- The Washington Times - Sunday, May 16, 2004

Richard G.A. Feachem is executive director of the Global Fund to fight AIDS, tuberculosis and malaria. He was interviewed last week in Geneva by John Zarocostas for The Washington Times and asked about the status of global efforts to stem the spread of the AIDS epidemic. International AIDS Day was marked worldwide yesterday.

Question: The World Health Organization report last week, “Changing History,” carried an optimistic tone about the global fight to contain the HIV/AIDS epidemic. Is that a fair assessment?

Answer: It is a fair assessment. There is a mood of optimism in the world today for the first time in the more than two decades of the HIV/AIDS epidemic.

The optimism is based on the fact that the three preconditions for a successful counterattack are now in place. And they are: leadership, affordable and practical technologies, and large amounts of additional finance. We now have sufficient quantities of those three preconditions to feel optimistic about making a big difference in the next five years.

Q: The new study says there will be a lot of attention on treatment, especially antiretroviral treatment, for people in poor countries who now can’t afford it. And I understand you hope to reach at least 3 million by the end of 2005. Can you elaborate a bit on this target?

A: Yes, the counterattack against HIV/AIDS is based on prevention — which is extremely important, and we need to do a lot more in the field of prevention. Second, on voluntary counseling and testing, encouraging people to come forward and determine whether they are HIV-positive or negative. And third, treatment and the availability of antiretroviral medicine.

It’s the treatment component that’s been so weak until now. And the campaign we have begun — the 3 by 5 campaign — is to get 3 million people on antiretroviral therapy by the end of the year 2005, and that will give a big boost to the overall effort.

Q: I suppose a lot of resources will go to sub-Saharan Africa?

A: That’s correct. The epicenter of the HIV/AIDS epidemic today is in Africa, and the greatest need for treatment is in Africa. About 60 percent of the Global Fund does go to Africa today, and we don’t expect that figure to change.

However, other parts of the world — India, China, Russia, Latin America — also urgently need to scale up access to treatment. So it’s mainly Africa, but it is by no means only Africa.

Q: You are sounding alarm bells about India, in particular, and to an extent, some of the countries in Eastern Europe, the Ukraine and Russia. What are your concerns about there?

A: These are sometimes called the “new wave” countries of the HIV/AIDS epidemic … and are of great concern. Epidemics in those countries are running roughly 15 years behind the African epidemic … but the numbers are climbing very rapidly.

In most of these “new-wave countries,” the effort under way today is insufficient to prevent catastrophe.

In countries like India, for example, we need to do a lot more in prevention. We need to do a lot more in voluntary counseling and testing, and we need to establish the infrastructure for treatment, because there will be millions of people seeking treatment in the next 10 years. At the moment, we’re simply not ready for that.

Q: For India, current estimates are that it has about 5 million people infected with HIV. Is that correct, and what are the projections?

A: In talking about the HIV epidemic in any country, one has to distinguish between the official statistics and the estimates based on good judgment. We find everywhere that the official statistics tend to underestimate, sometimes grossly underestimate, the true magnitude of the problem.

Looking at official statistics, the current Indian figure is 4.5 million [HIV infections]. But many Indian epidemiologists and public-health experts argue that the true figure is considerably higher … possibly 6 [million] to 8 million people already infected. If that is true, it already makes India the leading country in the world in relation to the number of HIV-positive people.

We know that the proportion of infected people, particularly in some states in India, is rising rapidly, and we can easily imagine figures of 20 million or more Indian people infected by 2010 or by 2015. So this epidemic can become very large very rapidly.

Q: As for China, some estimates are they have more than 800,000 people infected with HIV. Are you concerned?

A: Yes, we are very concerned about China. We believe that China also faces a large epidemic. Possibly not as large as India’s, but nonetheless a big problem.

We believe that the Chinese official statistics are underestimates … . The good news is the degree of engagement and mobilization by the Chinese government is considerably greater then it was a few years ago, and that’s encouraging. …

In both India and China, the Global Fund has approved large grants to programs implemented by governments and [nongovernmental organizations], and the focus of those grants are on prevention, although there is financing for treatment.

Q: How do you explain the epidemic takeoff in countries with relatively good [health] infrastructure —in the big urban areas, at least — in India and China, and yet have success stories in places like Uganda and Cambodia and a textbook case in Brazil? How do you explain this in terms of public-health policy?

A: The contrasts are very striking. A few countries have successfully reduced their infection rates and continue to do so year after year.

The essence of HIV protection is behavior change. We have to actually change human behavior, and particularly, we have to change human sexual behavior. And we know changing human behavior is difficult.

Wearing seat belts in cars was not an easy change to make. Stopping smoking is not an easy change to make on a national scale, and changing sexual behavior is uniquely difficult.

Some countries have managed to do this, and it is partly dependent on local culture. It is partly dependent on willingness to discuss sensitive subjects openly. It is very much linked to leadership. …

Q: Does this explain the successful campaign in Thailand with sex workers? Do you have any concerns about other countries — Indonesia, Malaysia, the Philippines?

A: Every country is in jeopardy. Every country in Asia faces a real risk of a large epidemic. No country is culturally immune. No country is protected because of their behavior or of their culture, and recognition of this is gradually spreading.

In some of the countries you mentioned, we do not yet have the frank leadership that we need. But we do see a beginning. We see leaders more willing to discuss HIV/AIDS in public fora, and this is essential. Thailand showed it was essential. Uganda showed it was essential.

Without that, you cannot mobilize the right degree of public awareness, and you cannot create an environment that legitimizes the work that public-health agencies have to do.

Q: How many years will it take to get an effective vaccine against AIDS?

A: It’s impossible to predict. The pace of research and development has increased a lot in the last five years, which is very good news. But there is no chance we will have an effective vaccine before another five years, so that would be the shortest possible horizon. It might be 10; it might be 15; it might be 20, we just don’t know. And it is certainly true scientifically that making an effective vaccine against HIV is much more difficult than previous vaccine efforts … many of which have been very successful.

Q: The price of AIDS treatment has come down dramatically, but next year, companies in developing countries making generic drugs will have to pay royalties or make other arrangements with patent holders. Will the Global Fund be able to sustain its low prices?

A: These are challenging questions; but first, the good news:

A few years ago, antiretroviral therapy cost something on the order of $25,000 a year in the [United States] and might have involved taking 20 to 30 tablets per day. Today, antiretroviral therapy can cost as little as $150 per year as a result of agreements between the Global Fund and the Clinton Foundation. It involves taking only two pills per day, and they are the same pills. You take one pill twice a day. Now, that is a revolution in cost and practicality of a kind that we have not seen in medical history. It’s a most remarkable change in only 3 or 4 years.

In 2005, the legal environment will change internationally. As you say, it’s hard to predict or be certain of the effect of this change on prices. I am an optimist in this area. I believe what we see today is a heavily segmented market, in which the companies in Europe and North America that own the intellectual property for these products are maintaining good profit margins in the rich-country markets, and that finances the [research and development] efforts that we desperately need.

Meanwhile, they are offering very low prices, sometimes cost-only prices, in the developing world and are in direct competition with the generic manufacturers. My optimistic view is that the situation will more or less remain the same … . I think it’s simply in the best interests of all parties to maintain this segmented market that we currently see. The role of the Global Fund is to be a large purchasing power in the high-volume, low-profit-margin segment of that market, and I hope we can continue to play that role.

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