Stefano Bertozzi, MD, PhD, director of HIV and tuberculosis programs at the Bill & Melinda Gates Foundation, oversees grants in HIV vaccine development, biomedical prevention research, diagnostics development and resistance monitoring, and strategies for introduction and scaling-up of interventions. He has held past leadership roles at UNAIDS, the World Health Organization, the World Bank, and the National Institute of Public Health (INSP) in Mexico. He spoke with Science Speaks about what he saw as the key developments in HIV/AIDS and TB in the last year and a half, as well as important trends coming up.
What do you see as the most important developments in AIDS in the past year?
If you ask me about recent developments, I think about it in terms of what we are doing with the tools we are already using and the tools we hope to have soon. In the midst of a global financial crisis, we need to get the most out of the money we are spending. We need to put more people on treatment, we need to do better work on prevention and we need to have more TB cases detected and treated.
In that regard, we had very encouraging news on the programs scaled up rapidly in the last few years. The cost per-patient, per-treatment is coming down rapidly. There are very encouraging signs of getting more treatment for our money. Those are trends we need to accelerate.
As far as the tools we don’t yet have available, in the almost 30 years that I’ve been around issues related to HIV, I don’t think we have had a year and a half like we just had. Last September, we had results from the first positive HIV vaccine trial. That really reinvigorated the whole area of searching for an HIV vaccine. We’re figuring out how to make the next trial work, not only in Thailand, but in Africa. We also hope the next trial will have greater efficacy than we did in the partial efficacy we saw in Thailand.
Over the past year we also saw positive results in the area of vaginal microbicides, which a woman can use to stop the transmission of HIV. We’ve been trying to do this since I’ve been involved in HIV, since the late 1980s. It’s really exciting we have a new product. It’s something a woman can use to protect herself.
The other really exciting development was the announcement at the end of last year that taking a combination (antiretroviral) drug on a daily basis to prevent being infected with HIV is also successful in preventing transmission. Those results were incredibly exciting. Like prevention of mother to child transmission, for those who took the drugs regularly, the suggestion was 90 percent of them were successful in preventing transmission.
What about developments in medical male circumcision, including Swaziland’s plan to scale up a plan to do circumcisions nationally? What are the prospects for scaling up male circumcision in eastern and southern Africa?
I’m very optimistic in some places and hopeful in others. Kenya has shown real leadership. They were the first out of the gates. In most areas of Kenya, a traditional circumciser will do the circumcisions, but western Kenya does not. They have been very successful in scaling up rapidly in western Kenya. Then we have South Africa, where again much of the population practices male circumcision. But the largest population in KwaZulu-Natal does not. The Zulu people did traditionally circumcise but that was stopped during the Bambatha rebellion (because of the danger). But after President Zuma announced an expansion of male circumcision, there’s lots of movement now in KwaZulu-Natal. Swaziland is the only national level effort. It’s very ambitious and it’s really to be celebrated.
What’s been holding up expansion of medical male circumcision? Funding? Acceptance by groups in countries?
I don’t think funding for male circumcision is a significant problem. The Global Fund is open to the possibility of reprogramming some of its funding for male circumcision, and the U.S. government also is open to that. Everyone is cautious about something linked to culture, in that we don’t want to be seen as dictating something that is culturally sensitive.
But the fact is the economics of medical male circumcision are so convincing. It is so cost effective that it saves money if you do it. It’s not just a humanitarian intervention. It’s just a good deal. It costs money not to do it.
With the global financial crisis putting pressure on global health funding from donors, are you concerned that a recent story showing corruption in a few Global Fund grants could reduce funding?
In this environment, any sort of negative press obviously raises concerns. In this case, it’s really a puzzle to me why this became a media story. The Global Fund is perhaps the most transparent international organization that I know of. These instances of fraud were publicized on the Global Fund website last year. This has been completely transparent and open. And the Global Fund has been seeking out repayment in incidences where money is misused. All of which is something we should be celebrating. I don’t know how it could be twisted in the recent coverage. The fraud identified was one-third of one percent of Global Fund funding.
You’ve stated in the past much support for more attention to TB detection and treatment. Where do things stand now overall in the fight against TB?
When I look at the Gene Xpert TB diagnostic tool, it is potentially a transforming factor in the context of HIV/TB co-infection. A person who is recently diagnosed with HIV is at high risk of contracting TB, if they don’t already have active TB. That person should receive treatment for TB if they have it, or should receive prophylaxis for TB if they don’t have it. But far too many people who are diagnosed with HIV receive neither. Just one-third of people diagnosed with HIV are getting screened for TB. That is something we are really hopeful to turn around.
With the Gene Xpert, in two hours they know if they have TB or not, which can give a doctor confidence on whether they should start treatment for TB. I’m hopeful we can scale up the Gene Xpert in areas of high HIV/TB co-infection. That will not only help the patient but it will have an effect in the whole community beyond, because they will be protected from infection.