Washington, D.C. — In our lifetime no disease has caused the havoc that the AIDS epidemic has, in the view of Dr. Wiliam H. Foege, a senior advisor on global health affairs to the Bill and Melinda Gates Foundation in Seattle, Washington. Dr. Foege was previously executive director of the Carter Center in Atlanta, Georgia and before that director of the Centers for Disease Control in Atlanta. The foundation has made the HIV/AIDS its top health priority and announced Monday that it will commit US$100 million to the Global Fund for AIDS and Health. AllAfrica's Charles Cobb Jr. spoke with Dr. Foege by telephone. Excerpts:
Could you put the AIDS epidemic in Africa in perspective for us?
We've not see anything like this in our lifetime. People often go back to the black plague as the closest example where the population of Europe was decreased by probably a third. With AIDS we now see such an explosive outbreak in Africa that people often say teachers are dying faster than they can be replaced, health workers are dying faster than they can be replaced. We look at the situation with orphans and we realize that this [AIDS] really is renting the cloth - the very fabric of African society. So it's just a major problem in our life now.
What about the relationship of AIDS in Africa to other infectious diseases; TB, malaria, and so forth?
I've come to the conclusion that one can't talk separately about AIDS and TB in Africa. The two are so closely linked that by convention -- WHO [World Health Organization] convention -- you list a single cause of death and so these are listed as AIDS deaths. But we know from studies in Botswana, for instance, that 60% of the deaths are actually the result of TB at the end, so you really can't separate them. How does this compare to other things? The two together -- AIDS and TB -- probably account for about 23% of the total burden of illness in Africa using the World Bank's approach of disability adjusted life years. There's nothing that comes close to that. You have to go to such things as injuries, malaria, respiratory diseases, each accounting for about 10% of the burden, so that puts it in perspective, that AIDS and TB together are far and away the largest share of the burden of disease in Africa at this time.
Would it be fair to say that is at the top of the list of the foundation's priorities given this kind of horrific picture you've just drawn?
That's right. To stop transmission of AIDS is our priority at the moment. We put a lot of attention in the past on vaccine preventable diseases and, of course, our hope is that AIDS will become a vaccine preventable disease so we put a lot of money into trying to develop an AIDS vaccine.
The foundation?
That's right. The foundation has put out $126m into the quest for an AIDS vaccine.
This is in addition to this $100 million?
That's right, it's separate and in the last few years the total amount of money given by the foundation for AIDS has amounted to about $ 350 million; $126 m of that has been in the search for a vaccine, the $100 million is added to the $350 million, which brings the foundation giving for AIDS up to $450 million.
Is an AIDS vaccine even possible anytime in the near future? And where does the foundation come out on this discussion of prevention versus treatment, if that's even a fair dichotomy?
First, on the question, 'is an AIDS vaccine possible anytime in the foreseeable future?' There is one vaccine now being tested in humans in Thailand and the United States. There are two other potential vaccines they're testing, and what's called 'phase 3 testing' now is starting in Africa. It's our hope within the next few years that we will see 10, 12, 15 different vaccine candidates being tested in humans, and we think by doing this kind of parallel research -- doing as many vaccines possibilities as one can -- it will speed up the opportunity to find a vaccine that actually works. So, I'm optimistic that we will find a vaccine. The problem, of course, is that even if you had a vaccine today, it would take some years before you effectively got it out to people; and then you have the problem of all the people already incubating the HIV virus so that the pandemic itself will go on for decades even after that.
On treatment versus prevention: We have a project in Botswana attempting to look at how much of our science totally can be introduced under African conditions. Everything from the testing and the counseling of people, every prevention approach that one can think of has been going on to the treatment of STDs: the treatment of TB, treatment of opportunistic infections and even the anti-retroviral drugs, trying to determine what does it take in the way of infrastructure, laboratory support, clinical support in order to do this. But it's also true that, at the moment, we're putting a lot of our attention on prevention because we know how to prevent the spread of AIDS and one simply has to be using every prevention approach possible. Twenty years from now, people will look back and they will comment on what they wish we had done today and one of the things that they will wish is that we had done everything to stop transmission right now even before we had a vaccine.
How did you arrive at this $100 million figure?
Well, as you have been reading in the last few days, people are saying it will require 7 to 10 billion dollars in order to adequately approach the AIDS pandemic and we would like to give a sufficient amount, [hoping] that it inspires other people to ask what more could we be doing
Would you include the US government in that?
That's right, and as you know, the US government has pledged 200 million dollars as a starting gift [to the Global AIDS Fund] and we're hoping now with the UN meeting this next week, the G7 meeting next month, that we will see many people in foundations, governments, and bilateral agencies deciding this is the time to give resources because we can see some light at the end of the tunnel if we are able to get adequate resources at this time.
How will this particular 100 million dollars be used, exactly? Can you detail that at this point?
All the foundation has said is that we would like it to be used for innovative preventive approaches. The fund itself has not yet been put together; the rules have not been drawn out. We expect that much of this will happen next week at the UN meeting; that people will decide how will the fund be constituted, what will be the controls, who will make the decisions on the spending, how money actually gets to countries. I think it will require, every country that is benefiting form the fund having to have a good AIDS plan for the country and then that will become the basis for making decisions on where the money will go.
Some people have said, "Well, a number of these countries in Africa really aren't able to handle or manage the amount of money that people are talking about putting into this AIDS crisis."
Well, I've heard that, but if resources are potentially available, I think this becomes a great stimulus for a country to develop the plan and infrastructure to use those resources. Why would you expect them to have such a plan now if there were no resources even available? So, I think this becomes incentive to develop an appropriate plan, I think that there are two objectives this next week: how to dramatically decrease the transmission of AIDS and how to dramatically increase the resources available.
Since the foundation has committed to this large sum, at this point have people called you and said, in effect, 'we're inspired by your contribution and you can count on us for putting 25 million dollars in the pot or more money in the pot' or something in the pot? Are you beginning to hear something like that?
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We are having such positive feedback from organizations saying that this was exactly what was required. I don't know that we have money in the bank, as yet, just 24 hours later, but the response has been so positive that there's no question in my mind that that will be one result of this.
As you may know, South African President Thabo Mbeki is coming to the US in another week or so for a working visit for a few days. I can't resist asking you if he stopped into the Gates Foundation for a chat, given the controversy that's swirling around him, on AIDS issues, what would you tell him?
I think we would be very anxious to talk about what would actually work in SA, one of the temptations people have is always to decide how a country should run a program, where it's really up to the country to decide that, so I think we'd be anxious to sit down and talk about what would work. And we have been funding projects, one with the Kaiser Family Foundation in SA and so, I think that this is a time of great change. I was saying yesterday that there are incubation periods and we find that this is a long incubation period in an individual, that it takes years after infection usually before you see clinical symptoms but there's a long incubation period for society to actually come to the realization that this is a social problem and there's an incubation period for response. I think that we're at the end of the incubation period for a global response and that now we're going to see that people truly will develop coalitions to figure out how to get resources, the skill, the expertise, into countries to assist in stopping this pandemic.
