Straight Talk with Gottfried Hirnschall, WHO's director of HIV

The UN World Health Organization (WHO) recently appointed Gottfried Hirnschall the new director of its HIV department. IRIN/PlusNews talked to him about the state of universal access to HIV prevention, treatment and care, and how countries need to respond to waning donor funding for HIV programmes.

QUESTION: WHO has released new ART [antiretroviral treatment] guidelines that recommend putting both adults and children on treatment at a higher CD4 count. How realistic are these guidelines in the current economic climate?

ANSWER: Putting people on treatment earlier has several benefits, including reducing morbidity and mortality, and the substantive preventive benefit of lowering the number of new infections.

Policy makers and civil society have welcomed the new guidelines, but have two major concerns: how to operationalize the guidelines and the cost implications of the new guidelines, which will require more people to be put on treatment.

One of our top priorities is to engage countries in discussions to see what the guidelines mean for their national programmes and how we can work together to strengthen their systems, such as procurement of drugs, building the capacity of health workers and so on. We also need to create efficiencies and use their resources more strategically.

Q: As task-shifting becomes more widely used to bridge health worker gaps, how do you help ensure that patients continue to receive the same standard of care whether they are being treated by a doctor, nurse or a lay health worker?

A: Task-shifting is definitely increasing, and the results we are seeing in the countries that have adopted it are very positive; it enhances acceptability of HIV services and improves adherence to life-long treatment.

However, even as we continue to advocate for it, we must constantly be looking at the model to understand - what can a nurse do better than a doctor, what can a community health worker do better than a nurse?

We also need more clarity in the quality criteria of the services being provided; high standards need to be set and adhered to.

Q: Are countries overly reliant on external funding? Does that put national programmes at risk?

A: There is a trend towards decreasing or flattening of resources from external mechanisms. This is concerning and we will continue to urge external donors to continue the international solidarity they have shown so far in the fight against HIV.

''[Treatment] scale-up is expensive in the immediate term, but has long term cost-saving benefits such as a healthier HIV-positive population and fewer new HIV infections''

More governments are taking on more of the burden of service scale-up, but what they need now is to find cost-saving ways to do this. Treatment scale-up is expensive in the immediate term, but has long term cost-saving benefits such as a healthier HIV-positive population and fewer new HIV infections.

So what we need is sustained funding from all parties and to use the available resources more strategically.

Q: What do we need to do to make HIV prevention effective? Where did we go wrong?

A: We don't yet have a magic bullet for prevention, which would be a vaccine, but we are still working towards one. We are also working on microbicides and pre-exposure prophylaxis.

But until we find a vaccine, we need to focus our energies on key populations - on injecting drug users, men who have sex with men, commercial sex workers, prison populations and so on. So far there has been insufficient focus on these groups.

In addition, we need to be more effective in our HIV prevention messages, moving away from messages that focus on one area of prevention, especially one as unrealistic as abstinence, as has happened in some programmes. The messages need to be all-inclusive and realistic if they are to succeed.

We are also looking at male circumcision, which has started in many African countries now, as well as treatment as prevention.

Q: Drug resistance has become an increasingly serious problem in national ARV [antiretroviral] programmes. What is taking so long to bring down the prices of second- and third-line regimens?

A: While drug resistance is in evidence in some countries, what we are seeing is that overall, there is much less of it than we had originally feared. WHO is working with countries to monitor the emergence and transmission of drug-resistant HIV strains as they scale-up treatment.

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We know that one of the causes of resistance is low adherence, so we need to make sure that the quality of service is high; it goes back to creating and abiding by high standards, even when task-shifting.

We are still negotiating with pharmaceutical companies for further reductions in the price of second- and third-line drugs, but in the meantime, we also need to invest in newer drugs that are more resilient to resistance, which would make the second- and third-line drugs less necessary.

We have kicked off the discussion of the development of these new drugs with donors and pharmaceutical companies and so far the interest has been overwhelming.

Q: There seems to be little progress in the fight against the twin HIV/TB epidemics. What is missing from the response, especially in southern Africa, where MDR [multi-drug resistant] and XDR [extremely drug resistant] TB are also major problems?

A: We need more investment in ensuring that comprehensive TB programming is built into HIV programmes and the other way round.

We need intensified case-finding; the health worker needs to be actively looking for TB, and so far we are not seeing this.

By looking for TB among the HIV-positive population and vice-versa, you minimize the risk of MDR and XDR TB. So the most important thing is to find and treat cases of TB and to treat HIV in people with TB immediately.