Washington, DC — As the HIV pandemic has become increasingly prominent as an international public policy issue, Dr. Helene D. Gayle has emerged as a central figure in governmental and multi-national mobilizations to fight the disease.
A native of Buffalo, New York, she has an undergraduate degree from Barnard College of Columbia University, a masters in public health from Johns Hopkins University and an M.D. degree from the University of Pennsylvania. A focus on pediatrics eventually led to a specialization in HIV/Aids, tuberculosis and sexually transmitted diseases, particularly among women, children and minority and international population groups.
As director of the National Center for HIV, STD and TB Prevention at the U.S. Centers for Disease Control and Prevention, she was known as one of the leading authorities in Aids research and was appointed Assistant Surgeon General of the United States and Rear Admiral of the Public Health Service. She has been a consultant to numerous international organizations, including the World Health Organizations, Unicef, the World Bank and UNAIDS.
During two decades at the CDC, she also evaluated and implemented domestic and international child survival programmes, regularly published scientific articles and received numerous awards, including the Columbia University Medal of Excellence. Honoring her as a "Lifesaver Hero," the then CDC director, Dr. David Satcher, cited her "significant contributions to the international and domestic study, control and prevention of HIV and AIDS and other infectious diseases."
Since 2001, on assignment from the CDC, Dr. Gayle has directed the Bill & Melinda Gates Foundation's HIV, TB and Reproductive Health Program. She also sits on the board of the United Nations-launched, Geneva-based Global Fund for HIV/Aids, TB, Malaria and Related Diseases, and she co-chairs the Global HIV Prevention Working Group, an international panel of HIV/AIDS experts convened by the Gates Foundation and the Henry J. Kaiser Family Foundation.
For World Aids Day, 2003, AllAfrica's Executive Editor, Akwe Amosu, asked Helene Gayle for a situation report on Africa's battle to overcome HIV.
Looking back over the past year, what were the most positive things that happened in terms of the fight against the pandemic in Africa? And what were the things that you wish there had been more progress on?
I think this has been, in many ways, a very encouraging year, particularly from the standpoint of funding. This was the year that the U.S. president announced a $15 billion commitment to the fight against HIV - and other diseases, but primarily HIV. This was the first full, totally functioning year of the Global Fund, with disbursement of resources and some examples of programmes that are actually getting started as a result of Global Fund money. And it's also the year that the World Health Organization really renewed its commitment to the fight against HIV/Aids, most notably by the announcement of the goal of [having] three million people on anti-retroviral therapy by the year 2005.
So at an international level, as well as in the United States, we see unprecedented commitment to increasing resources and increasing mobilization around HIV/Aids. I think the increased focus on access to anti-retroviral therapies is heartening. It's been a long time coming, but there are a lot of factors that make it realistic [to hope] that anti-retroviral therapy could become available on a much wider scale.
The caution to that is that we must continue to remember that access to anti-retroviral therapy must be accompanied by the same sort of enthusiastic increase in access to prevention services. We really must maintain a comprehensive approach to fighting the epidemic.
The availability of resources highlights progress at international level, to some extent. How do you feel about the big picture in Africa?
That's also, in many ways, encouraging. While we haven't seen the national declines in infections and the national declines in deaths that we hope to yet, I think we are seeing the kinds of programmes being put in place that will soon lead to those sorts of outcomes.
We see in a country like Botswana, under the leadership of President [Festus] Mogae, an aggressive stance towards HIV prevention and treatment. It's the first country that has made a commitment to providing access to anti-retroviral therapy through the public health services free to anybody who is eligible. That programme is up and running. I think it's the first programme that demonstrates that in Africa it is feasible to get anti-retroviral therapy to people in resource-poor settings. Botswana also announced the intention to increase the number of people who will be tested through the public service, which is going to have a huge impact for prevention, as well as for treatment. So I think Botswana stands out as a country that has made the kind of political commitment necessary for the right programmes to then be put into place.
