ACW Interview: Professor Mark Wainberg
Professor Mark Wainberg of McGill University AIDS Centre and the co-chair of the upcoming International AIDS Conference (IAC), was recently in New Delhi, India to attend the first national conference of the AIDS Society of India. While there, he spoke with Health and Development Networks (HDN) about care, treatment and support for people living with HIV and about his hopes for the next IAC in Toronto, 2006.
*****
ACW: A great deal of emphasis has been placed on the scale-up of antiretroviral (ARV) drugs for people living with HIV/AIDS at this conference. In your opinion, how vital are ARVs?
Mark Wainberg: The main way to help people who are HIV positive live longer is to give them antiretroviral drugs. There is no substitute for that. Countries like India can distribute very cheap drugs made by generic companies like Cipla, Ranbaxy, to patients here [in India] because it has really become very inexpensive. And from everything we know, giving people those drugs will not just help them survive, but it will also diminish rates of transmission. So there is a public health benefit to provide these drugs.
ACW: But how will we keep the millions of people alive today, who are waiting for antiretroviral drugs to become available and affordable?
Mark Wainberg: The best way to keep people living with HIV/AIDS (PWHA) alive is to ensure that they have proper nutrition, proper emotional support, and opportunities to continue to feel that their lives are meaningful and worthwhile. Ultimately, they also have to want to live and they have to be motivated to live. This means that they need the support of their families and their friends.
At the same time, we also need to provide these people with efficient counseling so that they don’t transmit HIV to other people. They need to be told to use condoms and they need to be encouraged to be a part of universal HIV/AIDS education programme, to talk about their disease.
This means we should not have stigmatization and discrimination. We should be open about talking about HIV and AIDS and this is one of the most efficient ways to clear myths that exist about HIV.
ACW: Do you think care and support initiatives have been given adequate attention?
Mark Wainberg: I think care and support initiatives have been remarkably successful [in India] and I hope that they will continue to be successful. A lot depends upon support from governments so that people can continue to do a very effective job. Also, I think agencies such as the Gates Foundation are now very involved and committed [to India] and also are making a difference here. I think as well that we cannot be complacent, we cannot rest on our laurels, and we need to continue to always talk about AIDS in a very outspoken manner.
ACW: But in India, there is a perception that care and support doesn’t always get adequate attention. People are afraid to speak out about their status because of stigmatization, and therefore care and support doesn’t come into picture at all.
Mark Wainberg: I think first of all we should be realistic and recognize that to come out and speak openly about HIV, for somebody to say that I am HIV positive, is often very difficult.
In India, which is culturally not in the category of US or Canada, where there is more openness and more willingness to discuss such situations. I think care and support which is provided in a clandestine way to people who are not open about their HIV status, is better than no care and support. In the meantime, people who receive clandestine support should be encouraged to ultimately be more open about their HIV status. But from a cultural standpoint, we have to understand that we cannot transform a country like India overnight and it may take decades. These kinds of changes cannot happen so quickly.
ACW: In this context do you think the World Health Organization’s (WHO) ‘3 by 5’ initiative will be able to meet its goal of providing 3 million people in poor countries with ARVs by the end of this year [2005]?
Mark Wainberg: I don’t think that 3 million people will be on antiretroviral therapy by the end of 2005. But I think just this goal of attempting is worthwhile. So I praise the WHO initiative and even though I think that everyone of us will agree that if we had to chose today the regimen which would represent WHO’s ‘3 by 5’ regimen, probably we would not chose this regimen. Probably we would choose a few changes in this regimen, but it’s the only thing that has stockpiled. So it is better to be treated today with a regimen which is second best and live 2 or 3 years more, and in the meanwhile, continue to find new better drugs. That’s better than dying in 3 months.
ACW: However access to ARVs is limited. How do you ensure equitable distribution?
Mark Wainberg: You cannot. It is impossible to ensure equitable distribution. We always have to be careful to ensure that the perfect is not the enemy of the good. If you go to Africa where I think that the needs are even much greater than they are in India, of course it is easier to have efficient distribution of drugs in urban centres than in rural areas. And it will happen more efficiently and in greater numbers than in rural areas of Africa. I would like to have equality and equitable distribution but if we cannot have equitable, I take what I can get because it’s better than nothing. I will prefer to treat as many as I can than none at all if that is my choice.
ACW: What is the most important component of care and support apart from ARVs?
Mark Wainberg: While people living with HIV/AIDS (PWHA) are waiting for access to affordable ARVs, I think they need proper nutrition, proper emotional support, and they need treatment for opportunistic infections. If PWHA have tuberculosis (TB), they need to be treated properly for that and we need all those things to help them stay alive while they wait for ARVs.
ACW: What needs to be done at the country and global level to manage HIV-TB co-infection?
