Ask the experts: Combating Aids 2009

What are the prospects for improving prevention and treatment of HIV, what more needs to be done and how can we balance efforts to tackle the infection with other health and development priorities?

Read the combating Aids special report

On Tuesday December 1, World Aids Day 2009 :

Michel Kazatchkine, executive director of the Global Fund to fight Aids, TB and Malaria, a doctor and France’s former Aids ambassador and
Peter Piot, head of the Institute for Global Health at Imperial College, London, and former executive director of UNAids, the United Nations’ Aids agency

Answered questions as follows:

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Should the Global Fund modify its country-led approach, to ensure money is used more cost effectively (eg on pooled procurement) and in line with best evidence (eg more targeted prevention)?

Michel Kazatchkine: The Global Fund is the only donor in the field of health that is truly country-driven. In that respect it has played a pioneering role. In the case of the Global Fund, an independent international expert committee reviews country proposals and assesses them e.g. it makes sure that the prevention programmes for which funding is sought are targeted to the specific needs arising from the epidemiological context in a given country. Pooled procurement of drugs and commodities (e.g. bed nets) is now offered as an option on a voluntary basis to countries that are recipients of Global Fund grants.

Peter Piot: The country-led approach of the Global Fund should remain, as it is the best guarantee for relevance and ownership of Aids programmes. However, as the Fund is starting to do, stronger conditionality should be set to ensure that country programmes are based on best evidence. Pooled procurement should also become an option.

Is it risky to launch a tenth round of funding when existing rounds are not fully funded and the financial crisis risks slowing momentum further?

Michel Kazatchkine: Our Board debated extensively what would be the ”best” timing for launching round 10 of grant-giving and decided that the risk it was taking in deciding to launch it next March (although it is still subject to final approval from our board in April 2010) was less than that of delaying action and of thereby losing the momentum that has been generated by making annual calls for countries to put forward requests for funding for health programmes.

Peter Piot: The Fund should have a tenth round of funding, but limited to low income countries with high aids, TB or malaria burden, and taking into account performance and other funding sources, in particular the US Government.

Have we wasted money on prevention, given the continued rising infection rates?

Peter Piot: HIV infection rates are actually declining in nearly all developing countries (not in some European countries...), but obviously we need to much better focus our efforts on where the highest risks of transmission are. However, we should bear in mind that transmission patterns evolve over time. For example, transmission in stable couples now accounts for the largest proportion of new HIV infections in several African countries, and in South East Asia.

Michel Kazatchkine: What happened is (1) that not enough funding has been invested in the prevention interventions of proven efficacy (e.g. condom distribution or else, harm reduction for intravenous drug users) to bring them to people who need them on a sufficient scale and (2) that in a number of country’s interventions, of insufficient relevance to the ongoing epidemic, have long been and are still in a number of instances, being implemented.

Doesn’t more need to be done to ensure countries monitor patients in the long term rather than being rewarded for new recruits to treatment, without which drug resistance is likely to grow fast?

Michel Kazatchkine: Countries do not seek to be ”rewarded” when initiating antitretroviral therapy programmes, but to save lives. The epidemic remains an emergency for millions around the world. This is in no way rules out improving the monitoring of virological and immunological failures and of drug resistance. Indeed this should improve even further the extension of life expectancy brought about by antiretroviral drugs.

Peter Piot: I agree that we should move from a nearly exclusive focus on enrolling new patients to ensuring patients remain under treatment.

Is it really in the economic as well as social interest of business to help support HIV and the Global Fund?

Michel Kazatchkine: There are many ways for companies to donate to the Global Fund. It can be in the form of cash donations, it may be by enrolling in a (RED) programme, it may be by providing pro bono services to grant recipients. Companies who have contributed in any one of these ways clearly see a social benefit in addition to gaining increased visibility.

Should the Fund and other agencies accept donated pharmaceuticals and other medical products from industry?

Michel Kazatchkine: This has been a topic of debate for several years at our Board which, once again, recently stated that it does not want the Global Fund to receive donations of drugs. To put it somewhat simplistically, it would rather see more drugs at reduced prices than drugs at high prices accompanied by drug donations.

