How did you get involved in AIDS?
I worked at the University of Zimbabwe for 18 years from 1984. During an exchange visit to the University of Zambia in the late 1980s we learned that a study had just shown shockingly high rates of a deadly new virus, recently named HIV, among clients at sexually transmitted infection (STI) clinics in Lusaka. We returned to Harare aware that the public health landscape in Africa had changed irrevocably and began working on HIV prevention research and programs.
What brought you to the World Bank?
During the 1990s I began working on and off with the World Bank on an STI project in Zimbabwe and several regional HIV prevention efforts. After the Bank made AIDS a corporate priority in 2000, I began working on several AIDS projects throughout Africa and joined the Global HIV/AIDS Program full-time in 2003 to work on improving our AIDS epidemic understanding and results.
What are the main trends you see today in the global AIDS epidemic?
We know so much more than we did 20 years ago. When I began working on AIDS, the global wisdom (which I shared) was that Zimbabwe—then a prosperous country with a robust primary health system—would have a much smaller HIV epidemic than West Africa with its vast slums or Asia with its teeming ports and brothels. Today, of course, we know that HIV rates in Zimbabwe are 10-times higher than much of West Africa and 50-times higher than much of Asia.
We know that alone among new viruses, HIV has spread to every country in the world, infected more than 50 million, killed more than 20 million and orphaned 16 million children (14 million in Sub-Saharan Africa alone). We know that its long, hidden latency period and ability to mutate faster than any other known pathogen make it a truly dogged multi-generational challenge.
Importantly, we have also learned how heterogeneous HIV is globally. In the 1980s we all feared that generalized HIV epidemics (in which most HIV is spread by casual sexual behavior in the general population) would affect all countries, developed or otherwise. We now know that generalized epidemics are largely limited to Africa and perhaps parts of the Caribbean and the Pacific. In the generalized epidemics of Southern Africa the epidemic has surpassed our worst fears. Nearly half of all women aged 15-49 in Swaziland and nearly 70 percent of women 30-34 in Francistown, Botswana, have HIV. A staggering 5 million South Africans have HIV—indeed, almost one in five people living with HIV globally is South African.
Elsewhere, we see concentrated rather than generalized epidemics. Concentrated epidemics occur when HIV is spread mainly by marginalized groups such as sex workers, men-who-have-sex-with-men, and injecting drug users and their sexual partners. These types of epidemics still pose a major public health challenge. Over 3 million people in India have HIV. We are also seeing an alarming rise in HIV infections among men-who-have-sex-with-men in most developing countries, which uncannily mirrors the devastating epidemics we saw among men-who-have-sex-with-men in the West in the 1980s and 1990s.
HIV prevention is working, though much too slowly. We now know far more about how to curb concentrated epidemics. In Thailand, for example, decisive action in the late 1980s limited HIV to 1 million people instead of an expected 8 million. Cambodia has been similarly successful. India, Brazil and recently, China, have reported reduced HIV transmission.
We know far less about how to arrest Sub-Saharan Africa’s generalized epidemics. We do know that male circumcision reduces HIV transmission by at least 60 percent. Fewer than 20 percent of men are circumcised in seven of the eight countries with the highest HIV rates. We also need effective behavioral interventions to reduce multiple concurrent sexual partnerships in generalized epidemics—and we know far less about how to implement such interventions.
We stand in awe of the remarkable scientific progress made in AIDS treatment. Today 5 million people in developing countries receive life-giving anti-retroviral treatment, but at least 5 million more also need treatment now. And for every two people we place on treatment, another five become newly infected. So treatment is only sustainable if prevention works.
How do these trends inform the Bank's role in HIV and AIDS?
The funding landscape has changed since 2000, when the Bank was the largest single AIDS program funder. Today, we are still one of the three largest investors, but some distance behind PEPFAR and the Global Fund—and the overall field is more crowded. As a result, we no longer need to be omnibus funders of entire national responses, and our financing can be more selective. Since much funding from PEPFAR and the Global Fund supports AIDS treatment, it makes sense for the Bank to focus its resources on strengthening HIV prevention. Through rigorous impact evaluation research and experience with successful prevention in India, Brazil, Vietnam, Cambodia, Rwanda and elsewhere, the Bank is well placed to advance global knowledge and practice in behavioral interventions.
The global health community is in transition from unprecedented fund-raising to a new era focused on spending money more strategically and effectively. As Julio Frank, Dean of the Harvard School of Public Health, says, the need is not simply more money for health, but more health for the money. The Bank’s lending and analytical work is aimed at assisting countries to sustain and improve the effectiveness of their AIDS responses.
Those of us working on AIDS in the 1990s recall when there was so little global attention to HIV that we expected national efforts to wither to nothing, alongside other neglected initiatives for specific health challenges. We never even remotely foresaw the extraordinary success of global AIDS advocacy, which turned AIDS into the cause célèbre of politicians and rock stars and raised unprecedented resources. As we seek to balance AIDS spending against other health and development priorities, we must ask whether AIDS funding will ebb as quickly as it flowed. Whatever the case, the Bank’s support will remain vital.
What are the major priorities for the Bank in helping countries halt or reverse the spread of the epidemic?
Our greatest priorities are to:
- Support countries, to make HIV prevention more effective, exploiting the Bank’s ability to support sensitive programs, including investments in programs to protect sex workers, men-who-have-sex-with-men and injecting drug users in concentrated epidemics and programs to promote male circumcision and partner reduction in generalized epidemics;
- Assist countries to transform AIDS treatment from an emergency to a sustainable response, integrating AIDS treatment and other health-related HIV services into national health systems;
- Capitalize on the Bank’s unique expertise in social protection to develop effective safety nests for those most affected by AIDs, including marginalized groups in concentrated epidemics and orphans, widows and the elderly in generalized epidemics; and
- Utilize the Bank’s core competence in economics and related policy areas to enable countries to develop better prioritized and more efficient, effective and sustainable AIDS responses.
What will be your philosophy as AIDS Director?
We must make every AIDS dollar work doubly hard—work for both AIDS and wider health and development outcomes—and that will be my guiding principle in this role.