Mark Wainberg: Well, if somebody is co-infected with TB and HIV, individual physicians have to make a decision which [disease] should be treated first since it is very difficult to treat both diseases at the same time, because there are interactions among some of the drugs. I would say that if somebody has CD4 count that is fairly high, probably we should treat the TB first, especially if antiretrovirals are not available. On the other hand, if somebody has a very low CD4 count, you probably should treat the HIV first if you could get the antiretrovirals. If somebody has very low CD4 counts and no chance of getting antiretrovirals, and also has TB, then he or she is going to be in a very bad shape and is probably going to die.
ACW: How grave are the dangers of developing resistance to drugs and the birth of drug- resistant strains of HIV?
Mark Wainberg: If anything, the virus becomes a little weaker in this situation. But, this is not good news because drugs won’t work in the same efficient way, and we shouldn’t forget that people die of resistant viruses all the time. In the United States a major reason why people die of AIDS is because of drug resistance. So drug resistance is bad news and we have to manage the situation.
There is no question that as we embark on treatment scale-up [in India] there will be more drug resistance. It’s obvious. We have to hope that there will be more new drugs in the next 2, 3 or 4 years that India will have access to, and we will be able to use those drugs as second line regimens and people will survive. In India, there are not enough trained HIV physicians but there are major training programmes that are underway.
ACW: Is there a need to challenge global treatment policy so as to include other components of care and support apart from ARVs?
Mark Wainberg: The World Health Organization is sometimes very defensive about being criticized. But I think they should recognize and should not be ashamed to say that if the ‘3 by 5’ regimen has been stockpiled, practically this is what people must take to survive as we continue to work trying to change this regimen in the next 2 or 3 years. I don’t think that will be so terrible for them to admit. I am surprised that they didn’t do it already.
ACW: Have you heard about the new AIDS-Care-Watch campaign and do you support its initiatives?
Mark Wainberg: Yes, Certainly I have read about AIDS-Care-Watch. Do keep up the good work. I think it is fine but I certainly hope with all my heart that the people who need ARVs don’t have to wait much longer.
ACW: The next International AIDS Conference will be held under your guidance in Toronto in 2006. What kind of progress have you made to encourage Canadian authorities to relax their entry requirements vis-a-vis declaration of their HIV status?
Mark Wainberg: Canada has no official policy to discriminate against people living with HIV/AIDS. When somebody from other countries like India require a visa to go to Canada to attend the conference, the visa form may ask the question ‘Do you suffer from any form of chronic illness or infectious disease?’
If you say ‘yes’ for this question, there is a possibility that you will have difficulty obtaining the visa. So we are now working together with Canadian Government officials to change the visa application form. It will be easier for people to get visas because this question will be changed and will no longer appear on the visa application form.
ACW: Who is the International AIDS conference for?
Mark Wainberg: In the beginning International AIDS Conference began as a purely scientific conference and for scientists alone. Over the years it has transformed into a major political event and community forum. Today, it is for everybody, scientists, community activists, people living with HIV/AIDS, and for politicians.
ACW: What is the main focus of IAC 2006 going to be?
Mark Wainberg: I would like to see the major focus of the Toronto conference to be on a theme which was related to the theme at Bangkok [Access for All].
I think the Toronto conference should have something very similar theme. The question to be asked at this conference will be about the promises made in Bangkok, Barcelona and earlier too. By ‘we’ I mean the developed countries, which made promises to developing countries that they would work together towards access for all. Have we fulfilled that promise? Certainly not. Why haven’t we fulfilled the promises? What must we do now to keep our promises? These are some of the issues that would be raised.
ACW: What is going to motivate people to attend the conference?
Mark Wainberg: I think the Toronto conference should be of interest to people from the community both – living and not living with HIV/AIDS. It will be certainly an opportune time to interact.
Of course we also want the Toronto Conference to be a very important scientific conference in which many breakthroughs are presented with regard to treatment, basic science, vaccine development and so forth. The International AIDS Conference tries to bring all things to all people and I think we should continue to try to do that.
ACW: How will the IAC 2006 conference connect policy to the people?
Mark Wainberg: This is really the role that should be played by the Canadian Government. As organizers we have involved many ministers very early on in this process. The Canadian minister for health will see this as an opportunity to speak and involve ministers of health from other countries. In terms of helping to formulate a global policy, we hope that the Canadian minister for international cooperation, who directs Canada’s International Assistance Programme, will want to interact with ministers of health from developing countries and also with ministers who are responsible for assistance from France, US and UK, and others towards establishing programmes that will put money on the table for purchase of ARVs.
Fortunately, increasingly we do have politicians who are committed to this cause and they want to make a difference. Political will is much greater than it has ever been. Whether we will be able to translate political will into achievement is what we will find out. I think the Toronto conference has great potential to establish policy in a very forward-moving direction. I do hope that after Toronto conference, the next International AIDS Conference will be in India.
