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Interview With Kevin DeCock, M.D.

U.S. Centers for Disease Control, Nairobi, Kenya

Winter 2003/2004

Kevin DeCock, M.D.

IFARA: We're here today with Dr. Kevin DeCock, who is Director of the CDC, Kenya. This is the third year you've been kind enough to grant us an interview. Thank you. Before we get too far along, I believe that you had a large part to play in the 11th Conference on Retroviruses and Opportunistic Infections, where we are today. Perhaps you can start us off there?

Dr. DeCock: Yes, thank you. This conference over the past few years has shown increasing interest and attention to the global aspects of the epidemic, which is very important. There was a workshop on Sunday morning, just before the main conference opened, for young investigators where members of the program committee presented some data, and I gave a 15-minute talk on the global epidemiology. We'd just heard from Dr. Jaffe from [the U.S.] CDC about the situation in the United States. The U.S., of course, remains the most heavily affected country in the industrialized world. I gave an overview of the rest of the world. The trends in Western Europe have been very much the same as you've seen in the United States with the dramatic impact on the reduction in new AIDS cases from the use of highly active antiretroviral therapy (HAART), a continuing epidemic of new HIV infections, particularly among men who have sex with men. But an interesting difference that we see in Western Europe that we don't see in the U.S. is the importance of imported infections from Africa -- African people who have migrated to Western Europe and are showing up with diagnoses of HIV and AIDS, and make up a substantial proportion of the heterosexual cases.

The other very important trend in Europe has been seen in Eastern Europe where there has been a very important, rather dramatic epidemic of HIV infection, in the former Soviet Union particularly, largely related to injection drug use. This is a very high incidence of new infections, and this will be a very important area to watch. Interventions for injecting drug users and their sex partners, prevention interventions, are really extremely important.

The situation in Asia is fairly stable. Some countries have had a very successful experience, particularly Thailand. Thailand has done a very good job of controlling the sexual transmission of HIV, reducing it. In that country it was largely related to commercial sex, and by instituting a successful condom utilization program in the context of commercial sex, as well as to reduce the utilization of commercial sex, there has been a very rewarding decline in the heterosexual transmission of HIV in Thailand. They've also instituted a quite successful mother-to-child transmission prevention program. Where they have not done so well is in the problem of injecting drug use. About 40 percent or more of injecting drug users in Bangkok, for example, are HIV infected and that's a much more difficult problem to deal with.

The future of the Asian epidemic, I think, will be largely determined by what happens in India and in China. These two countries have such huge populations that even a low prevalence of infection in those countries constitutes a very large number of people. The future of the epidemic will depend heavily on events in those two settings.

But all of that is fairly modest compared to what we continue to see in Africa. Africa continues to represent over two-thirds of the world's HIV infected people of the new HIV infections that occur annually, and of the HIV deaths. The latest report that was published at the end of last year, 2003, from UNAIDS and WHO, estimated there were about 40 million people in the world infected with HIV. About 28 million of those are Africans. Of the 3 to 3.5 million deaths that have occurred, again over two-thirds are in Africans; and of the 5 million new infections, close to 70 percent are in Africans. So, this very poor continent continues to bear the brunt of the disease.

In my talk I gave an overview of the data, but I emphasized some of the impact that we see in Africa. Firstly in parallel with the AIDS epidemic, there's a major escalation of tuberculosis, and we continue to see that in virtually all countries, uncontrolled. Secondly, the social demographic, economic, and family impact is, of course, enormous. The third major impact that I briefly mentioned was that of orphanhood. It's estimated that there are over 10 million children in Africa who have lost one or both parents to AIDS, and this is a problem that has widespread implications, including security implications because these children grow up with very few prospects, a very bleak future. When you see the swollen numbers of children on the streets, for example, many African cities to some extent -- to a large extent -- this is due to the AIDS epidemic. And finally, fourthly, one of the things that I think also is attracting more attention is the relationship between the HIV/AIDS epidemic in Africa and the question of food security. The interaction between HIV increasing mortality and so on, and the poor state of agriculture in the declining returns of agricultural work, is a complex interaction, but is receiving more attention. In a nutshell, that's what I talked about at my session.

