already weak health care systems. Based in Kenya for five years, his team was the first to highlight the importance of bacterial infections in HIV/AIDS patients in Africa, and more recently, the interaction of HIV with malaria.
After becoming a Professor at the Liverpool School of Tropical Medicine, his team evaluated several interventions to try to preserve the health of people falling sick with HIV. Some worked but most did not. The inescapable conclusion was that only anti-retroviral therapy will prolong life and restore quality of life, a fact well recognised in the US and Europe.
He is one of the Principal Investigators for the DART trial, a multicentre, multicountry trial of treatment strategies in Uganda and Zimbabwe, the largest antiretroviral treatment trial in Africa.
****************************************
ACW: Can you tell us a little about your recent work?
CG: I have been working in WHO for several years and have been intimately involved with the ‘3by5’ initiative from its first description. I led a lot of the initial work and the development of the strategy and its launch and then its subsequent delivery and I would like to believe in the success of ‘3by5’ – of putting treatment permanently on the agenda, and actually moving from the treatment being regarded as something that was not affordable and obtainable in most resource-poor countries – which is where we were December 1st 2003, and when we launched ‘3by5’.
We had the treatment target. We also had the treatment goal which was universal access.
Many people thought in 2003 it was lunacy, that it was suicidal for an international agency to commit to, and that we would never get there. We have gone from lunacy to global policy in two years and I think that is probably one of the most stunning public health achievements, and we need to have some recognition of that.
We have had slippage on the target numbers. The target was there to really push countries to take responsibility for treating their own citizens. Many have done. We always knew it was going to be difficult to roll it out. But the commitment is there, the momentum is there, communities are engaged and beginning to be much more open about demanding this. And I think it has worked. History will say we did the right thing.
ACW: The vast majority of people with HIV/AIDS (PWHA) do not have access to antiretroviral (ARV) drugs. Can you comment on current progress in scaling up antiretroviral (ARV) provision in your context? What are the consequences of the delay in expanding ARV access?
CG: In our position at WHO we have seen major advances in some countries and slower progress in others, slower than we would have anticipated or wanted. The reality is that in many countries people don’t just lack access to ARVs they actually lack access to any sort of quality health services.
The real challenge is to deliver ARVs – not just to start people on treatment but to deliver quality care which is necessary to get the treatment benefit of ARVs. We actually have to build a functioning health service, and that includes supply chain management and procurement; it includes training staff and supervision, ensuring they have better conditions of work.
We focussed on a numerical target but we have always recognised that beyond the target there are some extremely challenging health systems issues. We deliberately did not emphasise those at the beginning because we did not want didn’t want any distraction from the need to start treatment initiatives.
ACW: Comprehensive HIV/AIDS care ranges from HIV counselling and testing services through to palliative care for those close to the end of life. Aside from ARVs, which other care and treatment options do you think are likely to add years or quality to someone's life?
CG: We have recently completely revised the global guidelines in light of some new evidence. One of the problems with a simple slogan like ‘3by5’ is that it has not captured the fact that the care continuum starts with the identification of infection, and then leads through routinely following up the child or the adult with infection, to see how they are progressing, and to identify the relevant points to start OI [opportunistic infection] prophylaxis, and then to start treatment, before people get very sick.
We are playing catch up in many places because there are so many people who are already sick, but we have got to look forward to develop the proper programmes. Cotrimoxizole and Isoniazid will prolong survival if they are used appropriately.
The other issue that we haven’t paid enough attention to is the nutrition issue. From a household point of view, if you have nutritional stress, that is often more important, actually, than even cotrimoxizole or ARVs, and we believe that you can’t give treatment to somebody who is starving, so we have got to do more work on nutrition.
Finally, of course, you come to the treatment interventions. Our public health approach has been to try and simplify and standardise these interventions so that they can be rolled out outside of specialist centres. I think it has been one of the key developments that WHO has been involved in, and it is now universally accepted that we have first-line treatment, and then when you fail first-line treatment, as we expect the majority of people eventually will, you move on to the more expensive second-line treatment with protease inhibitors.
