Straight talk with
WHO’s new director of HIV
The UN World Health Organisation (WHO) recently appointed Dr 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
■ IRIN: 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?
■ Gottfried Hirnschall: Putting people
on treatment earlier has several benefits,
including reducing morbidity and
mortality, and the substantive preventive
benefit of lowering the number of new
Policy makers and civil society have
welcomed the new guidelines, but have
two major concerns: how to make the
guidelines operational 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.
■ IRIN: 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?
■ GH: 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
We also need more clarity in the quality
criteria of the services being provided; high
standards need to be set and adhered to.
■ IRIN: Are countries overly reliant on
external funding? Does that put national programmes at risk?
■ GH: 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.
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
So what we need is sustained funding
from all parties and to use the available
resources more strategically.
■ IRIN: What do we need to do to make
HIV prevention effective? Where did we
■ GH: We don't yet have a magic bullet
for prevention, which would be a vaccine, but we are still working towards one.
are also working on microbicides and preexposure
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
We are also looking at male circumcision,
which has started in many African
countries now, as well as treatment as
■ IRIN: 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
■ GH: 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 drugresistant
HIV strains as they scale-up treatment.
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
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.
■ IRIN: 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?
■ GH: 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 minimise 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.
of upload: 25th Sep 2010