In this country, when we are trying to obtain new funding, we go to the Congress and we testify, we send letters with arguments based both in fiscal and moral responsibility, and sometimes global activists come to the U.S. to testify about the need and ask directly for help. As you've said over the years, there are infrastructure needs, and now we're seeing programs delivering actual treatments, and it seems to be an advance.

Dr. DeCock: Yes, I think we have to be careful not to paint everything as a totally hopeless picture and an empty glass. Over the years there has been progress in every sphere. We've seen real examples of leadership resulting in increased resources. Compared to last year the resources that will be available this year are substantially increased, and I think we also need to focus on how those resources are used at the country level. We need to keep asking, Are we doing enough in the industrialized world for this problem? But we also need to ask, Is Africa doing enough in terms of leadership, in terms of responsible use of the available resources, in terms of doing what doesn't take any resources sometimes, and using money responsibly? Everybody has their part to play.

IFARA: You talk about leadership and we have certainly seen it at the conference. Over the years we've had Bill Gates, Jimmy Carter, and Bill Clinton who have done good things for AIDS, and now in this other panel there are some clear leaders there. Maybe you can talk about that. Maybe you'd like to start with David Miller?

Dr. DeCock: Yes. Before the conference formally opened, there was an international symposium. We had four speakers. The first was from the World Health Organization (WHO) in Geneva. The WHO has launched an important initiative, the so-called "3 By 5 Initiative," which aims to get 3 million people onto antiretroviral therapy by 2005. That is really working in parallel with the PEPFAR, the President's Emergency Plan For AIDS Relief, the U.S. government effort to increase access to therapy, which is aiming to provide care in the general sense of the word, including for orphans, to 10 million to prevent 7 million new infections by 2008, and to have 2 million people on therapy. We're seeing international movement for sure. David Miller from the WHO talked about a very important issue, which is that of HIV testing. I think there's increasing realization that we have not used HIV testing adequately as a prevention tool and as a tool for entry into care, and if we're going to meet the targets of 3 By 5 or the PEPFAR targets of 2 million on therapy by 2008, we have to test many tens of millions of people, because we can't provide care if we don't know who's infected. It's estimated that in Africa probably less than 10 percent of people who are infected know their serostatus. This raises huge questions about our approaches to the use of the HIV test: how do we make it much more routine and demystify it? It raises very practical logistics questions as well. How do you develop the infrastructure to do all this testing? Can we produce enough rapid tests to meet the demand? And so on. That was the subject of David Miller's talk, a very timely and essential topic.

We then heard two presentations from sub-Saharan Africa that were encouraging and inspiring in their own way, rather different but both illustrative of the kinds of multidisciplinary responses needed. The first was from Dr. Gavin Churchyard, who works for the Anglo-American Gold Mining Company. The gold mines in South Africa are an interesting and challenging work environment. They've traditionally over the years had very high rates of tuberculosis, because South Africa has high rates but also because there's a particular lung disease related to gold mining, an industrial lung disease called silicosis, which predisposes people to tuberculosis. They've then had a rapidly escalating HIV epidemic related to sexual behavior, heavy use of commercial sex, and so on. Again, in the context of everything we know about the gold mines and South African history, the single-sex hostels that men live in and so on, really it's a very conducive environment to generating a rapid HIV epidemic and associated TB epidemic. [Dr. Churchyard] talked about what the company is doing to provide HIV/AIDS prevention and care, and they've mounted an apparently very successful program. It's in its early stages, but they have many hundreds of people on therapy with very promising results, such as a dramatic decline in mortality in men accessing care. It's a very good example of leadership; a well thought out program ethically conducted, really quite impressive, and a role model for other multinational businesses and local businesses as well. Working with the private sector is immensely important.

At the other end of the spectrum, Dr. Alex Coutinho from The AIDS Support Organization, TASO, in Uganda, talked about how to deliver care to people living in poor rural areas. He opened his talk with a picture of a mango tree, with some people underneath it, and said, "This is the clinical situation in which we have to deliver care. Deliver it under the mango tree." TASO has existed for a long time now. It's one of the first NGOs for AIDS set up in Africa. It's a wonderful organization, and they have developed a most impressive comprehensive HIV care program. Dr. Coutinho talked about his experiences related to that. Just like in South Africa in the gold mines, if people are sick and they get triple-therapy, they do well if they take their drugs. That's true in South Africa, it's true in rural Uganda, it's true in New York City.

