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The XVII International AIDS Conference (AIDS 2008)
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Newsmaker Interviews: Gregg Gonsalves

August 4, 2008

Gregg Gonsalves
Gregg Gonsalves
Jackie Judd: Gregg Gonsalves, I appreciate you coming in to talk to me, welcome.

Gregg Gonsalves: My pleasure.

Jackie Judd: In Toronto, you gave a speech that got a lot of attention and you said, I am telling you right now, we are losing the struggle against this disease. Is it a different message here in Mexico City?

Gregg Gonsalves: I think the message is slightly different because we are two years later into the epidemic. We still have too many new infections and too many deaths. We still have only 31-percent coverage of antiretroviral therapy for those in need. We have far less coverage of key prevention interventions like PMTCT and access to clean needles and methadone.

But the world has sort of shifted against us over the past two years. As many people at this conference will know, there has been a lot of backlash against AIDS since Toronto telling us that the figures about AIDS have been inflated by UNAIDS, that AIDS gets too much money, and why does it not go to maternal and child health or to sanitation, and even that AIDS programs for treatment are distorting and destroying health systems. So, we are not in a good position, either politically or epidemiologically, two years after Toronto.

Jackie Judd: But it does not sound like you would go quite so far as you did in Toronto. Losing the struggle, those are powerful words.

Gregg Gonsalves: We now have 3 million people on antiretroviral therapy. It is an achievement. Of our lifetimes, it is probably the single most ambitious public health achievement that I can think of, in terms of the ambition and the scope of what has been done. That is a good thing. Right now we are on the trajectory to universal access to 2010. When you look at where we are in terms of where we need to be by 2010, we are not winning that battle.

Jackie Judd: You do not expect that the 2010 goal will be met?

Gregg Gonsalves: We will not meet the 2010 goal, in terms of universal access, for many, many different reasons.

Jackie Judd: Such as?

Gregg Gonsalves: Such as we never set targets. I was in the meetings with UNAIDS and the Department of International Development of the U.K. government and they argued as well as the U.S. government that we did not need global targets now, that 3 by 5, we do not need to do something like that anymore. We need to sort of give countries more control and be more flexible about it. But basically what we have gotten is no milestones to reach for, not timeline or deadline to bring us forward, so we will not reach universal access to treatment, prevention and care by 2010.

Jackie Judd: Where do you think we will be?

Gregg Gonsalves: We will have slightly more coverage than we do now in key interventions, but the pace and the momentum of 3 by 5 and other initiatives just a few years ago is gone. We are back to sort of the old way of doing things, the way WHO likes to do them, the way UNAIDS likes to do them, the way the U.S. government likes to do it, the way the U.K. government likes to do it.

Jackie Judd: I want to go back to where you started, and that is a discussion of the kind of backlash that we are hearing about here in Mexico City. And one thing you hear about -- in fact, Peter Piot addressed it last night in the opening ceremony when he talked about rejecting the argument that AIDS should be normalized or not considered exceptional because if someone does have treatment, it is a chronic disease, it is not a death sentence. Where has that debate originated and what does it do to the fight against AIDS?

Gregg Gonsalves: Well, there are different ways to think about exceptionalism. For AIDS treatment, for instance, do we need a standalone ARV clinic or do we, like I do, get my ARV care in the context of primary care? That is normalizing HIV care into a broader framework of comprehensive primary care. The other way people talk about exceptionalism around AIDS is that it has gotten too much money, that it has gotten too much focus and that it has gotten special treatment of some sort. But what they seem to do is people seem to have some sort of envy about AIDS, some sort of jealousy about AIDS. Nobody talks about bringing everything else up, you know, let us bring up sexual and reproductive health up, let us bring maternal and child health up, let us bring sanitation up, let us bring everything up. It seems like they want to push AIDS down to the level of unexceptionalism of everything else. And so I think Peter and me and many other people are saying, AIDS is exceptional, but everything else should be exceptional, too, so that means that governments have to pony up 0.7-percent of GDP for overseas development aid, including health, that they have to treat all health and development issues as exceptional issues. We are not in a race to the bottom. People like Roger England, people like Daniel Halperin and other people who have made these cases that AIDS is getting too much money are not thinking of an expansionist, maximalist view about public health and human development. They are saying, let us go back to the days when the idea of anybody getting such a sophisticated intervention, like we see in HIV with ART, was a pipe dream and people thought it was unsustainable and not cost effective.