We’re promoting the need to think about salvage options, after that, recognising that this is going to be difficult and expensive, and that actually with the first-line and second-line options exhausted, some salvage therapy is going to be difficult to construct, and therefore recognising that as with some chronic disease therapies and life threatening infections, palliative care and end-of-life care is going to be important.
ACW: People living with HIV have a much higher lifetime risk of developing a range of common, potentially fatal, and yet treatable diseases, such as TB and meningitis. Is adequate or appropriate attention being given at the national or international level to preventing and treating these conditions? Would greater attention significantly add years or quality to PWHAs lives?
CG: That is a very interesting question. I think our strategies around some of the common opportunistic infections is that it is better to prevent than to have to treat, and I think the TB work with the isoniazid preventive therapy illustrates that, and also obviously the cotrimoxizole prophylaxis interventions.
We’ve stressed the need to start that particularly in children where sadly, globally, there is very, very limited use of cotrimoxizole prophylaxis, and I think actually there are tens of thousands of very easily preventable paediatric HIV deaths.
The issue with preventing tuberculosis is more complex because of the need to exclude early active disease, and then ending up making the situation worse for the individual by just giving isoniazid alone. The standard treatment for an active tuberculosis case is triple drug or sometimes quadruple drug therapy.
If you give just one drug alone you will very quickly get resistance to that. So isoniazid prophylaxis is much more complicated to implement than cotrimoxizole. As a result we are still going to have to deal with the immense challenge of identifying TB, because it presents differently in people with underlying HIV infection.
On the positive side, it means that we are beginning to understand how TB control programmes are very important entry points for, first of all, the identification of HIV infection, and then, with or after the anti-tuberculosis treatment, the starting of anti-retroviral therapy.
Another really important opportunistic infection that is emerging as an important killer after tuberculosis, is cryptococcal meningitis. This is potentially preventable. There are trials of prevention using Fluconizol in people who are also starting on antiretroviral therapy with low CD4 counts. We await those trials with interest because if Fluconizol works, and possibly also minimises the serious but not life-threatening candida infections, that might also be an important development.
ACW: I just want to take you back to the quality or extention of life. How does this pan out in terms of quality of life for the person living with HIV or AIDS or addition of life years?
CG: Antiretroviral therapy appears to be as effective in programmes in Africa as it is in the US, and I think we can confidently look forward to 4 to 5 years of additional quality of life where you become clinical symptom free. Obviously this isn’t a cure but it takes away the weight loss and the fatigue and the minor and major opportunistic infections.
For some, at the moment, we will have started too late, because we are playing catch-up in many countries, and very sick people are presenting for care with CD4 counts in the 10s or 20s and with really very high viral loads. For them, clearly, the prognosis is sadly much less with antiretroviral therapy because it has been started too late.
I think some issues of quality of life are going to be some of the drug side effects. We know that antiretrovirals are not perfect drugs. We know each of them has a measurable toxicity. One of our major issues in the next year is to start to collect the toxicity information.
ACW: Many – if not almost all – HIV-related interventions are concerned with doing things or providing material for people. In what ways do you think affected people can be empowered to take more control of their own health? What impact do you think this would have on their day-to-day lives?
CG: When the communities are mobilised around health as a right rather than something that they are scared to ask for, I think that is an important step. Where this has happened in Europe and in North America, I think it has actually transformed the doctor-patient relationship, making it less authoritarian in its approach, much more a relationship of information-sharing. I hope that transformation will happen in resource poor countries as well, as it has happened to great positive effect in the North.
ACW: In addition to a positive frame of mind for the individual, are there other things you would suggest that an individual can do, in order to maintain and, in fact, potentially improve their health in the context of HIV infection?
