Looking toward Vienna: Gottfried Hirnschall

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`How can we maintain interest in HIV?’

Two months ago, Dr Gottfried Hirnschall took over as director of the HIV Department at the World Health Organization (WHO). He previously was director for Partnerships, External Relations and Communications for WHO’s “3 by 5” initiative, and then oversaw the Caribbean HIV programme of the Pan-American Health Organization, and served as WHO/PAHO Senior Adviser for Latin America based in Washington.

Gottfried Hirnschall, director of the HIV Department at the World Health Organization

At the International AIDS Conference next week in Vienna, WHO will formally announce its new set of guidelines for AIDS treatment of adults, children and prevention of mother-to-child transmission. These will expand upon documents released late last year that called for initiation of antiretroviral treatment when a person’s CD4 count falls below 350 and the start of antiretroviral treatment for all HIV-positive people diagnosed with tuberculosis.

Hirnschall talked this week with John Donnelly about Vienna and beyond.

Q: WHO’s 3 x 5 initiative (putting 3 million people on treatment by 2005) was a bold initiative when launched in 2003. Do you have a similar initiative coming?

A: It was the right idea at the right time. It was a very brave idea because a lot of people didn’t think it was the right thing to do. But I don’t think we can at this point redo 3 x 5 and call it 15 x 15 and just do it all over again. The time has changed. It (3 x 5) has laid the groundwork for a global initiative, and we are still harvesting the fruits. What I see now is a different opportunity to advocate for a strongly funded HIV response, a comprehensive response. We obviously need to be more strategic in positioning this response vis-a-vis other health matters, by linking it with child and maternity health, outcomes of Millennium Development Goals (MDGs), and also to fully consider how health services are delivered.

Q: Why not call for 15 x 15 – treating 15 million people by 2015?

A: The world doesn’t need just another number. What we really need is full commitment that in every part of the world, in every country, everyone who needs it can access treatment and other services. It would not be enough to simply set an isolated treatment target. Other things need to also happen. We need to strengthen health systems, we need to look much more carefully at how the HIV response will contribute to reduction of maternal mortality, and the reduction to child mortality. We also need much stronger commitment to prevention.

Q: Are you considering setting any new targets?

A: I’m not saying we shouldn’t have targets. We do need them. We need goals. We have MDG targets and we have the universal access target in 2010. We are developing our next five-year strategy for the health sector response, and we are widely consulting with governments and civil society, and certainly we will have targets in that strategy … What is new and exciting about treatment is that we have additional arguments for scaling up. We now know that treatment does have a prevention benefit. By scaling up access to treatment, we know we will prevent new infections and drop transmission quite importantly. And we know of a whole range of other prevention interventions that work.

Q: Will that happen in Vienna?

A: I think Vienna will be a really important conference. A few themes are developing — one is how can we maintain the interest in HIV, and how can we specifically make the argument for further scale-up and now even more demanding treatment guidelines? How can we make the case for a fully-funded response? How can we justify this in a global economic situation that is not favorable? We clearly cannot let go. We cannot get back to a conversation that we had in 2001 or 2002 and say, `Sorry there isn’t enough money to do it,’ or `Sorry, we can’t treat all the people in the South, only treat all the people in the North.’ We need to make a very strong argument for a fully-funded response that applies the best science and knowledge that we have to all.

An additional incentive is cost savings. We know that additional treatment will reduce mortality and will reduce the number of infections. The other important conversation related to the theme of the conference is human rights. In many parts of the world, there’s an important human rights gap that often hinders an effective response.

Q: Are advocates delivering these messages effectively?

A: Civil society and treatment advocates were instrumental in making the case and making it loud and clear some 10 years ago. It was about life or death for millions. A good thing is that has changed, unfortunately not yet for everyone. What we are seeing again — and I’m saying this because we had a meeting with 18 civil society leaders last week in Geneva – is a sense that advocates are regaining spark and focus. On the issues of where is this going, where will the money come from, how can we look in the future together – the tone has shifted. It’s not against government. It’s how can we really work on it together with governments.

Q: But money is tight. Give examples where the AIDS response can be less wasteful and more integrated.

A: When it comes to money, we’re always thinking it’s only the drugs that cost a lot, but if you do a more careful analysis, we see that about 70 percent is not drug-related – it’s related to service delivery, patient monitoring, and lab costs. No. 1, we need to bring HIV services, where they are not integrated, into the routine services of health care. No. 2, treatment delivery shouldn’t be a doctor-driven model. What is the role of the nurse, other health care providers, and more importantly, how can we move toward more simplification of treatment? We need to have more community involvement and more clarity on the community’s role in service provision than we had in the past. Lastly, and again, I think we need to see how we can really make substantial inroads in prevention scale-up to turn off the tap of new infections.

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