Washington, DC — As World Aids Day again called attention to the continuing spread of HIV/Aids in Africa and elsewhere, AllAfrica talked to Dr. Helene Gayle, director of the U.S. Centers for Disease Control and Prevention (CDC) National Center for HIV, STD and TB Prevention. Currently, Dr. Gayle is detailed to the Bill and Melinda Gates Foundation, where she directs the HIV/AIDS and Tuberculosis program. Certified as a pediatrician, she has received numerous awards and honors, including being named Assistant Surgeon General.
She also serves on the board of the Global Fund to Fight AIDS, Tuberculosis and Malaria, which has just announced its first round of grants, despite a sizeable shortfall in requested funding. The Fund is a public/private partnership aimed a mobilizing resources and expertise for a coordinated attack on the interrelated scourges of HIV, TB and malaria.
Although the Fund's executive director, Dr. Richard Feachem, says the world has never faced a health catastrophe to rival that of Aids, contributions have been far less than hoped. The UN Secretary-General's Special Representative for HIV-Aids in Africa, Stephen Lewis, told the Namibian newspaper that the lack of support from wealthy industrial nations is a "moral default" that treats "a whole continent as expendable." The Fund estimates its need at $30 billion, but only $2 billion, of which it has collected $700,000, has been committed. We asked Dr. Gayle about the Fund.
Some critics have said that the existence of the Global Fund distracts the public from the fact that, in Stephen Lewis's words, "no one even approaches the level of commitment" that should be devoted to fighting these diseases. What do you think?
I'm actually encouraged that there is growing commitment. It is not enough, and clearly no government is doing enough. The private sector is not doing enough. But the Global Fund has been a source of increasing resource commitment to HIV, TB and malaria. So I think we as a global community need to make the call and make the case for why resources are both necessary and could be used effectively.
What do you say to someone who is not focused on this issue? What is the argument that people should be paying more attention?
I make a variety of different arguments. First - and foremost - there is a clear humanitarian imperative, when you see a disease that didn't exist about two decades ago and now is the leading cause of death in some parts of the world, that has already meant death for over 20 million people, that has changed life expectancy in parts of Africa by 20 years or more and that has reduced child survival in countries that had made huge leaps in decreasing child mortality. For all those reasons, there is a clear humanitarian interest. If we are a humane society, sitting back and watching people die is not an indication of that humanity.
But I think there are also economic imperatives. We know that countries that have over a certain level of HIV infection are likely to have decrements in their economic growth, that there are peace and stability implications. Look at the rate of NIV among the military. Look at the destabilizing impact of having a large proportion of your childhood population orphaned, who can potentially become roaming bands of children without supervision and guidance, and emotional and physical nurturing. So you look at all those different issues - the humanitarian and health imperatives, the economic imperatives, the peace and stability imperatives. There a variety of reasons, all of which I think are pretty strong arguments for why standing back and letting happen a disease for which we know many of the solutions.
New analyses say that the starvation stalking Africa is a new kind of famine - the product of disease and drought combining to wipe out the ability of communities to cope with food emergencies. Is this nexus of hunger and HIV something you and the Gates Foundation are paying a lot of attention to right now?
As a foundation that is very involved in HIV prevention, it is an issue, although it's not an area where we have specific expertise or have made particular investments. But in areas like sub-Saharan Africa, where drought has led to severe crop reductions, HIV is only going to exacerbate that.
What are the major prospects for successes in the short term, particularly for Africa?
Our main focus of work is in the area of research and development. We've invested a considerable amount in looking for increased options in the area of prevention, like HIV vaccine, like microbicides - products that women can use to reduce their chances of getting HIV. We've also invested selectively in a few countries, for instance in Botswana, where we have a project with Merck pharmaceutical to have a comprehensive prevention as well as treatment program. We've recently announced a grant for India because of the expected growth in HIV in that country, and we have some other activities. For example, working with the Kaiser Family Foundation we've invested in Health Systems Trust, an adolescent prevention program in South Africa called Love Life. And in Nigeria we're also working with Harvard University in a prevention program.
