As the 2018 International AIDS Conference kicks off in Amsterdam (23-27 July), Gottfried Hirnschall, Director of the HIV/AIDS Department and the Global Hepatitis Programme of the World Health Organization, discussed in a wide-ranging interview with John Zarocostas for Health Policy Watch the advances, setbacks, and challenges ahead in the global fight against the HIV/AIDS epidemic. On 18 July, a new report by UNAIDS warned that new infections are rising in around 50 countries, and that AIDS-related deaths are not falling fast enough and flat resources are threatening success.

Dr Hirnschall leads the WHO’s work in development and implementation of cutting-edge normative policies and guidance, and of technical support to countries to scale up national responses to HIV and hepatitis. He also oversees the Global Hepatitis Programme, which coordinates the organisation’s response to viral hepatitis. Hirnschall holds an MD from the University of Vienna, Austria, and an MPH from the Johns Hopkins Bloomberg School of Public Health.

Health Policy Watch (HPW): What have been some of the positive developments globally in the fight against the HIV/AIDS epidemic in the last year?

GOTTFRIED HIRNSCHALL: Clearly, we are seeing that more people are having access to certain essential services – specifically to testing and treatment services – where we now have 75 percent of people globally who know their HIV status, and we have more people on treatment. 21.7 million people are now on treatment, which is an increase of more than 2 million compared to the previous year, and we are also seeing – proportionally – more people are virus-suppressed. Obviously, that’s good for your health and you will not obviously pass the virus if there is a viral spread. So, that’s really good news. It does translate into an obviously slightly reduced number of people dying. There’s still 940,000 people dying, close to 1 million, which is not that much of a reduction compared to the previous year, and we all obviously wanted to see the reduction to have been greater. We feel it’s an important gap between that number and target which we call the fast track target by 2020. With the reduction, that we have seen in the last 2 years that trajectory continues it is clear we are not going to reach that 2020 reduction target [of fewer than 500,000 deaths]. Also, more people on treatment is great, however, we still have more than 15 million that need to be reached with testing and treatment. Overall, there is good news but ultimately it is not as good as we would like it to be even on the treatment story, that’s very clear. I also think when it comes to countries taking on the responsibility, we do see that some countries are doing really well. Southern and Eastern Africa has been doing really well compared to other parts of Africa, and as you know, West and Central Africa are not doing as well and we’re seeing major gaps there. We also see other parts of the world where treatment access is very compromised, basically, Eastern Europe and Central Asia, and we also see other countries not doing very well like Nigeria, a country with a large disease burden and with large numbers of people HIV positive. They still have major gaps of people getting on treatment. Obviously, global figures are global figures, but if we become a bit more granular we see it’s not the same story in all countries, and we need to be a little bit more differentiated.

Overall, there is good news but ultimately it is not as good as we would like it to be even on the treatment story

HPW: On the setbacks, looking at the latest data released by UNAIDS, there seems to be stalling on a segment where you had made major progress on preventing transmission from mother-to-child. New infections are now stuck at around 180,000 for children between 0-14 years of age. What are the reasons for this?

HIRNSCHALL: On mother-to-child-transmission and infections in children, obviously we have again a gap to come down to 40,000 new infections [by the end of 2018]. I think that is a very ambitious target and if you look again at global figures some countries are doing very well and other countries are not. Nigeria is not scaling up for example. Nigeria has a very large population and that obviously will drive the numbers. I think we are waiting for some countries to step up to the plate in those areas. Nigeria simply isn’t when it comes to prevention of mother-to-child transmission (PMTCT). That’s certainly one of the aspects in some of those countries. If Nigeria is not contributing to that reduction more significantly then those global figures won’t be working out.

HPW: With Nigeria being the largest country in Central and Western Africa, antiretroviral treatment is very low at only 26 percent of children and 41 percent for adults. What are the reasons the region is lagging so far behind? Is it partly due to the political crises?

HIRNSCHALL: Well, I think there’s a number of reasons. You already mentioned one. I still think we haven’t seen over the years that major inputs from the international community. They have been very focused on those high priority countries in Eastern and Southern Africa. I think the international community belatedly realized they have a real problem in Western and Central Africa as well. I think we also have more work to do if the political commitment is not as strong as we have seen it in other countries as in Eastern and Southern Africa. Linked to that, we have policies in place that are not making it easy for people to access services. For example, and we talk a lot about that, is there are formal user fees where people have to go in and pay for services, and some of those are informal user fees. So, if somebody needs to get to another service, they need to pay in addition because the health systems are not very strong, some of the salaries are not paid in time, etc. People may depend on that from a health perspective but that might also deter some of the patients to really seek services. I would also like to say that health systems, as such, in some of these Central and Western African countries are not as advanced as we see them in other countries in Africa and elsewhere. It is a more broadly defined system weakness. Last but not least, since the prevalence wasn’t so high, it was never so visible. I would suggest it’s also stigma. It’s also probably a stronger factor in some of these countries because it was not as visible as it was in Uganda, in Tanzania, in South Africa, in Zimbabwe, countries that have high levels of prevalence but where I believe with the much earlier and well-funded response from political leadership in some of these countries I think it became so much more visible.

HPW: Talking of stigma, I was wondering whether that has also played a role in the low number of people accessing ARV treatment in the Middle East and North Africa, adults only 29% and children 35% and overall a very low percentage, and secondly what’s behind the low levels of adults accessing treatment in  Eastern Europe and Central Asia?

