Dr Gottfried Hirnschall, Director of HIV Department, World Health Organization
In the first of a two-part exclusive, we present a fascinating interview with Dr Gottfried Hirnschall who heads up the WHO’s body charged with coordinating the global response to HIV/AIDS
Could you outline the circumstances that brought about the formation of the HIV Department and how long it has been in existence?
WHO has been at the frontline of the world’s response to HIV/AIDS since the very beginning of the epidemic. In 1986, when the growing global spread of the epidemic had become more evident, WHO established its first Special Programme on AIDS. The programme aimed to establish worldwide surveillance on the disease and to develop global policies to respond to what was still an emerging infectious disease at that time. Between 1986-1996, WHO’s HIV work was coordinated through the Global Programme on AIDS, with dedicated HIV units established in all six WHO regional offices and many WHO country offices. With the need to develop a multi-sectoral response against HIV, a new Joint United Nations Programme on HIV/AIDS (UNAIDS) was established in 1996. Between 1996 and 2000 WHO aimed to mainstream HIV throughout the organisation. Then in 2000 in recognition of the need for a strong health sector response to HIV, and in particular the development of highly effective antiretroviral therapy, WHO established the Department of HIV. WHO’s core HIV/AIDS activities have been continuing throughout the past 25 years with a key focus on health sector action.
What does the department see as its main mission and goal?
The HIV Department’s main mission is to coordinate the organisation’s efforts related to HIV. Its goal is to support the achievement of universal access to HIV services for all people in need and the HIV-related Millenium Development Goals (MDGs). Universal access and the MDGs are the goals of the Global health sector strategy on HIV/AIDS for 2011-2015, which was endorsed by all WHO Member States at the World Health Assembly in May 2011. We believe that full implementation of this strategy will greatly help us in attaining universal access targets and the MDGs.
In your role you oversee the organisation’s HIV mandate to provide countries with vitally needed normative and policy guidance to deliver HIV services and to build health systems. How is this achieved? What strategies support this mandate?
The cornerstone of our strategy is the agreement of collaboration and partnership with all of our Member States. The core functions of the Department of HIV are to provide technical and policy leadership on the health sector response to HIV, developing global norms and standards for HIV prevention, treatment, care and support. We also monitor and report annually on the health sector response to HIV. We work with our six regional and 149 country offices to ensure that global guidance is effectively translated into country policies and programmes. In many countries, WHO and the national counterparts develop Country Cooperation Strategies, which embody the principles of collaboration between WHO and the national governments on country-led priorities. From the HIV Department at the headquarters, we develop a joint workplan that includes not only global activities, but also those agreed by Regional and Country Offices, so that we can make a truly global impact.
Do all countries accept your support and is there a case of some trying to hide the extent of their HIV problem?
The Global health sector strategy on HIV/AIDS for 2011-2015 provides a framework for a comprehensive, evidence-based health sector response to HIV. It recommends specific policies, approaches and interventions that countries should adopt. Given that HIV epidemics vary greatly between and within countries and that each country has different health systems and social and economic contexts, HIV responses must be tailored to meet country needs. Together with UNAIDS, WHO issues annual epidemiological updates with the most current strategic information on HIV in countries. Good quality datasets provide the basis for sound HIV policies both at global and country levels. We work closely with countries and other partners to develop their capacity to collect and analyse reliable and relevant country-level data so that they can make evidence-informed policy decisions. Such strategic information helps us identify where progress is being made and where major challenges exist, demonstrating where we may need to focus our efforts. Effective HIV responses need to address highly sensitive political and social issues, such as sex, sex work, homosexuality and illicit drug use, and the criminalisation of certain behaviours and populations. WHO’s role is to provide guidance to countries on effective public health approaches and the public health consequences of policies and actions of other sectors. Good public health is based on principles of equity and human rights. Ultimately, countries need to make their own policy decisions, and it is the role of WHO that those decision makers are fully aware and optimally advised of the public health evidence and recommended approaches.
Do you think HIV is sufficiently considered in the healthcare planning of countries?
In 2010, UNAIDS reported that the majority of surveyed countries (162 out of 171) indeed responded to having ‘a policy or strategy to promote comprehensive HIV treatment, care and support’. But we also know that a great majority of people requiring HIV services are not able to access them. For example, in HIV treatment, only one third of people in need were able to get it by end of 2009. So HIV is featured in most national strategies and policies, but often these national strategies are not translated into effective programmes on the ground.
To what degree is HIV increasing in Asian countries? Are we seeing figures declining in any countries where they previously soared? In other words, is there tangible progress in terms of impacting predicted figures or is it more a case of prevention?
