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Roselyn Sachiti THE INTERVIEW

Zimbabwe successfully hosted the 18th edition of ICASA between November 29 and December 4, 2015. The event was attended by the global Aids family that included donors, researchers, activists and NGOs. A total of 55 African countries were also represented.
Many African countries, Zimbabwe included, have benefited from the President’s Emergency Plan for AIDS Relief (PEPFAR).
Features Editor Roselyne Sachiti (RS) speaks to Ambassador at Large and US Global AIDS Co-ordinator Dr Deborah Birx (DB) on the sidelines of ICASA on this and other issues.

RS: Ambassador Birx, welcome to Zimbabwe. What are your thoughts on the country’s hosting of ICASA?

DB: This conference was really quite extraordinary and I have to congratulate Zimbabwe for organising it and importantly for the tagline of the conference “Science, Leadership and Human Rights”. I think that really encapsulates what shared responsibility it is in this epidemic.

You have brilliant scientists here and clinicians. Your Zimbabwe medical society is really quite amazing. I met them maybe a decade ago and they made a cutting edge in their analysis in how to improve the lives of those infected with HIV.

But I think showing that science leads to new guidelines, guidelines lead to new policies and new policies need to be implemented at the community level to serve others.

RS: You brought an interesting aspect of human rights. African governments have often resisted or shunned recognising LGBT rights as priority populations in the fight against HIV and AIDS. Is the United States supporting these groups directly in countries such as Uganda and Zimbabwe?

DB: I think the continent and all of us learned a big lesson with Ebola because obviously there were community practices related to burial that had to be addressed and effectively addressed to stop the epidemic.

And the communities when they understood the issues made those modifications because that was a public health response. We need to ensure that communities, physicians, nurses, community health workers and policymakers have that same respect for the public health implementation of the response you need to control this epidemic.

And in order to control the epidemic you have to ensure that sex workers have access to knowledge and services. That they are protected in a way to access the knowledge and services. The same with men who have sex with men, the same with people who inject drugs and the same with transgender people.

So there is no place for stigma and discrimination in a public health response to combat an epidemic. And so this is the very fundamental piece and with ICASA having human rights in its tagline here in Zimbabwe I hope it starts.

We are talking about starting a movement that really results in everyone having access to treatment. We need a movement that says everyone has access to treatment independent of their gender, sexual orientation, colour, race and religion.

In a public health response none of those features should impact your ability to reach others. I think what you are talking about here, in Uganda, Nigeria and a large number of countries, even countries that have social protection for men who have sex with men at the community level there is still adverse events.

And I think what PEPFAR is doing to show its commitment is we have increased the funding to the Robert Car Foundation that is very much focused on funding national and regional groups to work on human rights issues related to HIV and Aids.

So I think we have learned from the history of this pandemic that leaving no one behind requires funding and funding at every level. Not just funding governments but funding civil society to support the community awareness and implementation of these course services.

RS: That is an interesting issue but I have also noticed that there is a growing concern that heterosexual men are lagging behind in terms of testing, accessing medicines even education. What is Africa doing wrong? What can be done to change this?

DB: That is a really terrific question. You know sometimes there are unintended consequences of our very good actions. So I think out of concern and the lack of complete evidence a lot of countries decided not to treat until client CD4 fell under 350 or under 500.

Now at the same time we told these discordant couples and partners or women coming in pregnant that they should be tested. And so for the last 12 years we have been testing men but by and large telling them that they don’t qualify for treatment.

So when you tell 50 percent or 60 percent of the men who have been tested that they don’t qualify for treatment, I think I would interpret that to say I have HIV but I am fine. And then you expect them to be concerned about transmitting the virus to others when we haven’t really been concerned and worried about the health of men.

And I think that’s why I am so excited about the WHO guidelines that say when you test, you treat. That you offer treatment the minute people find that they are positive.

Because we know now as soon as you are infected by the virus it starts destroying elements of your immune system. Now yes it may take eight or nine years for that to leave to what we call an opportunistic infection but that doesn’t mean that for the last eight or nine years whole elements of your immune system have been destroyed.