CG: They obviously have to have an understanding of their own disease, and they need to adhere very carefully to their medication. I think that is one of our big challenges, that, for many people, regardless of where they live, long-term adherence to medicine is difficult. I think the most important action somebody can take, is to take control of their own treatment.
It is their illness; their responsibility, to take their medicine regularly and stay in control of their own disease. I think we are in the infancy of learning how to promote adherence in a positive way. I think we have some learning to do from other chronic diseases like blood pressure management or diabetes, where people have to take, their medications for life. So we need to start that sort of dialogue with those managing other chronic diseases where there is a wealth of experience.
ACW: Four years ago, the United Nations (UN) General Assembly held an unprecedented special session on HIV/AIDS – the first time the assembly had ever addressed a specific health issue. The resulting Declaration of Commitment on HIV/AIDS (UNGASS), signed by all member states of the UN made explicit pledges to "provide the highest attainable standard of treatment for HIV/AIDS, including the prevention and treatment of opportunistic infections and effective Anti-retroviral therapy" and "make significant progress in implementing comprehensive HIV/AIDS care strategies by 2005." Can you comment on the progress WHO has made towards fulfilling the 2001 commitments to improving comprehensive care and treatment?
CG: I think what is interesting with the UNGASS 2001 declaration is that, whilst treatment was mentioned, there was never a treatment target, because in reality in 2001, we weren’t looking towards treatment targets, or even universal access to treatment, as a right and as a goal.
Since then we’ve established targets such as ‘3by5’, so I think we have made, at the global level, huge progress beyond what was anticipated. I think, also, that that has helped increase the flow of resources that have gone to the Global Fund, the President’s Emergency Fund and the World Bank, the three major resources for global health, particularly with HIV. So, I think we have made a major difference. Obviously many other groups, partners, individuals, activist groups, have been involved, but I think our role has been fairly key.
What we haven’t done as well, is been clear, right from the start, to say that the treatment issue that we focussed on was plugging a gap, but there were existing prevention interventions that also needed to be strengthened and reinforced. Whilst we’ve put a lot of our energy into filling the gap, we should have spent more energy on reinforcing prevention, because ultimately in the long term, if we don’t prevent infection, if we just treat it alone, this won’t be sustainable.
ACW: A number of initiatives and policy activities in 2005 – for example the Millennium Development Goals (MDG) review in September, pressure among G8 governments to accelerate debt relief and increase overseas development aid, and the final benchmark of the WHO ‘3by5’ initiative – suggest that this year may be a crucial 'tipping point' that leads to greater attention to development in general and HIV/AIDS in particular. What is your feeling about this? Do you consider 2005 to be a significant year?
CG: I think it is a significant year because it is the end of ‘3by5’ because the 5 was 2005. It is an important point to review progress. We believe up to now, that much if not all of the additional financing that has come into the HIV arena is new money.
Previously, there have always been concerns when a new initiative has come forward in health or agriculture that it isn’t really new money, it’s just money from the pot for that sector that is reallocated visibly to the particular priority or programme or initiative. But we believe there is substantial new money that has come into health and development. In terms of how that is maintained – we are at a critical point.
We started a lot of people on treatment, we need to start a lot more. If the money runs out, or the pledges aren’t fulfilled, we will have very difficult choices to make. I think the next year is going to be critical.
ACW: 2006, the next year…
CG: Yes, because it is going to become very apparent then, as we look at the increasing numbers on treatment, and we have more clarity on the cost and the pledges that have been made, what the long term mismatches emerging are. It will be critical, to say not just “this is happening”, but “what are we going to do about it?”
Countries need to have long term commitment, and I mean long term, I am not talking about even 5 years here, I am talking about 10 and 15 years. If they are going to plan for a chronic disease programme, they have to have some certainty that there will be the international support. If they don’t get that they will never reprioritise and increase the health budget themselves.
I don’t think we’ve got the necessary full commitment to treatment and scaled up prevention intervention. We haven’t properly included and costed the prevention component. And it will be even more costly than treatment. And we have to recognise that the prevention component is critical. This is universal access to prevention, care and treatment. We have to see it as a unified new approach.