Every November, WHO and UNAIDS release new annual statistics on HIV/AIDS. So we’re quite close to announcing the latest data for 2010. But based on previous reports, I can say that HIV epidemics in Asia have been stabilising over the past years. About 5 million people were living with HIV in Asia at the end of 2009. All countries in the region have concentrated epidemics, where the infection has been spreading among most at-risk and vulnerable groups such as sex workers, men who have sex with men and injecting drug users. We have also seen that in some countries such as Bangladesh and the Philippines, HIV incidence has increased by 25 per cent between 2001 and 2009. So in order to respond to the epidemic in Asia, we need to give utmost attention to the services needed by key populations with high risk of HIV infection.
What strategies do you find most successful in the a) detection, b) control, and c) prevention of HIV?
From the past 30 years of the global experience in HIV, we learnt that HIV is a fast-evolving epidemic and there is no one magical intervention that can fully defeat it. Each year, with the continued advances in science, we have been improving our strategies to prevent, detect and treat the disease. We know that the success of the response will depend on how well we design our HIV programmes, depending on the specifics of the epidemics in each setting, and the needs of the people affected by it. And our programmes need to be comprehensive to meet various needs based on the most optimal combination of existing prevention, treatment and care services. In the past year we have witnessed some exciting new developments. Research has demonstrated that antiretroviral therapy can also be highly effective in preventing the transmission of HIV, as shown among discordant couples, where one partner has HIV. Antiretroviral drugs given to uninfected individuals can significantly reduce the risk of them acquiring HIV. More effective approaches are available for preventing transmission of HIV from an infected mother to her infant during pregnancy, delivery and breast feeding. There have been positive results in the development of topical microbicides for the prevention of sexual transmission of HIV. Progress is being made in the development of simpler HIV diagnostics. WHO is reviewing and analysing this new evidence to determine its implications for low- and middle-income countries and for the revision of WHO guidelines.
In what way are you enhancing the capacity of countries to perform this themselves?
WHO has a very unique role in global health in providing leadership and guidance for public health policy development. Our approach is working closely with the Ministries of Health and other partners in all Member States, and supporting them with normative guidance. Our country offices are well placed to provide day-to-day technical support to national HIV programmes, supporting national adaptation of WHO guidance and convening key partners to support implementation of effective programmes. We have supported the establishment of more than 20 HIV Knowledge Hubs in Africa, Europe and Middle East to provide tailored capacity-building activities for policy makers and programme planners and to help strengthen national and regional institutions. Given that WHO isn’t an implementing agency we rely on partners, including civil society, government organisations, academic institutions, development agencies and the private sector to implement programmes based on WHO norms and standards.
HIV has reached pandemic proportions – do you think it receives suitable research to match its spread? Are governments investing enough? Has WHO been able to stimulate governments to increase funding and/or the emphasis that they place on HIV?
We have many unanswered questions in HIV and research should indeed remain a key priority for the world. From the early 1980s HIV epidemics have stimulated an impressive scope of research, from the basic sciences of virology and immunology, through clinical and implementation science to behavioural, social and political sciences. It could be argued that no other disease has resulted in such an investment in research and such remarkable innovations that have application way beyond HIV and even public health. HIV has driven new discoveries in health sciences and has changed the way that we look at and respond to public health issues. For WHO, we aim to bridge the gap between science and reality, by translating scientific evidence into policies and tools that countries can implement. While our repertoire of effective HIV prevention and treatment interventions expands we are facing a situation of shrinking HIV funding globally. In this situation, it is even more important now to use existing resources on interventions where the biggest impact can be achieved, for example in addressing the needs of populations at greatest risk, and in ways that are most cost-efficient, for example through better integration of services. Countries need to assume greater responsibility to contribute with their own, domestic funding and make best possible efforts to reduce over-reliance on donor funding. This is especially true for middle-income countries and emerging economies. If anything, it would be lack of political will and scarcity or inefficient use of resources, not the lack of effective technologies and approaches that could stop us from achieving universal access. We have seen very encouraging progress over the last few years. The end of HIV should no longer just be a dream. The vision of zero new infections and zero new deaths due to HIV can become a reality.
The ‘3 by 5’ initiative, launched by UNAIDS and WHO in 2003, was a global target to provide 3 million people living with HIV/ AIDS in low- and middle-income countries with life-prolonging antiretroviral treatment (ART) by the end of 2005. Was this goal realised and did it serve to change the way HIV is responded to?
The global ‘3 by 5’ initiative has radically changed the way we acted on HIV. Since ‘3 by 5’, we have seen the number of people accessing HIV treatment increase 16-fold between 2003 and 2010. We have nearly 7 million people accessing HIV treatment now. Most importantly, the initiative has been a real testimony of what we could achieve if we work with countries towards a tangible target to deliver life-saving interventions. The principle remains vital in our work to advocate towards universal access, and we already have more than 20 countries which have achieved this target for different HIV interventions, while there are many more countries making significant progress.