What conclusion do you draw from experiments on the ground about the impact of treatment on the rates of transmission?
There isn't data yet to demonstrate whether or not treatment has an impact in reducing infection. Studies are being done now to look at the impact. There's a theoretical possibility that by lowering the rate of virus in the blood, transmission could be decreased, but the studies haven't yet been done.
Is there not at least some anecdotal evidence that when treatment is available, people are more likely to get tested and perhaps less likely to transmit it?
Yes, there is at least good reason to believe that if people know that there is a personal reason for getting tested - that they might benefit from treatment - that that might encourage more people to get tested. There's also evidence that if people know their HIV status, that might help them be more motivated in their individual prevention. All of that is important. [We need] a better idea if in fact some of what we think could make a difference does have that kind on impact on prevention, but at this point, that's unknown.
I think there are a lot of reasons to increase access treatment that don't have anything to do with prevention. When people have a life-threatening illness, it is a humane thing to provide therapy that could improve the length and the quality of their lives.
What are the prospects for being able to prevent the "next wave" of infections in such countries as Nigeria and Ethiopia, where the infection rate is beginning to soar?
In the countries where there have been successes in reducing the spread of HIV there are things that stand out: high-level political commitment; the ability to speak openly and honestly so that HIV is de-stigmatized and people feel motivated to change behaviors and feel support to do that; providing information so that people who are unaware of the risk factors for HIV are will have that information; and making services available, like treatment for other sex transmitted diseases and access to condoms for either people who are infected or people who may engage in risky behaviors. Getting young people to delay the onset of sexual activity has been very effective. Getting people to reduce their number of partners. Getting people to know their HIV status. All those things have been demonstrated to be effective in reducing the spread of HIV.
Among the articles from African media posted on the allafrica.com site just today is one calling for HIV to be a campaign issue in Kenya, because the next Kenyan president will lead almost two million people with Aids. The Namibian Minister of Health has called for desperate measures in response to skyrocketing prevalence rates in a truck-route town on the TransKalahari highway. And in the Democratic Republic of Congo, in Katanga province, Unicef is reporting that people are speaking publicly for the first time on the issue and their illness. Does this constellation of reports signal a major change in attitude?
People are becoming more aware, taking the situation more seriously. There is a grassroots activism emerging. All those things are, I think, a good trend. I'm always a glass half full person. I continue to be very optimistic that we can turn this epidemic around.
What can a concerned public do to make that happen?
One thing is to make it known that they feel that this is a priority, so that those who represent them in key policy-making positions, people in Congress, people in the administration. Beyond that, people can contribute resources to the Global Fund and to Care, Save the Children, UNAIDS, the World Health Organization, the Elizabeth Glazer pediatric aids foundation - there are so many organizations that people can contribute resources to. Telling friends, engaging others, so that there is, in this country, growing support for this as an issue that people care about.
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About 300 groups have faxed an appeal to President Bush, calling for an increased commitment of resources? Is this an effective approach?
People organize in different ways, whether through direct mailings, groups of people working through church organizations, civic organizations. I think oftentimes people have the most influence over places where they are already members. There's a strong example of Rotary International, for instance, which took on the issue of polio eradication. Rotary had not done global health efforts before, but they took this on and said, "This is something that we want to do."
Are women, as such, becoming more involved?
I hope so. Women are more vulnerable than men to most sexually transmitted diseases. When you have a disease that is sexually transmitted, women are at great risk for biologic as well as social factors. So this is clearly a women's issue. Hopefully, women will get involved just like they have with other key issues that affect their health and the health of their families.
Should the status of women be addressed alongside the fight against Aids?
Yes. Gender inequality has a huge impact on women's ability to negotiate sexual interactions, to say no to sex, and that's particularly the case of young girls who are often the most vulnerable to sexually transmitted diseases. So the ability for women and young women to negotiate sex and determine where and when and how and under what circumstances sex occurs is a key part of this. When women are economically dependent or socially dependent on a male partner, this puts them in a difficult position to negotiate sex.