HDN Key Correspondent Team
Email: correspondents@hdnet.org
(April 2005)
*****
ACW: A great deal of emphasis has been placed on the scale-up of antiretroviral (ARV) drugs for people living with HIV/AIDS at this conference. In your opinion, how vital are ARVs?
Mark Wainberg: The main way to help people who are HIV positive live longer is to give them antiretroviral drugs. There is no substitute for that. Countries like India can distribute very cheap drugs made by generic companies like Cipla, Ranbaxy, to patients here [in India] because it has really become very inexpensive. And from everything we know, giving people those drugs will not just help them survive, but it will also diminish rates of transmission. So there is a public health benefit to provide these drugs.
ACW: But how will we keep the millions of people alive today, who are waiting for antiretroviral drugs to become available and affordable?
Mark Wainberg: The best way to keep people living with HIV/AIDS (PWHA) alive is to ensure that they have proper nutrition, proper emotional support, and opportunities to continue to feel that their lives are meaningful and worthwhile. Ultimately, they also have to want to live and they have to be motivated to live. This means that they need the support of their families and their friends.
At the same time, we also need to provide these people with efficient counseling so that they don’t transmit HIV to other people. They need to be told to use condoms and they need to be encouraged to be a part of universal HIV/AIDS education programme, to talk about their disease.
This means we should not have stigmatization and discrimination. We should be open about talking about HIV and AIDS and this is one of the most efficient ways to clear myths that exist about HIV.
ACW: Do you think care and support initiatives have been given adequate attention?
Mark Wainberg: I think care and support initiatives have been remarkably successful [in India] and I hope that they will continue to be successful. A lot depends upon support from governments so that people can continue to do a very effective job. Also, I think agencies such as the Gates Foundation are now very involved and committed [to India] and also are making a difference here. I think as well that we cannot be complacent, we cannot rest on our laurels, and we need to continue to always talk about AIDS in a very outspoken manner.
ACW: But in India, there is a perception that care and support doesn’t always get adequate attention. People are afraid to speak out about their status because of stigmatization, and therefore care and support doesn’t come into picture at all.
Mark Wainberg: I think first of all we should be realistic and recognize that to come out and speak openly about HIV, for somebody to say that I am HIV positive, is often very difficult.
In India, which is culturally not in the category of US or Canada, where there is more openness and more willingness to discuss such situations. I think care and support which is provided in a clandestine way to people who are not open about their HIV status, is better than no care and support. In the meantime, people who receive clandestine support should be encouraged to ultimately be more open about their HIV status. But from a cultural standpoint, we have to understand that we cannot transform a country like India overnight and it may take decades. These kinds of changes cannot happen so quickly.
ACW: In this context do you think the World Health Organization’s (WHO) ‘3 by 5’ initiative will be able to meet its goal of providing 3 million people in poor countries with ARVs by the end of this year [2005]?
Mark Wainberg: I don’t think that 3 million people will be on antiretroviral therapy by the end of 2005. But I think just this goal of attempting is worthwhile. So I praise the WHO initiative and even though I think that everyone of us will agree that if we had to chose today the regimen which would represent WHO’s ‘3 by 5’ regimen, probably we would not chose this regimen. Probably we would choose a few changes in this regimen, but it’s the only thing that has stockpiled. So it is better to be treated today with a regimen which is second best and live 2 or 3 years more, and in the meanwhile, continue to find new better drugs. That’s better than dying in 3 months.
ACW: However access to ARVs is limited. How do you ensure equitable distribution?
Mark Wainberg: You cannot. It is impossible to ensure equitable distribution. We always have to be careful to ensure that the perfect is not the enemy of the good. If you go to Africa where I think that the needs are even much greater than they are in India, of course it is easier to have efficient distribution of drugs in urban centres than in rural areas. And it will happen more efficiently and in greater numbers than in rural areas of Africa. I would like to have equality and equitable distribution but if we cannot have equitable, I take what I can get because it’s better than nothing. I will prefer to treat as many as I can than none at all if that is my choice.
ACW: What is the most important component of care and support apart from ARVs?
Mark Wainberg: While people living with HIV/AIDS (PWHA) are waiting for access to affordable ARVs, I think they need proper nutrition, proper emotional support, and they need treatment for opportunistic infections. If PWHA have tuberculosis (TB), they need to be treated properly for that and we need all those things to help them stay alive while they wait for ARVs.
ACW: What needs to be done at the country and global level to manage HIV-TB co-infection?
