Interviews with Dr. Joep Lange and Dr. Helene Gayle—Changing of the Guard at IAS
Bangkok Ushers in a New Era
April 2004—At the 15th International AIDS Conference in July in Bangkok, Dr. Joep Lange will step down as president of the International AIDS Society (IAS) and hand the reins to Dr. Helene Gayle, Director, HIV, TB, and Reproductive Health at the Bill & Melinda Gates Foundation. Dr. Lange, a clinician who has fought hard for expanded treatment access, leaves behind him a changed organization to which Dr. HeleneGayle brings extensive experience in resource mobilization and global AIDS policy.
The TREAT Asia Report spoke with the president and president-elect about the progress and promise of the IAS, the Bangkok Conference, and the future of the epidemic in Asia and beyond.
Dr. Joep Lange
Dr. Lange has more than twenty years of experience in treating and researching HIV and AIDS. He served as Chief of the Clinical Research & Drug Development Global Programme on AIDS at the World Health Organization and is currently Chief Scientific Adviser of the International Antiviral Therapy Evaluation Centre and Chair of the Steering Committee of the International HIV Treatment Access Coalition. Dr. Lange was a member of the Partner Advisory Group for the WHO’s “3 by 5” initiative and is the Chairman of PharmAccess International.
TREAT Asia Report: How will this summer’s conference in Bangkok differ from conferences past?
Dr. Joep Lange: This is going to be a time of accountability. In that respect, one difference is the leadership component. We will have the Prime Minister of China, the President of Uganda, President Clinton, President Mandela. We will also have a number of media personalities with big names, CEOs of companies, and community leaders. The lesson of Durban was that this conference can have an enormous impact, and bringing leaders to the conference will actually make them do better in their countries.
TREAT Asia Report: If Bangkok turns a spotlight on Asia as Durban did on Sub-Saharan Africa, what else did we learn from Durban that should inform our response in Asia now?
Lange: The situation in Asia is different from Africa because in Asia we can still accomplish an awful lot with prevention. By the time the conference took place in Durban, we already had infection rates of 10–30 percent in most countries in Sub-Saharan Africa. In Asia, although the numbers of infected people are huge, it’s still a relatively small proportion of the population. So I think we’ve got an enormous opportunity still to turn the tide in Asia and people should realize that. If they don’t do it now, they’ll end up in an African situation.
TREAT Asia Report: Are you encouraged by the response of the Indian and Chinese governments to their emerging epidemics?
Lange: I’ve been quite impressed by the Prime Minister of China. I think he’s really turned around the whole Chinese attitude to HIV. Verbally the Indians are also now making commitments. I have to see what it amounts to on the ground. But the capacity to deliver is much greater in those countries than it is in Africa just because the resources and personnel are there.
TREAT Asia Report: There is always a high level of community involvement at the conferences; do you think there’s scope for greater involvement of the community within the IAS generally?
Lange: I think the IAS has tried to work more closely with the community. We’ve given them a more prominent role in the conference. At the same time, we have a different role. IAS is a professional organization that brings science to the table. We need to be able to say politically incorrect things. There are a lot of slogans in the field, and we should be free to speak out of a base of evidence and say things that others may not be able to say.
TREAT Asia Report: As your tenure at the IAS comes to an end, what impact have you made on the organization?
Lange: I’ve turned it into a more professional organization. IAS was normally responsible for organizing the international AIDS conferences, but I don’t think it was a very professional organization. I’ve also consolidated programs. We have a number of new programs. One is the “Industry Liaison Forum” where we have regular interaction with the pharmaceutical industry to discuss issues of relevance to them for research in developing countries. It is important to increase their interest in developing country research. If I look at internal accomplishments, the move from Stockholm to Geneva is a major accomplishment. That was a hard battle.
TREAT Asia Report: What affect will the move to Geneva have?
Lange: Being located in Geneva will make the IAS better connected to organizations like the World Health Organization (WHO), UNAIDS, and the Global Fund. In the past few years, IAS has become more of a player. IAS played a major role in actually putting access to antiretrovirals on the agenda. Being a catalyst is a role that IAS can play. In the end, an organization like WHO will take over because they are perceived to have the mandate. But they need some pushing sometimes. All the UN bodies and the Global Fund are very much tied to governments, so they are very restricted in what they can and cannot say. The strength of IAS is independence; it can be the voice of reason. It could be a welcome addition to the whole Geneva complex, which is, in a way, the world AIDS capital.