ACW: What do we call the next chapter beyond ‘3by5’?
CG: We were lucky with ‘3by5’ that our target turned into our slogan and we got a brand out of it. It was unintentional. We need a catchy slogan. “Universal Access to Prevention, Care and Treatment and Support for HIV” isn’t particularly catchy, but we do need a brand or a slogan because it helps in our global advocacy work.
ACW: What do you see as the best case scenario for the next chapter?
CG: In the next ten years that we have truly universal access and that we can demonstrate huge prevention gains. We cannot sustain a treatment-only approach.
ACW: Perhaps not the best question to consider, but, what’s the opposite. What do you think is the worst case scenario from here?
CG: The doomsday scenario is falling resources; impossible decisions to be made; and a global disenchantment around this area such that communities are completely discouraged, and that the optimism and the energy is lost; that the epidemic continues, then, to go out of control, and that this unique opportunity with the global commitment is lost.
We have an opportunity now, and if we screw up, that’s it. This is a critical time. The doomsday scenario is the funding is reduced, the political commitment goes away, and the epidemic just continues. I don’t think it will happen because I think there is enough recognition at all levels of what a threat HIV is.
I am not personally a doomsday scenario person, but I think it is an important question to pose because the threat of failure now, would be catastrophic, and I do not see if we failed now, how we would ever be able to get back into the same position of being able to confront this epidemic head on and actually have some confidence that we could reverse it. It was very difficult for communities to take on board a prevention-only message. They didn’t want to hear. Now we can do treatment and prevention together. It’s a positive message. It’s a reinforcing message, and I think we can turn the corner… We can’t even think about failure.
(ends)
Thank you to HDN Key Correspondent Team for conducting this interview on behalf of the ACW campaign.
Dr. Gilks has been working in the HIV/AIDS field since 1988, largely in Africa, and has seen first hand how the epidemic has grown out of control, with the suffering and untimely death of hundreds of his patients, and the distortions imposed on already weak health care systems. Based in Kenya for five years, his team was the first to highlight the importance of bacterial infections in HIV/AIDS patients in Africa, and more recently, the interaction of HIV with malaria.
After becoming a Professor at the Liverpool School of Tropical Medicine, his team evaluated several interventions to try to preserve the health of people falling sick with HIV. Some worked but most did not. The inescapable conclusion was that only anti-retroviral therapy will prolong life and restore quality of life, a fact well recognised in the US and Europe.
He is one of the Principal Investigators for the DART trial, a multicentre, multicountry trial of treatment strategies in Uganda and Zimbabwe, the largest antiretroviral treatment trial in Africa.
****************************************
ACW: Can you tell us a little about your recent work?
CG: I have been working in WHO for several years and have been intimately involved with the ‘3by5’ initiative from its first description. I led a lot of the initial work and the development of the strategy and its launch and then its subsequent delivery and I would like to believe in the success of ‘3by5’ – of putting treatment permanently on the agenda, and actually moving from the treatment being regarded as something that was not affordable and obtainable in most resource-poor countries – which is where we were December 1st 2003, and when we launched ‘3by5’.
We had the treatment target. We also had the treatment goal which was universal access.
Many people thought in 2003 it was lunacy, that it was suicidal for an international agency to commit to, and that we would never get there. We have gone from lunacy to global policy in two years and I think that is probably one of the most stunning public health achievements, and we need to have some recognition of that.
We have had slippage on the target numbers. The target was there to really push countries to take responsibility for treating their own citizens. Many have done. We always knew it was going to be difficult to roll it out. But the commitment is there, the momentum is there, communities are engaged and beginning to be much more open about demanding this. And I think it has worked. History will say we did the right thing.
ACW: The vast majority of people with HIV/AIDS (PWHA) do not have access to antiretroviral (ARV) drugs. Can you comment on current progress in scaling up antiretroviral (ARV) provision in your context? What are the consequences of the delay in expanding ARV access?
