Dr. Rochelle Walensky has been a member of the Cost-effectiveness of Preventing AIDS Complications (CEPAC) team since 1998. She is a member of the Office of AIDS Research Advisory Council at the National Institutes of Health and the Department of Health and Human Services Panel on Antiretroviral Guidelines for Adults and Adolescents. Dr. Walensky has been an independent NIH-funded investigator since 2001; in 2005, she was a recipient of the Doris Duke Charitable Foundation, Clinical Scientist Development Award. Dr. Walensky is the Co-Director of the Medical Practice Evaluation Center at Massachusetts General Hospital, Associate Professor of Medicine at Harvard Medical School, and a practicing Infectious Disease physician at Brigham and Women’s and Massachusetts General Hospitals. Her research has focused on HIV/AIDS policy and cost-effective strategies of HIV care in the US and in resource-limited settings.
Dr. Walensky answered these questions for Science Speaks’ Blueprint series.
In her address to the International AIDS Conference in July, Secretary Hillary Clinton called for the U.S. Office of the Global AIDS Coordinator to create a blueprint — a plan for what the U.S. would contribute reach the goal of an AIDS-free generation — to be released by World AIDS Day in December. From your perspective as a scientist and clinician, what key elements should be a part of this blueprint?
I think it is essential to demonstrate that we now, scientifically, believe we have the knowledge to achieve an AIDS-Free Generation with a combination prevention approach – including treatment as prevention. I believe it is similarly critical not to lose sight of what the treatment has done for those living with HIV infection and for the economies of countries heavily afflicted. Not only is treatment valuable because it will prevent HIV disease, but treatment improves individual survival, prevents orphans and orphan-related mortality, promotes health-related infrastructures and returns young individuals once dying back into productive societal and family members. All of these magnificent benefits happen while we are using treatment as prevention.
When policy makers talk about a combination prevention package, what interventions would you highlight as critical components of a combination prevention package?
When considering all possible mechanisms of prevention, the menu should be limited to those proven as effective (e.g. condoms, circumcision, PrEP, TasP). Others should be employed in a research setting until documented to work. Not all prevention components will be applicable or feasible in all settings and for all persons. Scale up considerations must include a conversation about efficiency (economic value) of these interventions as we want to ensure we are using our limited resources to maximum potential.
Should OGAC and the blueprint put forth a prioritization process for use of U.S. tax dollars? What should the priorities be? Are there elements of the current program that should be abandoned in favor of these priorities? If so, which ones?
Prioritization has to be country-specific. In settings with poor testing coverage, timely diagnosis has to be a priority over one that recommends “early ART,” as early ART would be completely impossible to achieve in such a setting. Some settings need more attention to prevention in centralized epidemics while others in generalized epidemics; we need to understand that the tools to tackle HIV in these settings may be as diverse as the epidemics themselves. Yes, there needs to be prioritization but the “how” and “where” need to be at the local level.
Based on the latest research, what should global programs like PEPFAR be aiming for in terms of timing to initiate treatment in HIV-positive people?
While aiming to start millions on therapy is an admirable goal, we need to ensure that the mechanisms are there for people to effectively remain on that therapy and in care, as well as to reach and sustain virologic suppression. In the absence of getting “effective” therapy, initiating therapy should be viewed as a much less critical endpoint.
What role should research play in the blueprint?
This blueprint needs to ring with optimism, motivation and excitement. For the first time ever in this ravaging epidemic, we are using words like “vaccine”, “cure”, “AIDS-free” and “elimination”, and they are now viable. We need to use this blueprint to create the pathway and political will to allow us travel reach these destinations, and to hit accelerate until we to get there.