HIRNSCHALL: Well we have these concentrated epidemics, primarily through transmission in key populations, these are, depending on the country, overall, people who inject drugs, sex workers, men who have sex with men, transgender, prisoners, more and more the vulnerability comes through forced migration, etc. That is with the exception of sub-Saharan Africa, basically all countries have concentrated epidemics where they occur primarily within these [risk] populations. So what we see in some countries, these behaviours, if you wish let’s say drug use or male- to-male sex are criminalized ,and where these laws are very much enforced, all kinds of services including harm reduction, etc, are not provided to the population. Clearly, these are some reasons why we see in different parts of the world that you mentioned – Eastern Europe and North Africa and parts of Eastern Europe and Central Asia – particularly in the Russian Federation – the numbers that you just quoted.

HPW: If I can turn now to the new infection rates among the young people – aged 15 to 24 years-, again the new UNAIDS data show that 58% of the new infections among adults more than 15 years old plus were among women (6600 young women between 15 and 24 years became infected with HIV every week). Are the awareness and outreach campaigns not working? Why this big number?

HIRNSCHALL: Well, among young women it’s primarily in sub-Saharan Africa where we see in some parts of South Africa, Zimbabwe, etc, areas of very high transmission among very young women and this is one of the biggest problems that we see.  This drives to a large extent the bigger picture where we still have 1.8 million people that were newly infected. We still have a largely inadequate prevention response. In sub-Saharan Africa, it is because we have a very high transmission in young women. We also have in sub-Saharan Africa not a response that addresses also key populations, as we have in other parts of the world, simply those people are not reached by information/education and services – testing services, prevention services, and if they are (HIV) positive, treatment services. I really think it’s a failure overall that we see in [not] having a strong prevention response. We have something like 50 countries where the numbers of new infections are going up. That is very serious. Dr Tedros [Adhanom Ghebreyesus, the WHO director-general] will speak to that, Michel Sidibé [UNAIDS Executive Director] has spoken about it, that we need to get serious about it.

We have something like 50 countries where the numbers of new infections are going up. That is very serious.

HPW: Do you think there is an element of complacency? Why after so many years of progress is there suddenly a reversal in that trend?

HIRNSCHALL: I think in some parts of the world there is an element of complacency. I think in some parts there may be an element of the resources. I think it is also because in some parts of the world the prevention response is not efficiently focused on people that are most vulnerable and at greatest risk with the interventions that could work. And in some instances, I think it is also simply that governments have not made the commitment to take this forward.. Again, I believe it is a combination of things. One of the things we at WHO – and Dr Tedros will speak very strongly about when he comes to the 2018 AIDS conference – is we need to say, first of all, we can’t accept those [high] numbers, and we also need to embed the HIV/AIDS response into the broader universal health response. This needs to be built into the approach of universal health coverage (UHC) and not to expect this separate funding continues, forever.

HPW: On costs, the prices for ARV drugs have certainly come down for the first-line regimens but are the costs still too high for second-line generation drugs and is that still a cost factor for governments? Is that holding back more people not having access to ARV treatment?

HIRNSCHALL: No, I don’t think the cost of second-line is a major delay constraint anymore. To be clear, the cost of second-line drugs has also been quite substantially reduced. As you are aware, this course of new and better drugs – and dolutegravir regimen inhibitor is a very effective drug and has fewer side effects- than the other regimens that are currently given as first-line. It is also more robust and the cost of that drug has also come down quite substantially. It’s become very cheap, around $100 per person per year. So, that’s fantastic. It is a first-line drug that can be used in combination with a second-line drug. I think drugs will still have a price and that needs to be paid for by the Global Fund [for AIDS, Tuberculosis and Malaria] to a large extent. But more and more this needs to be taken on by national health systems except in those countries that are really low-income countries and will require more support. That’s why we have a Global Fund and why we need a well-funded Global Fund in the years to come. But overall in middle-income countries, there is no easy way out but to pay for their response and the drugs that they require.

In middle-income countries, there is no easy way out but to pay for their response and the drugs that they require.

HPW: What is your message to the 2018 International Aids Conference from your vantage point going forward?

HIRNSCHALL: The message for the conference is, I think we really cannot have the same conversations over and over. We really need first of all to closely look at the data, and we need to find new approaches to dealing with some of those issues. Again, coming from WHO, we need to build the HIV response into the broader health context ,and now, as WHO is pushing countries very much to fully embrace UHC and this is one of the strong messages we would like to come out of this conference. But we also need to focus on countries where key populations are ostracized and stigmatized and not getting access to services. The international community, and the WHO , will continue to work with these countries where we feel there are major gaps, and continue to play an important role and work with countries so that they can quickly transition to better drugs. We also need to look at more effective ways of testing – 75% of people know their status, but 25% don’t – and we also need to introduce other prevention efforts such as exposure prophylaxis for those people who are at high risk of transmission and scale up more interventions that we know work. In particular we need to focus more on condom promotion, and condom use, and also voluntary male circumcision in those African nations where we know there is a benefit from it. However, the prevention response needs to be focused, it needs to be solid, and it needs to include the innovations we have seen that work. Last but not least, countries really need to step up to the plate and put their own resources to the response and have to remove policies that deter people from accessing services.

HPW: Thank you.

Image Credits: WHO.