CG: In our position at WHO we have seen major advances in some countries and slower progress in others, slower than we would have anticipated or wanted. The reality is that in many countries people don’t just lack access to ARVs they actually lack access to any sort of quality health services.
The real challenge is to deliver ARVs – not just to start people on treatment but to deliver quality care which is necessary to get the treatment benefit of ARVs. We actually have to build a functioning health service, and that includes supply chain management and procurement; it includes training staff and supervision, ensuring they have better conditions of work.
We focussed on a numerical target but we have always recognised that beyond the target there are some extremely challenging health systems issues. We deliberately did not emphasise those at the beginning because we did not want didn’t want any distraction from the need to start treatment initiatives.
ACW: Comprehensive HIV/AIDS care ranges from HIV counselling and testing services through to palliative care for those close to the end of life. Aside from ARVs, which other care and treatment options do you think are likely to add years or quality to someone's life?
CG: We have recently completely revised the global guidelines in light of some new evidence. One of the problems with a simple slogan like ‘3by5’ is that it has not captured the fact that the care continuum starts with the identification of infection, and then leads through routinely following up the child or the adult with infection, to see how they are progressing, and to identify the relevant points to start OI [opportunistic infection] prophylaxis, and then to start treatment, before people get very sick.
We are playing catch up in many places because there are so many people who are already sick, but we have got to look forward to develop the proper programmes. Cotrimoxizole and Isoniazid will prolong survival if they are used appropriately.
The other issue that we haven’t paid enough attention to is the nutrition issue. From a household point of view, if you have nutritional stress, that is often more important, actually, than even cotrimoxizole or ARVs, and we believe that you can’t give treatment to somebody who is starving, so we have got to do more work on nutrition.
Finally, of course, you come to the treatment interventions. Our public health approach has been to try and simplify and standardise these interventions so that they can be rolled out outside of specialist centres. I think it has been one of the key developments that WHO has been involved in, and it is now universally accepted that we have first-line treatment, and then when you fail first-line treatment, as we expect the majority of people eventually will, you move on to the more expensive second-line treatment with protease inhibitors.
We’re promoting the need to think about salvage options, after that, recognising that this is going to be difficult and expensive, and that actually with the first-line and second-line options exhausted, some salvage therapy is going to be difficult to construct, and therefore recognising that as with some chronic disease therapies and life threatening infections, palliative care and end-of-life care is going to be important.
ACW: People living with HIV have a much higher lifetime risk of developing a range of common, potentially fatal, and yet treatable diseases, such as TB and meningitis. Is adequate or appropriate attention being given at the national or international level to preventing and treating these conditions? Would greater attention significantly add years or quality to PWHAs lives?
CG: That is a very interesting question. I think our strategies around some of the common opportunistic infections is that it is better to prevent than to have to treat, and I think the TB work with the isoniazid preventive therapy illustrates that, and also obviously the cotrimoxizole prophylaxis interventions.
We’ve stressed the need to start that particularly in children where sadly, globally, there is very, very limited use of cotrimoxizole prophylaxis, and I think actually there are tens of thousands of very easily preventable paediatric HIV deaths.
The issue with preventing tuberculosis is more complex because of the need to exclude early active disease, and then ending up making the situation worse for the individual by just giving isoniazid alone. The standard treatment for an active tuberculosis case is triple drug or sometimes quadruple drug therapy.
If you give just one drug alone you will very quickly get resistance to that. So isoniazid prophylaxis is much more complicated to implement than cotrimoxizole. As a result we are still going to have to deal with the immense challenge of identifying TB, because it presents differently in people with underlying HIV infection.
On the positive side, it means that we are beginning to understand how TB control programmes are very important entry points for, first of all, the identification of HIV infection, and then, with or after the anti-tuberculosis treatment, the starting of anti-retroviral therapy.