Jackie Judd: You were involved in the release recently of a report from the International Treatment Preparedness Coalition that evaluated the response and the health systems. One of the strong points you made was what you were just saying, that it lifts everything up, the response to AIDS. And how do you see that happening in a village in Africa, for example?

Gregg Gonsalves: Well, look, there are bad ways to do things and there are good ways to do things. I was at a session yesterday on health systems where the Health Minister of Ethiopia spoke and he said, look, AIDS money was vital to pump up our health systems. Before AIDS, there was no great investment in any kind of public health the world over. He has used it to strength primary care, to integrate HIV programs into primary care, to build up human resources, to build up training, to build up laboratory capacity, and to build up physical infrastructure.

And so there are bad ways to think about ARV care. If somebody comes in with an ARV program, sets up a separate shop, puts an ad in the paper that says, we need doctors, and they all come running to you to make a higher salary, that is not the way to do it.

Jackie Judd: Because then people who do not have HIV will not be treated there.

Gregg Gonsalves: No, well, if we create perverse incentives for people to move out of the primary health system into vertical programs, that is a bad thing to do. But in many cases, in Rwanda, in Haiti, we know of people who are saying, you know what? The long-term vision for HIV care is something that is driven by comprehensive primary care. We are going to manage a chronic illness over time. It is not going to be based on a bevy of specialists dealing with individual patients. It is going to have to go through the regular health system.

Jackie Judd: Do you believe that some of what you describe as the backlash will gain political traction and will serve as an excuse for some governments to not be as aggressive as you would like them to be?

Gregg Gonsalves: The backlash is coming from very important people, people who work at the Council on Foreign Relations, people who have been affiliated or work for the Department for International Development in the U.K. These are not sort of outsiders, people who are outside the system. This is coming from deep within the health and development establishment. Basically what I see this backlash driving is proving an excuse for governments to pull back on AIDS, to go back to the old way of doing things where civil society was not really important, where there were back-room deals between the good old boys in the Ministry of Health in this country and Ministry of Health in that country. So, a lot of the critique, the backlash right now is a negative vision. They are not saying, let us pour more money into everything. Let us get civil society into doing other health work like it happens in AIDS. Let us have accountability and transparencies, like the missing the target reports in maternal health or for sanitation. They are talking about a negative vision, about what they do not like or see as bad. They do not draw their vision to the future. They draw their vision to the past in my estimation.

Jackie Judd: You are giving a plenary speech later in the week here in Mexico City. Can you give us a preview?

Gregg Gonsalves: The preview is that 30 years ago, ministers of health and public health experts met in Kazakhstan and issued the Alma-Ata Declaration saying that we should have health for all by 2010. We are the heirs of Alma-Ata. We are going to drive the movement to primary care. If we build on AIDS the way we have garnered resources, the way we have forced governments to take the health of poor people into account, to enforce accountability and good governance, we will take that and we can build a strong, comprehensive primary care movement. That is where AIDS should go now, both because it is a clinical necessity because people like me need to depend on good primary care infrastructures to provide services, but also because that that is the right thing to do. It is not right that somebody dies of a diarrheal disease when they can get ARVs. What we are saying is join us, learn from what we have done, the innovations, the successes that we have had, and we will heparin to build health for all even though it seemed 10 or 15 years ago that it was a joke in the Public Health Committee.

Jackie Judd: Your definition of success coming out of Mexico City?

Gregg Gonsalves: My definition of success coming out of Mexico City includes basically three things. One is to say that we reject these sterile debates that Roger England, Laurie Garrett, Daniel Halperin and others are putting forward. What we want to do is refocus our attentions on universal access with hard targets and hard deadline about when we are going have X number of people on ARVs by Y? When we are going to have full coverage for key prevention interventions? How many people, by when? And also, start to broaden the AIDS movement to that say we are going to take on a larger mission of extending and building up primary care. That was called for 30 years ago in a place very far away from Mexico City, but the call is still a good one.

Jackie Judd: Okay, thank you very much, Gregg Gonsalves. I appreciate it.

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