If there has to be a painful trade off in funding, should prevention be given greater priority than further expansion in treatment?

Michel Kazatchkine: It is not a matter of one vs the other. Access to testing is a key element of prevention strategies and understandably people would not consider to be tested if there was no hope for treatment if the test was to be positive. Also, there is growing evidence that large scale treatment reduces the reservoir of transmitters and thus has a preventative effect. Finally, boundaries between what is prevention and what is treatment may be ill-defined, e.g. when it comes to antiretroviral therapy to prevent mother to child transmission of HIV. Anti-HIV strategies need to integrate both components.

Peter Piot: We clearly have to give much higher priority to HIV prevention, but for both treatment and prevention we also need to focus much better our resources where they can make a difference, and improve management, programme delivery and content of prevention programmes. In addition efficiency gains can be made by better linking treatment and prevention, and develop other programmatic synergies. Trade offs should be made in function of local epidemiology and needs, not globally.

Adjusted for impact, ”lifting all boats” to continued increasing HIV funding and that of all other high impact diseases would likely require a 5-10 fold increase in global health spending. How realistic is it, especially in the middle of a recession, to have that happen any time soon?

Peter Piot: You are right, meeting all needs in terms of health in low and middle income countries will require a major boost in funding - in addition to the mega needs to deal with climate change, and in a time of continuing financial crisis and enormous budget deficits in many countries. Where would the money come from? It is clear that we need additional and alternative approaches for Aids funding, and that we need to greatly increase the efficiency of what we do. On the former, international agencies such as the Global Fund should focus on the countries in greatest needs, and make the tough political choice of stopping funding middle income countries - with the exception of those experiencing hyper endemic HIV. On the latter, we can save costs through better targeting prevention interventions on those at greatest risk, eliminate most expensive laboratory treatment monitoring following the results of the DART trial in Africa (up to 30% cost savings), better integrating treatment and prevention of mother to child transmission prevention with existing clinical services (but increase community based HIV prevention), and breaking the taboo of reducing costs and number of intermediaries used by funding agencies. Finally, it will be crucial to maintain Aids on the political agenda.

Michel Kazatchkine: Yes indeed, more resources will be needed. The amounts are not unrealistic in view of the human, societal, developmental and economic benefits that are expected. The crisis clearly adds to the challenges.

Thus more efforts are needed in diversifying the sources of financing(e.g. through the so-called innovative financing mechanisms) involving all sectors (public and private) in creative ways. But sustainability and expansion of programs is not only about resources. It is also about spending the funding more efficiently (particularly through strengthening partnerships between agencies and between sectors at country level), targeting the interventions (e.g. prevention) to those who are most in need, addressing the challenges of weak health systems, and creating an enabling policy environment to fight stigma and discrimination.

Peter Piot co-authored a study 20 years ago showing a very dramatic protective effect of male circumcision, so why have the international agencies only in the past 2 years finally woken up to this important co-factor for transmission/prevention?

Peter Piot: Male circumcision is undoubtedly one of the major breakthroughs in prevention interventions. It is correct that our research collaboration at the University of Nairobi found a statistical association between lack of male circumcision and the risk of HIV acquisition. However, a statistical association does not necessarily mean causation, as found over and over again in epidemiologic research. This is particularly the case when we are dealing with an issue such as circumcision which is confounded by cultural and religious factors. The evidence for a causal relationship came out of three controlled clinical trials in Africa, paving the way for a strong policy recommendation and programme implementation. We now have the benefit of hindsight, but it would have irresponsible to recommend a major policy change in the absence of scientific evidence. Another epidemiological association with HIV transmission, herpes simplex infection, did not pass the test of controlled clinical trial, and therefore cannot be recommended as an intervention, illustrating that we need to be careful in our interpretation of epidemiological data.