Another really important opportunistic infection that is emerging as an important killer after tuberculosis, is cryptococcal meningitis. This is potentially preventable. There are trials of prevention using Fluconizol in people who are also starting on antiretroviral therapy with low CD4 counts. We await those trials with interest because if Fluconizol works, and possibly also minimises the serious but not life-threatening candida infections, that might also be an important development.
ACW: I just want to take you back to the quality or extention of life. How does this pan out in terms of quality of life for the person living with HIV or AIDS or addition of life years?
CG: Antiretroviral therapy appears to be as effective in programmes in Africa as it is in the US, and I think we can confidently look forward to 4 to 5 years of additional quality of life where you become clinical symptom free. Obviously this isn’t a cure but it takes away the weight loss and the fatigue and the minor and major opportunistic infections.
For some, at the moment, we will have started too late, because we are playing catch-up in many countries, and very sick people are presenting for care with CD4 counts in the 10s or 20s and with really very high viral loads. For them, clearly, the prognosis is sadly much less with antiretroviral therapy because it has been started too late.
I think some issues of quality of life are going to be some of the drug side effects. We know that antiretrovirals are not perfect drugs. We know each of them has a measurable toxicity. One of our major issues in the next year is to start to collect the toxicity information.
ACW: Many – if not almost all – HIV-related interventions are concerned with doing things or providing material for people. In what ways do you think affected people can be empowered to take more control of their own health? What impact do you think this would have on their day-to-day lives?
CG: When the communities are mobilised around health as a right rather than something that they are scared to ask for, I think that is an important step. Where this has happened in Europe and in North America, I think it has actually transformed the doctor-patient relationship, making it less authoritarian in its approach, much more a relationship of information-sharing. I hope that transformation will happen in resource poor countries as well, as it has happened to great positive effect in the North.
ACW: In addition to a positive frame of mind for the individual, are there other things you would suggest that an individual can do, in order to maintain and, in fact, potentially improve their health in the context of HIV infection?
CG: They obviously have to have an understanding of their own disease, and they need to adhere very carefully to their medication. I think that is one of our big challenges, that, for many people, regardless of where they live, long-term adherence to medicine is difficult. I think the most important action somebody can take, is to take control of their own treatment.
It is their illness; their responsibility, to take their medicine regularly and stay in control of their own disease. I think we are in the infancy of learning how to promote adherence in a positive way. I think we have some learning to do from other chronic diseases like blood pressure management or diabetes, where people have to take, their medications for life. So we need to start that sort of dialogue with those managing other chronic diseases where there is a wealth of experience.
ACW: Four years ago, the United Nations (UN) General Assembly held an unprecedented special session on HIV/AIDS – the first time the assembly had ever addressed a specific health issue. The resulting Declaration of Commitment on HIV/AIDS (UNGASS), signed by all member states of the UN made explicit pledges to "provide the highest attainable standard of treatment for HIV/AIDS, including the prevention and treatment of opportunistic infections and effective Anti-retroviral therapy" and "make significant progress in implementing comprehensive HIV/AIDS care strategies by 2005." Can you comment on the progress WHO has made towards fulfilling the 2001 commitments to improving comprehensive care and treatment?
CG: I think what is interesting with the UNGASS 2001 declaration is that, whilst treatment was mentioned, there was never a treatment target, because in reality in 2001, we weren’t looking towards treatment targets, or even universal access to treatment, as a right and as a goal.
Since then we’ve established targets such as ‘3by5’, so I think we have made, at the global level, huge progress beyond what was anticipated. I think, also, that that has helped increase the flow of resources that have gone to the Global Fund, the President’s Emergency Fund and the World Bank, the three major resources for global health, particularly with HIV. So, I think we have made a major difference. Obviously many other groups, partners, individuals, activist groups, have been involved, but I think our role has been fairly key.