Mark Wainberg: Well, if somebody is co-infected with TB and HIV, individual physicians have to make a decision which [disease] should be treated first since it is very difficult to treat both diseases at the same time, because there are interactions among some of the drugs. I would say that if somebody has CD4 count that is fairly high, probably we should treat the TB first, especially if antiretrovirals are not available. On the other hand, if somebody has a very low CD4 count, you probably should treat the HIV first if you could get the antiretrovirals. If somebody has very low CD4 counts and no chance of getting antiretrovirals, and also has TB, then he or she is going to be in a very bad shape and is probably going to die.
ACW: How grave are the dangers of developing resistance to drugs and the birth of drug- resistant strains of HIV?
Mark Wainberg: If anything, the virus becomes a little weaker in this situation. But, this is not good news because drugs won’t work in the same efficient way, and we shouldn’t forget that people die of resistant viruses all the time. In the United States a major reason why people die of AIDS is because of drug resistance. So drug resistance is bad news and we have to manage the situation.
There is no question that as we embark on treatment scale-up [in India] there will be more drug resistance. It’s obvious. We have to hope that there will be more new drugs in the next 2, 3 or 4 years that India will have access to, and we will be able to use those drugs as second line regimens and people will survive. In India, there are not enough trained HIV physicians but there are major training programmes that are underway.
ACW: Is there a need to challenge global treatment policy so as to include other components of care and support apart from ARVs?
Mark Wainberg: The World Health Organization is sometimes very defensive about being criticized. But I think they should recognize and should not be ashamed to say that if the ‘3 by 5’ regimen has been stockpiled, practically this is what people must take to survive as we continue to work trying to change this regimen in the next 2 or 3 years. I don’t think that will be so terrible for them to admit. I am surprised that they didn’t do it already.
ACW: Have you heard about the new AIDS-Care-Watch campaign and do you support its initiatives?
Mark Wainberg: Yes, Certainly I have read about AIDS-Care-Watch. Do keep up the good work. I think it is fine but I certainly hope with all my heart that the people who need ARVs don’t have to wait much longer.
ACW: The next International AIDS Conference will be held under your guidance in Toronto in 2006. What kind of progress have you made to encourage Canadian authorities to relax their entry requirements vis-a-vis declaration of their HIV status?
Mark Wainberg: Canada has no official policy to discriminate against people living with HIV/AIDS. When somebody from other countries like India require a visa to go to Canada to attend the conference, the visa form may ask the question ‘Do you suffer from any form of chronic illness or infectious disease?’
If you say ‘yes’ for this question, there is a possibility that you will have difficulty obtaining the visa. So we are now working together with Canadian Government officials to change the visa application form. It will be easier for people to get visas because this question will be changed and will no longer appear on the visa application form.
ACW: Who is the International AIDS conference for?
Mark Wainberg: In the beginning International AIDS Conference began as a purely scientific conference and for scientists alone. Over the years it has transformed into a major political event and community forum. Today, it is for everybody, scientists, community activists, people living with HIV/AIDS, and for politicians.
ACW: What is the main focus of IAC 2006 going to be?
Mark Wainberg: I would like to see the major focus of the Toronto conference to be on a theme which was related to the theme at Bangkok [Access for All].
I think the Toronto conference should have something very similar theme. The question to be asked at this conference will be about the promises made in Bangkok, Barcelona and earlier too. By ‘we’ I mean the developed countries, which made promises to developing countries that they would work together towards access for all. Have we fulfilled that promise? Certainly not. Why haven’t we fulfilled the promises? What must we do now to keep our promises? These are some of the issues that would be raised.
ACW: What is going to motivate people to attend the conference?
Mark Wainberg: I think the Toronto conference should be of interest to people from the community both – living and not living with HIV/AIDS. It will be certainly an opportune time to interact.
Of course we also want the Toronto Conference to be a very important scientific conference in which many breakthroughs are presented with regard to treatment, basic science, vaccine development and so forth. The International AIDS Conference tries to bring all things to all people and I think we should continue to try to do that.
ACW: How will the IAC 2006 conference connect policy to the people?
Mark Wainberg: This is really the role that should be played by the Canadian Government. As organizers we have involved many ministers very early on in this process. The Canadian minister for health will see this as an opportunity to speak and involve ministers of health from other countries. In terms of helping to formulate a global policy, we hope that the Canadian minister for international cooperation, who directs Canada’s International Assistance Programme, will want to interact with ministers of health from developing countries and also with ministers who are responsible for assistance from France, US and UK, and others towards establishing programmes that will put money on the table for purchase of ARVs.
Fortunately, increasingly we do have politicians who are committed to this cause and they want to make a difference. Political will is much greater than it has ever been. Whether we will be able to translate political will into achievement is what we will find out. I think the Toronto conference has great potential to establish policy in a very forward-moving direction. I do hope that after Toronto conference, the next International AIDS Conference will be in India.
HDN Key Correspondent Team
Email: correspondents@hdnet.org
(April 2005)
posted by AIDS-Care-Watch at 4:30 pm
0 comments