But we're also seeing countries like Uganda - the first country to demonstrate that it is possible to decrease rates of HIV infection - continue to have dropping HIV prevalence over the years. They have dropped their prevalence in anti-natal women from about 30 percent in some of the large cities to now eight percent. So we're continuing to see declines in a country that was the first to give us hope in Africa that it is possible to make a difference.
I think, increasingly, we'll start to see that in other places, as major political entities, as well as health entities, within Africa take this on as a very serious commitment. What's happened in South Africa over the last few weeks - the announcement of rolling out a comprehensive plan to scale up anti-retroviral therapy, along with maintaining their focus on high-quality prevention, is again heartening, from a country where people have been watching for a long time to see what they were going to do, as it was obvious that HIV was going to have a major impact on that country.
So I think there are a lot of encouraging signs throughout Africa.
Do you think that the kind of doubts that were obviously harbored at the heart of government in South Africa - President Mbeki himself, but also ministers, have expressed doubts about the preeminent importance of fighting HIV over other problems like poverty - is that really in the past now? Are we looking at a case of "everybody on board", pressing ahead with scaling up, or is there still a kind of political battle to be fought in South Africa?
Well, I think they have made a firm commitment. They have made a firm financial commitment all along. Even though there have been concerns about whether or not the policies were moving in the right direction, South Africa has for the last five years made a major financial commitment, a major commitment of resources. This is not inconsistent for a country that has said for a long time, in many ways, through the allocation of resources, that this is a priority. I think what's heartening is that it looks like everyone is one the same page, that there is going to be an ever more aggressive moving forward, more commitment of resources.
But I think it's not surprising that a country like South Africa, with all the complexities - all the issues that they are trying to focus on in a very complex nation, with a lot of expectations - that it would take some time to figure out how this all fits in the scheme of everything else that they are trying to accomplish. In a country where equity is such an important guiding principle, the concern about the cost of anti-retroviral therapy - if you make a commitment, that it's a commitment for all - is just one of a variety of issues that they're struggling with. I think the bottom line is that there are signs that South Africa is more committed than ever to fighting the epidemic, and, hopefully, there will be the kind of support internationally to really make that happen.
What about the so-called "next-wave" countries like Ethiopia and Nigeria? We had a journalist come back from Nigeria talking about the enormous disaffection among civil society groups about what they see as their government's lack of real engagement with the HIV problem at the grassroots level. There's quite a lot being done at the level of international meetings, billboards, that kind of thing, but they say the actual hands-on business of getting services to people, is not happening.
You raise an important point. The countries that will really contribute the largest numbers of new infections are probably Ethiopia and Nigeria. They're big countries, so even if their rates don't get as high as countries like Botswana, just numbers-wise, Nigeria and Ethiopia will contribute substantially to the numbers of HIV-infected people in Africa. Clearly, we've got to look at what those countries are doing and make sure that the support is there.
Nigeria is a very complex country, a very federalized country. President Obasanjo has demonstrated real commitment to this issue, but he also has a very complex system, where states hold an incredible amount of power, where there are lots of conflicts among different states and among different regions. HIV is always able to get into the fault lines of politics and culture and all the other issues. As we well know, communities and people and nations become more vulnerable when there are those sorts of fault lines to take advantage of.
It is going to continue to be complex in Nigeria. But I do think that at the top level there is commitment. If that can now become much more rooted throughout the states, and throughout the country, Nigeria has the ability to really make progress against this epidemic.
In general, how good is the data that African governments are using?
A lot of focus needs to be on getting good information, so people can make the right policy choices. There are concerns that in many places there is a lot of undercounting. Some of it may be [a result of] not having the infrastructure. Some of it may still be intentional.