The new data from the Start trial that NHI supported shows that putting people on treatment immediately results in that individual thriving. And so they are healthier but they are also preventing transmission because their viral load is undetectable.

That is a very exciting piece and I think now we have the tools to say to men please come back, be tested, get on medication right away to save your own lives and to also decrease transmission. I think we have a very different message.

And the women who came forward and received B-Plus therapy, when that first started we couldn’t promise them that was helping them.

We could promise them that it would prevent their baby from getting infected and protect their baby through breastfeeding.

But if they were over 350 CD4 cells we couldn’t promise them they were going to have an impact on their own health and now we know it does. So we have been great at getting women on treatment and that’s why we are very interested in disaggregated gender, sex and age data because I think that will show that probably of our individuals who are on treatment 60 to 75 percent of them are women.

RS: You also brought in an interesting aspect of option B-Plus. My understanding is once you are on option B-Plus you are on lifelong ART and knowing the issue of scarce resources with our African governments how then are we going to keep up with that and what is your commitment as PEPFAR so that we keep track?

DB: I think all evidence shows that the United States has unwavering support for PEPFAR. Through two different presidents, multiple different congresses PEPFAR has been supported and consistently supported.

We are a third of the contribution to the global fund; we are approximately a $6 billion a year programme. We have invested $65 billion in saving lives and changing the very course of this pandemic.

And the United States knows that in order to protect its investment we have to end this pandemic as a public health threat. So I think that you can see that traditional leadership not only talks about its commitment but puts dollars behind its commitment and people behind its commitment.

You know sometimes we only talk about dollars but there is a whole team here, a PEPFAR team, a Dreams team very much devoted to working hand in hand with Zimbabweans to change the course of this pandemic.

RS: There have been reports that Zimbabwe is one of the countries doing great when it comes to voluntary male circumcision, but the issue affecting that has been funding though we have found innovative ways to keep on track. What can be done to fill in those gaps in the event that countries are not so innovative?

DB: That’s an excellent point and it’s also why we gave Zimbabwe more money just in the last couple of months to expand their circumcision programme and, of course, all of the Dreams funding to prevent infections in young women.

Through SIF Zimbabwe has gotten funding to treat additional children. So I think within PEPFAR we have been working very closely with countries and I saw data out here on one of the computers, to really work down to the site level, to really understand performance at the site level.

Because I agree with you completely understanding what an effective programme looks like at the site level not the country level, but the site level, will allow those innovations that are both here in Zimbabwe and in Malawi and over in Botswana and across to Namibia to really be written up as an evidence base so that other countries can take up specific approaches.

Previously it’s been anecdotal. We know as a country Zimbabwe has controlled significantly new paediatric infections and new adult infections. But I can’t tell you these 10 sites are the top performers and what they are doing is unique and we have to learn how to do that for the rest of Zimbabwe and for PEPFAR at large.

That’s what we are hoping to do with this granularity of the data and quarterly reporting to really understand what works and not wait a year to make the changes but only a quarter. And I think you hear the sense of urgency with UNAids, you hear the sense of urgency at WHO and we want to be part of translating that sense of urgency.

RS: As part of your work, you co-ordinate activities in line with host governments. I know that US/Zimbabwe relations haven’t been so rosy in the past decade or so. How have you been working with the Government of Zimbabwe?

DB: We are here to support the people of Zimbabwe and I think we have demonstrated that with the consistency of our funding and with additional dollars that we have put here in Zimbabwe to work with the organisations that want to confront this epidemic.

And I think our support there remained unchanged and has actually increased because we believe the people of Zimbabwe are working beside us to change the course of the pandemic.

RS: There is the issue of streamlining your support to Zimbabwe to cover specific areas mostly populations that you have really targeted like you said earlier. What is the rationale of selecting a certain population ahead of the others?

DB: It is all data driven. If you get the new UNAids report that they just published, the report is called “Location and Populations”.