Michel Kazatchkine: You are right, circumcision was identified as likely to be protective in early observational studies. It then took a prospective and randomized trial in South Africa (the ANRS-sponsored Orange county study) to demonstrate that circumcising adult males has a strong protective effect on HIV acquisition. The results were further supported by two additional prospective trials leading eventually to WHO and Unaids recommendations. International funders such as the Global Fund are committed to fund prevention programs including circumcision. However it will take time before acceptability, safety and feasibility are addressed at country level to an extent that would allow large-scale population-level implementation.

A recent article has suggested that a low cost treatment with praziquantel aimed at young females would prevent female genital schistosomiasis which in turn would reduce the transmission risk of HIV in young women. Would the panel support the mass treatment of school age girls with praziquantel to reduce the risk of Aids?

Peter Piot: Whereas an association between urogenital schistosomiasis and HIV infection has been found in a few studies, there is no evidence as yet that praziquantel treatment would reduce the risk of HIV acquisition in women. A (very complex and large scale) controlled trial is necessary to prove this hypothesis.

Michel Kazatchkine: A number of studies have suggested that infections of the genital tract may result in an increased risk of HIV acquisition. Some co-infections are better documented (e.g HSV2) than others in being a risk factor for HIV infection. No strong evidence is available with regard to schistosomiasis. And there is no randomised trial or population-level study that would, at this time, support the hypothesis that mass treatment of young women for schistosomiasis would decrease their risk of becoming infected with HIV upon exposure to the virus.

In Subsaharan Africa, over 60 percent of adults, and 75 percent of young people ages 15-24, living with HIV are female. What specific changes are needed in national Aids programmes to reduce girls’ and women’s vulnerability?

Peter Piot: The greater vulnerability of women and girls to HIV infection will require more attention at several levels: accelerate microbicide and pre-exposure prophylaxis research; designing prevention programmes in such a way that they meet women’s needs; getting serious about interventions addressing women’s vulnerability to problems such as sexual violence; programmes to change social norms, in particular concerning men’s sexual behaviour; making sure women are at the table when decisions are made.

Michel Kazatchkine: We need both changes and a scaling-up of existing interventions targeting young women. There is also a strong need for better integration of HIV testing and counselling with sexual and reproductive health services (often hardly available in settings where HIV incidence is high), a need to address social determinants of risk, e.g. disempowerment and violence against women and inter-generational sex. And there is a need to increase research efforts to provide women with the means to protect themselves, i.e. microbicides or pre-exposure prophylaxis with antiretroviral drugs.

The female condom is the only protective method that women can initiate, and it has strong uptake in Africa when offered, but it is not widely available. What three actions would make it widely accessible?

Michel Kazatchkine: There are no ”three” such measures. It is essential that female condoms are made available free or at affordable prices in any national prevention program.

Peter Piot: The female condom should be part of the options of HIV prevention methods. They should be subsidised, and promoted as part of prevention programmes.

A UN Aids report last week was quoted as saying: treatment for HIV may be one of the best future forms of prevention of the disease. I may be misunderstanding the message, but surely that flies in the face of experience, since UK infection rates have started rising again since the efficacy of HAART (and the ease of taking it) rose and HIV infection in western nations came to be seen as a manageable chronic condition rather than a terminal disease. And if it meant that the reduction in viral loads from treatment meant infection was more difficult, that surely is a risky idea to put about and slightly ignore the possibility of cross-infection. What are your thoughts?

Peter Piot: If Unaids really stated that treatment is prevention, I would be interested in knowing what the evidence is, as it is not in the literature. There is some biological rationale, and mathematical modelling support for a prevention effect of antiretroviral therapy, but we still lack the scientific evidence, and the situation in Europe indeed does not support such a hypothesis as you mention. This is an important research question, and we urgently need large scale population-based research to resolve this question

How would you compare the effectiveness of prevention campaigns in different countries? What works better - hands-on government involvement or leaving it to the private and charitable sectors?

Peter Piot: What works best in HIV prevention is combination prevention: combination of methods, and a combination of actors. There is no magic bullet, nor a single solution

How are matters improving in South Africa under the new Zuma administration?

Peter Piot: The official aids response in South Africa has significantly improved over the past year, but the challenges are daunting