What I can say is that Africa has made a huge step forward from the early days, fifteen or twenty years ago, when people intentionally would not report the fact that they had people living with HIV and Aids, because of the concern for what it will do for the image of their nation. I think most countries now recognize that the world realizes that HIV is everyone's problem, that it doesn't disproportionately stigmatize one country or another, and that the countries that have been most willing to step forward and admit that they have a problem have actually had a better PR face, if you will. Places like Uganda and Botswana, where countries have openly said, 'This is an issue, but we're committed to openly tackling it."
Getting good data is important. It's something the World Health Organization and UNAIDS put a high priority on.
At a conference on Botswana the other day [sponsored by the Center for Strategic and International Studies in Washington, DC] one of the speakers made a very strong point about the situation of women and HIV; he argued that so long as there was not just stigma, but major cultural and legal constraint surrounding girls and women, it was going to be hard making progress against HIV on any front. This point is being made all over Africa, I know. I just wonder whether you would put it as strongly as that?
I think it's absolutely critical. Study after study has demonstrated that if a woman has economic power, if she has political power, she is more likely to be able to negotiate safer sex than if she doesn't. Or vice versa, the women who are least empowered, least economically dependent, are often the ones that have the least ability to maintain low-risk behavior themselves or to have low-risk partners.
We know that HIV is a virus that causes Aids, that it is the virus that has the most direct impact, but we recognize that people and communities are vulnerable because of broader societal issues, of which gender inequality is perhaps one of the greatest. So we ourselves, along with other organizations, are really trying to look at what that means, what are some of the things that are "intervenable." We can talk about gender and equity in a very broad sense, and recognize that societies change at a different pace. But are there some things that can be done in a concrete way today that will make an impact on the lives of women and decrease their vulnerability to HIV? That's going to have to be an important agenda as we see that more than 50 percent of new infections around the world - and about 60 percent of new infections in Africa - are occurring among women.
I want to ask you about the prevention goals that you were mentioning earlier, but I'd like to talk a little bit first about treatment. I suppose the question of how to decide who gets the treatment is temporary, in the sense that, in the long run, one hopes to have scaled up to a point where everybody who needs treatment with anti-retrovirals, ARVs, can have them.
Right.
But, in the meantime, there's a huge set of ethical and challenging decisions to be made about who should get cared for. I was looking at a case in Burundi where nearly a thousand people were being given ARVs and only 42 of them were children. Obviously children aren't able to fight their corner in the way that adults are, and there have been several comparable issues: should treatment go to educated people, as opposed to other people, because of their vital value to the nation? Should there be a priority list? I just wondered what your thoughts were about how to target treatment?
I think it's real tough. That's why I hope that there will be a vigorous enough mobilization so that we don't have to make difficult choices. But in the meantime, difficult choices may have to be made. I think those ought to be based on medical choices. Who most needs treatment? And we need clear criteria for that. And then, to the extent that it is possible, without getting into difficult social rationing, there may be some considerations for mothers, who will be able to keep children healthy longer. Or family breadwinners.
But if we can work to scale up access to treatment as rapidly as possible - which I think is doable - and too, if we have medical criteria for when people need to go onto treatment, and have that be the guiding factor, I think we can stay away from social engineering and too much rationing based on what may be very subjective judgments. I think we will look back and really question some of the criteria used for making those sorts of judgments. I think it's a dangerous precedent.
I read that in Latin America - Guatemala and Chile - they've actually held lotteries so they can deliver the limited treatment available to the winners.
Yeah, well, lotteries may be a better way than coming up with criteria for who "deserves" it and who doesn't! But the main thing is to work to get anti-retrovirals out and give access as rapidly as possible and to make sure that we have sound medical criteria for making those decisions.
Earlier this year you were part of an initiative that was trying to identify what was needed in terms of cash to support a really full range of preventative measures for countries trying to stop the spread of the virus. This is a huge issue, because you're looking for funds to handle problems that facilitate the spread of HIV, like Tuberculosis or sexually transmitted diseases or ensuring good quality nutrition, as much as for directly preventing HIV infection. Having identified that there's a four billion dollar gap, is there money available to fill that gap, and can it be mobilized in the context of the fight against HIV, given that what needs to be done covers such a diverse range of problems?