The final talk in this introductory session was from Thailand, giving an overview of Thailand's quite successful prevention program and their efforts at delivering mother-to-child prevention services using antiretroviral drugs, as well as care. It was a useful session and very encouraging, I think, because literally two or three years ago, certainly not in 2000, I don't think we could have imagined seeing real programs developing, delivering real care interventions including antiretroviral drugs at an affordable price.

IFARA: Are there any other challenges that you feel are worth mentioning at this point?

Dr. DeCock: I think there are. There are a couple that I spend my time pondering about. Firstly I'm glad that you didn't ask me about what I said last year, because I think I'd have a challenge remembering what I said last year or the year before. (Laughter.) There are some constant themes that I do think about.

The first one, very basically, is, Are we taking this problem seriously enough in relation to what it represents? There is no greater problem facing the African continent, and I still think that the situation in Africa is radically different from elsewhere in the world. We won't go into why that is, but there is nowhere else in the world where you find rates of infection as high in as many places as you do in Africa. And we have to ask, Is Africa itself responding to this with the necessary vigor and is the rest of the world supportive enough? I think the answer is no, that it's not. There is no greater problem. We read in the newspapers of all the terrible things that go on, the wars, the conflicts, the crises that governments deal with, and yet none of them have the implications of the AIDS epidemic. It's the greatest crisis the continent has faced since slavery, since the slave trade. It has the same implications. So that's one general theme.

The second one, I think, is more difficult. In terms of our policies and our interventions, are we being vigorous enough? An example of what I mean is the new attitudes we need toward HIV testing, to make it much more routine if we're going to deliver prevention and care interventions. I often challenge people with the question, "If we had a prevalence in the United States of 25 percent, what would our prevention and care programs look like? What would we do? What would we do for children, for adolescents? What would we do about HIV testing? Would it be completely voluntary with pre-test counseling? Would we make it more routine? Would we be much more exacting about it, as we have been in the past for other diseases?" I compare it to how we responded to the SARS epidemic, compared to what we're doing for AIDS in Africa. I think there's some deep thinking to be done, especially now that there's hope for therapy and there's more resources. I think there is some deep thinking to be done about what else we should be doing. I think there are a lot of difficult questions that we haven't adequately faced and the reason has always been, Well, we focus only on prevention in Africa and there's nothing one can do when you find people are HIV infected. That's always been a sort of let-out clause. I think we seriously need to ask, in a high-prevalence setting should our prevention and care programs be based on universal knowledge of serostatus, should every citizen know their HIV status? Ideally on a voluntary basis, of course. If we had such a situation in the United States I think that's probably what our programs would be based around.

IFARA: So you would think that maybe we wouldn't look at reporting, or is that something we would continue to work on -- required reporting?

Dr. DeCock: Well, reporting is important as a surveillance activity. The reason we do HIV and AIDS reporting is that we track the epidemic sing that information, and that's a core of public health responsibility, so we know where prevention and care services are needed, where to target the interventions. So that's a quite separate issue.

IFARA: When you have a stigma so heavily attached to AIDS ...

Dr. DeCock: You're right to raise the issue of stigma. Stigma remains a big problem in Africa. A very, very big problem. On the other hand, how do we deal with it? I've come to believe that stigma needs to be dealt with face on. That if we keep treating AIDS as different, then indeed it will be viewed as different and will be stigmatized. Everybody needs to work together to make it more normal, to take the stigma away. One of the ways of doing that is for more people to know their serostatus and share their status. That's where we need leadership from African leaders themselves, from prominent members of society. Someone to say, I live with HIV.

IFARA: I really appreciate your efforts and your presence here today and the interview. I'm hoping that we can have you back again.

Dr. DeCock: It's a pleasure. Thank you for inviting me.

Back to the Winter 2003/2004 issue of Positives for Positives.

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This article was provided by Wyoming: Positives for Positives. It is a part of the publication Positives for Positives.
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