TREAT Asia Report: Do you get a sense that these organizations are working well together, or are there too many players now?
Lange: I’m very positive about the momentum that access to treatment has gotten, but it’s merely political. If you look at delivery on the ground it’s still a sad story. There’s an enormous lack of coordination. If we needed concerted action to eradicate smallpox, we need much more concerted action to tackle HIV. I don’t think WHO has managed to be a leader, basically because it doesn’t have enough finances. But the problem is that everybody thinks it is WHO’s mandate so they should lead. But they can’t. They don’t have the resources.
TREAT Asia Report: Does IAS have a role to play?
Lange: I really wanted to bring together the different players. That’s why we started this international treatment access coalition at the Barcelona conference last year to which WHO quickly signed up and then took over the secretariat. I’ve learned that IAS can be a catalyst and a voice of reason. But in the end, the world doesn’t perceive us to have the mandate to coordinate everybody.
TREAT Asia Report: Do you think that WHO’s “3 by 5” initiative—to have three million people on antiretroviral therapy by the end of 2005—can succeed?
Lange: What we need is sustainable scale-up, where all HIV-infected people will receive the treatment they need. I’m not sure that setting artificial goals is the most productive way forward. What may happen is that a push to reach such a goal could neglect a number of essentials. Now there’s a push for the cheapest fixed dose combination regimen, because that’s the quickest way to get people on therapy. But that may not be the best combination. There’s not enough thinking about robust regimens that will be tolerated in the long term, etc. So there are a lot of missing pieces in the puzzle and nobody has enough power to get everybody in line.
TREAT Asia Report: From what you have learned over the past two years, where do you think we will be with this epidemic five or ten years down the road?
Lange: Unless there’s an enormous scientific breakthrough, we will not see an effective vaccine for at least another decade and we may be saying the same a decade from now. But there may be other prevention methods that are able to make a difference. I think the ongoing trial supported by the Bill & Melinda Gates Foundation investigating an oral prophylactic is very important, because that might be an alternative to a vaccine. I think the oral prophylaxis is going to work. Some of the microbicide work may give us better ways to prevent infections. So we will have an effective preventive measure for vulnerable populations. As for putting people on treatment, the scale-up will happen but will be much slower than is necessary.
TREAT Asia Report: What is next for you?
Lange: I’ve learned one lesson: I don’t want to go into politics! I want to go back to science. I’m also chairing the foundation called PharmAccess International, which is helping partners implement treatment on the ground in developing countries. My clinical work has really suffered from this IAS commitment. I long to get back to work.
TREAT Asia Report: When Helene Gayle takes over, what will be the biggest challenges that she will face?
Lange: Expanding the role of IAS, consolidating programs, and finding the funding. Helene is exceptionally well suited to do those things. She’s the best person at the right moment in time. She has the skills. She’s a good diplomat. She can also be very tough, and she has a very broad view of the epidemic. She knows the essentials. A lot of prominent people in IAS’s past have had a very clinical background. I’m a clinician myself. Usually, the scope of clinicians is rather limited. Helene brings a lot that we didn’t have before.
TREAT Asia Report: Thank you very much, Dr. Lange.
Dr. Helen Gayle, Photo courtesy of the Bill & Melinda Gates Foundation.
Dr. Gayle directs the Bill & Melinda Gates Foundation’s HIV, TB, and Reproductive Health Program. Her portfolio includes more than $1.2 billion in grants for prevention, treatment, and research. Before joining the Foundation, Dr. Gayle was the director of the National Center or HIV, STD, and TB Prevention at the U.S. Centers for Disease Control and Prevention where she helped launch a global AIDS initiative. Dr. Gayle has served as a health consultant to international agencies including the World Health Organization, UNICEF, the World Bank, and UNAIDS and has worked extensively in Africa, Asia, and the Americas.
TREAT Asia Report: What challenges will IAS face in the future?
Dr. Helene Gayle: IAS has been associated primarily with the conferences, and increasingly we see the conferences as both an opportunity for sharing information and a strategic opportunity to get important messages across. That is why the Bangkok conference is important for the global epidemic. IAS has the possibility to be more strategic about the way the conferences actually educate and share information, but also about the message that we give the world.
TREAT Asia Report: What will the message from Bangkok be?