What we haven’t done as well, is been clear, right from the start, to say that the treatment issue that we focussed on was plugging a gap, but there were existing prevention interventions that also needed to be strengthened and reinforced. Whilst we’ve put a lot of our energy into filling the gap, we should have spent more energy on reinforcing prevention, because ultimately in the long term, if we don’t prevent infection, if we just treat it alone, this won’t be sustainable.
ACW: A number of initiatives and policy activities in 2005 – for example the Millennium Development Goals (MDG) review in September, pressure among G8 governments to accelerate debt relief and increase overseas development aid, and the final benchmark of the WHO ‘3by5’ initiative – suggest that this year may be a crucial 'tipping point' that leads to greater attention to development in general and HIV/AIDS in particular. What is your feeling about this? Do you consider 2005 to be a significant year?
CG: I think it is a significant year because it is the end of ‘3by5’ because the 5 was 2005. It is an important point to review progress. We believe up to now, that much if not all of the additional financing that has come into the HIV arena is new money.
Previously, there have always been concerns when a new initiative has come forward in health or agriculture that it isn’t really new money, it’s just money from the pot for that sector that is reallocated visibly to the particular priority or programme or initiative. But we believe there is substantial new money that has come into health and development. In terms of how that is maintained – we are at a critical point.
We started a lot of people on treatment, we need to start a lot more. If the money runs out, or the pledges aren’t fulfilled, we will have very difficult choices to make. I think the next year is going to be critical.
ACW: 2006, the next year…
CG: Yes, because it is going to become very apparent then, as we look at the increasing numbers on treatment, and we have more clarity on the cost and the pledges that have been made, what the long term mismatches emerging are. It will be critical, to say not just “this is happening”, but “what are we going to do about it?”
Countries need to have long term commitment, and I mean long term, I am not talking about even 5 years here, I am talking about 10 and 15 years. If they are going to plan for a chronic disease programme, they have to have some certainty that there will be the international support. If they don’t get that they will never reprioritise and increase the health budget themselves.
I don’t think we’ve got the necessary full commitment to treatment and scaled up prevention intervention. We haven’t properly included and costed the prevention component. And it will be even more costly than treatment. And we have to recognise that the prevention component is critical. This is universal access to prevention, care and treatment. We have to see it as a unified new approach.
ACW: What do we call the next chapter beyond ‘3by5’?
CG: We were lucky with ‘3by5’ that our target turned into our slogan and we got a brand out of it. It was unintentional. We need a catchy slogan. “Universal Access to Prevention, Care and Treatment and Support for HIV” isn’t particularly catchy, but we do need a brand or a slogan because it helps in our global advocacy work.
ACW: What do you see as the best case scenario for the next chapter?
CG: In the next ten years that we have truly universal access and that we can demonstrate huge prevention gains. We cannot sustain a treatment-only approach.
ACW: Perhaps not the best question to consider, but, what’s the opposite. What do you think is the worst case scenario from here?
CG: The doomsday scenario is falling resources; impossible decisions to be made; and a global disenchantment around this area such that communities are completely discouraged, and that the optimism and the energy is lost; that the epidemic continues, then, to go out of control, and that this unique opportunity with the global commitment is lost.
We have an opportunity now, and if we screw up, that’s it. This is a critical time. The doomsday scenario is the funding is reduced, the political commitment goes away, and the epidemic just continues. I don’t think it will happen because I think there is enough recognition at all levels of what a threat HIV is.
I am not personally a doomsday scenario person, but I think it is an important question to pose because the threat of failure now, would be catastrophic, and I do not see if we failed now, how we would ever be able to get back into the same position of being able to confront this epidemic head on and actually have some confidence that we could reverse it. It was very difficult for communities to take on board a prevention-only message. They didn’t want to hear. Now we can do treatment and prevention together. It’s a positive message. It’s a reinforcing message, and I think we can turn the corner… We can’t even think about failure.
(ends)
Thank you to HDN Key Correspondent Team for conducting this interview on behalf of the ACW campaign.
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