Because this epidemic will be beaten community by community and you have to have a different response and a level of response if your prevalence is 15 percent versus a prevalence of 3 percent.

And we have to ensure that access to services when you have 15 percent of the adult population infected is equivalent to the access of services when you only have 3 percent of the population infected.

What we found had happened is resources had been distributed equally rather than equitably. In other words, let’s just say everybody got $50 even though this side had 10 times more clients to reach and 100 times more disease spread.

So what we are saying is use data just as Rebecca Man did in the UNAids report to ensure you are reaching the locations and the populations where HIV is. Because HIV requires a human to human contact for transmission by and large because in sub-Saharan Africa the majority of transmission is still heterosexual sex and so it has to be confronted as a heterosexual transmission.

And so we are working very closely with communities and with UNAids and WHO to really get that granularity of data to understand where people need to be reached and reaching them there. So as we bring up the high burden areas to the same coverage of services, the percent of access as the low burden areas then we can have a broader discussion about where PEPFAR with the people of Zimbabwe is going.

But as long as the high burden areas lag behind the low burden have catch-up work to do.

RS: I say so because in Zimbabwe we have been having a challenge where when it comes to the issue of giving condoms to under-16s as a way of preventing the transmission of sexually transmitted diseases that include HIV, and also pregnancy. This has been as contentious issue with parents saying no, Government saying we want to push for condoms in schools and you have this dilemma. How can Zimbabwe go around that and ensure we have a win-win situation on both sides?

DB: Well, I think we have a very good evidence base. Right now you have a very important ongoing study called Zimbabwe ZIMPHIA that will be looking at the community level for where HIV is. It will look at both age disaggregated and sex disaggregated data.

And I think when community realises that their young women at 13, 14 and 15 are at risk for both pregnancy and HIV then hopefully people will understand that taking a public health approach, making sure there is sexuality education that really talks to young men and young women about behaviours and understanding and having the knowledge to protect themselves that will have to be married with the interventions that are critical to ensure that young men and young women can remain HIV free.

We have invested; the globe has invested so much in protecting young babies from HIV. We need to invest that same amount in ensuring that young women are protected and making sure that they have access to the services that will keep them HIV negative.

And I know those are always difficult discussions but they need to occur at the community, family and church levels. They need to occur at every level so that we are ensured that the messages that we are giving are grounded in public health truth and that young women and men understand behaviours that put them at risk and can make the choices that are right for them. And that they have the resources to intervene in transmission.

RS: We see that in Zimbabwe most HIV/Aids programmes are funded by donors. One of the initiatives we came up with as a country to fund our own response is the Aids Levy. What can we do as a country in the event that donors like PEPFAR decide to pull out?

DB: Well, first let’s just say that Zimbabwe by being ahead by having that Aids Levy and maintaining it through some very difficult times and in continuing access to treatment was extremely quite extraordinary.

So I think we have to start with and build on the platform that is already there. Many other countries don’t contribute that large an amount. But this gets back to the shared responsibility. Sometimes shared responsibility is not just about the money and if we want to control the epidemic together we have to do what you just described.

Find those innovations that can be taken to scale like you talked about circumcision. This will ensure that within the funding envelope that we have, that we are doing everything that we can collectively to end the pandemic because an epidemic that is growing is never going to be sustainable.

But an epidemic that is shrinking then gives government the reassurance that the investments that they are making are not only paying off but are also not forever.

And I think countries that make the investment now in controlling the pandemic will have those resources to combat non-communicable diseases when their population which I think in Zimbabwe I’m not sure but in many of the countries in sub-Saharan Africa, 50 percent of the population is under 30.

They are going to grow up. So understanding the health issues that are confronting Zimbabweans, ensuring that we make the HIV investment now, turn of the epidemic, those are dollars that will be available in the Ministry of Health from the Ministry of Finance to confront non-communicable diseases 10, 15, 20 years from now when the under 30 population will become the age of the rest of us.