Gayle: The theme of Bangkok is “access for all.” What we’ve tried to get across is the message that we are in a truly global epidemic, and that we must make sure that the resources—technical and financial—are where the epidemic is most serious. I think a big highlight will be an effort towards greater access to treatment around the world. I think we are at a new day in terms of being able to provide antiretroviral therapy in poor nations, and with that comes the challenge of making sure we balance treatment with maintaining a strong focus on prevention.
TREAT Asia Report: As treatment takes center stage, are you concerned that prevention will be given short shrift?
Gayle: While we have a huge deficit to make up for in the area of treatment, we also still have a deficit in prevention, and more and more people are recognizing that the mobilization around access to antiretroviral therapy needs to go hand in hand with a mobilization to increase access to prevention services. We have an opportunity to make sure prevention is not seen as a stepchild of treatment and to look at how to move them forward together.
TREAT Asia Report: Will that be one of the issues that you will emphasize during your tenure at IAS?
Gayle: Yes, I think one of the biggest issues we face is making sure that as we focus on getting treatment to people, we recognize that it has to go hand in hand with prevention. If we let our guard down, we could have the same situation in the developing world that we are starting to see in rich nations, where HIV rates are starting to go back up. I think there are all sorts of incredibly positive benefits to getting treatment to people, but it also offers tremendous opportunities for prevention that we haven’t had before. We need to make sure we optimize the potential for both.
In addition to being a conference organizing body, IAS has the potential to mobilize its membership to develop capacity at the country level and be a voice for evidence-based interventions. I think that’s the promise of what IAS can bring, even more broadly than it has in the past.
TREAT Asia Report: Can you give an example of how the membership could be better utilized?
Gayle: One of the things that is a potential barrier to scaling up treatment is having enough people with clinical skills to manage care of people with HIV. A lot of the IAS members are clinicians. We could have some members, particularly from northern countries where they have had a lot of experience with antiretroviral therapy, work with doctors from southern countries that haven’t.
TREAT Asia Report: What do you see as the major challenges facing Asia? What encourages you and what concerns you?
Gayle: In contrast to Africa, where rates of infection in small populations are relatively high, in Asia there are large populations that may not have high rates but will produce very high numbers of people living with HIV. So in terms of both the toll for Asia, as well as the toll for the global epidemic, Asia is going to be defining because of the number of people that will be added.
I think the flipside of that is that larger populations and relatively smaller rates of infection make HIV easier to ignore and to be viewed as a problem that only affects parts of society. It’s important that the impact that HIV can have on societies in Asia is well understood, so that the region can avoid both the health impact, as well as the economic impact that will come. I also think that because transmission in Asia is a mix of both injecting drug use and sexual behavior (heterosexual as well as male-to-male sexual contact), a complex set of interventions will be necessary to prevent the spread of HIV and to care for the diverse population affected.
TREAT Asia Report: Do you think there will be any surprises coming out of the Bangkok Conference?
Gayle: As far as scientific breakthroughs, probably not. As we’ve seen at the last few conferences, there probably will be good, incremental progress in areas like drugs, vaccines, and microbicides. Increasingly there is more news on the global response to the epidemic. There will be more sites that have good data on what it takes to scale up antiretrovirals. Is that startlingly new? Perhaps not, but given that five years ago we didn’t even think that care of people with HIV was possible in developing countries, that’s pretty good. I think there will be more countries that will report successes in prevention, in terms of reduced numbers of new STDs and changes in behavior. It’s not a new blockbuster drug, but that is the kind of incremental progress that, bit by bit, is ultimately going to stop this epidemic.
TREAT Asia Report: How does the world focus attention on a 20-year-old epidemic? Do you have ideas for how IAS can keep it on the front burner?
Gayle: The Bangkok conference is so important. At least two years after the Durban conference, there was still buzz from the revelations that came out of it. The world turned its eyes to the global epidemic in a way that it never had before. I don’t think we will ever go back to the days that I remember all too well, when the whole international contribution to fighting the global epidemic was in the realm of a couple of hundred million dollars. Now we’re in the billions of dollars. We have to make it clear why this is not just a health problem, though health is important, but why it’s also an economic problem, why it touches on security issues, why it is in all of our best interests to be involved. You just keep the drumbeat going. I don’t know any other way.
TREAT Asia Report: Thank you, Dr. Gayle, and good luck!