Well, the critical things that need to be done that most affect people's risk for HIV are knowable and doable. It's getting high quality information out that's appropriate to the population that's at greatest risk. It's making sure that condoms are available for those for whom that is the best option. It's making sure there are high-quality services for treating sexually transmitted diseases; getting people tested so they know whether or not they're infected and at risk of passing the virus on; getting anti-retroviral therapies to mothers who are HIV infected and pregnant; making sure that the blood supply is safe, etc. etc.
So there is a finite set of prevention services that we know can make a difference. In addition to that, we also know there are a whole range of social factors that make people vulnerable to HIV. There ought to be some work done to identify some discreet ways that one can intervene, knowing that we're not going to change society tomorrow. We're not going to wipe out poverty tomorrow but there is clearly a set of preventive services that is definable and doable.
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At the same time, we should also recognize that the scale-up of anti-retroviral therapy provides an incredible opportunity for prevention. Because, as we all know, HIV infection occurs when somebody with the infection passes it on to somebody without. As a result of treatment, we will be seeing more people who are themselves infected who didn't know that before.
Ninety-percent-plus of infected people in the developing world do not know they're HIV-infected. If there's a greater incentive to test, because treatment is available, there's also a greater opportunity to work with people who are infected to reduce the chance of transmitting on to another. So every time somebody comes in to get their treatment, we should also be treating their sexually transmitted disease. Every time somebody comes in for their treatment, we should also be talking to them about whether or not using condoms is appropriate, about reducing their risk of passing HIV on, through abstinence, monogamy, whatever the best way is. We should be making sure that a woman who is HIV-infected and pregnant has access to contraception, so that if she doesn't want to have a child the next time, she has a way of reducing the risk of passing it on. So there are a whole range of services that can be incorporated into the treatment setting that will also help to enhance HIV prevention.
Is this an area where the Gates Foundation is spending, for example on training people to do better health delivery in the clinics?
It's a variety of different things, but one of them is figuring out how to better integrate services and to make sure that people don't miss the opportunity in the context of treatment. And to also make sure that all the different factors that could influence prevention are incorporated into the treatment setting.
Even in this country, where we have had access to anti-retroviral therapy for many, many years, we're now seeing an increase in HIV among high-risk populations and an increase in other sexually transmitted diseases. So we know that when prevention services are not given equal priority with treatment, and integrated into the treatment, it's very easy for society to become complacent and forget that, ultimately, the real goal is to protect people, to prevent people from getting HIV to begin with.
I wanted to ask you about the Global Fund. It came in for a lot of criticism, some of it probably unfair but it's been perceived by some in Washington and in the US Congress, as not being worthy of funding, while on the other hand its' been accused of not fund-raising aggressively enough. Could you give me your view, as somebody who works in the field of how the Fund is doing.
I think the Fund is doing tremendously well. I'm on the board of the Global Fund, and I think that, in a very short period of time, they have been able to get an organization up and running and functioning, all at the same time. I think that's extraordinary for as complex an organization as the Global Fund is. They have already begun to disperse hundreds of millions of dollars, to get a system in place for dispersing resources, along with measures of accountability for how those resources are spent, and they have continued to be able to increase the commitments from the major donors.
Rightfully, people are asking tough questions. Those questions have been well answered, and our Congress just appropriated more resources than was originally anticipated for the Global Fund. So I think the Global Fund is moving in the right direction. As with any new entity, we need to be tough, we need to make sure it's accountable, but we also need to be realistic about what can be accomplished in what is really less than two years time.
Is [Global Fund head] Dr. Feachem asking for enough money? Is he being aggressive enough?
I think he has been, recognizing that he's had the task of both fundraising and putting in place an organization to accountably and effectively spend resources. Now that the organization is up and running, more of his focus will be on the fundraising aspect of it. But I think that all things being equal, he's done a tremendous job of both.
