Global scaling up of ART: interview with NCHIV14 speaker, Professor Matthias Egger
The 2015 deadline for the UNAIDS’ target of 15 million people on ART is rapidly approaching. SHM recently spoke to NCHIV14 speaker, Matthias Egger (Professor of Epidemiology and Public Health at University of Bern, Switzerland) on whether he believes this target is realistic and about the challenges he feels still stand in the way of achieving this goal.
Could you tell us how you became involved in HIV research?
I graduated from medical school in 1983 when the HIV virus was discovered and CD4 was identified as the main receptor for HIV. I had always been interested in epidemiology and public health and, with a strong interest in infectious diseases, I went on to do a Master in Epidemiology at the London School of Tropical Medicine in 1986. This was at the time when HIV had become an increasingly urgent issue because it became clear that many were getting infected but nothing could be done: people were dying of AIDS and there were no effective treatments. I subsequently helped set up the Swiss HIV Cohort Study and have been a member of the Scientific Board of this study ever since.
With the advent of the highly active antiretroviral combination treatments (cART), it became clear that we needed larger studies to look into the factors that drive outcomes in the era of cART. To achieve this goal we set up collaborations of many different cohort studies. The ART Cohort Collaboration (ART-CC) in Europe and North America was one of the first, followed by the ART in lower income countries (ART-LINC) collaboration, which evolved into the International epidemiological Databases to Evaluate AIDS (IeDEA) which I currently chair. IeDEA includes data of almost a million patients across the globe.
What are the main changes you have seen take place in HIV treatment and care during your time in the field?
Obviously the biggest development was the widespread introduction of cART following the Vancouver International AIDS Conference in 1996. Then, from 2002 onwards, these treatments increasingly became available in Sub-Saharan Africa and other resource-limited settings. This was a really exciting development: after successful pilot projects, for example in West Africa, it became clear that it was difficult but feasible and effective to provide these treatments in the weak African health systems, and that it was possible to save the lives of large numbers of people through these treatments.
Your talk at NHCHIV 2014 will be on the challenges of global scaling up of ART. UNAIDS has set a target of 15 million people on ART by 2015. In your opinion, is this a realistic goal and what do you think will be the biggest challenges?
Sadly probably no, but it’s important to set ambitious targets to get and keep the ball rolling. We are probably at over 10 million now, which is fantastic considering that less than 10 years ago we were well below one million. Ultimately, the biggest challenge remains the health systems that have struggle to cope with the very large number of patients. As the eligibility criteria for treatment have increasingly moved towards higher CD4 counts, the number of patients who should be treated is constantly increasing. So, in a way, it’s like running behind a train that picks up speed. Other challenges include poverty: people find it difficult to access treatment and stay on treatment because they lack the resources required, for example, to travel to the clinic, and therefore get lost to follow up. Treating people when they are still fairly healthy does not help to keep patients on treatment. For example, we are seeing very high rates of loss to follow-up among pregnant women who are immediately starting cART under the B+ strategy [that recommends that all pregnant women living with HIV in resource-limited settings are offered life-long ART, regardless of their CD4 count]. Monitoring of cART is another challenge. In poorer settings viral load is often not available (in some clinics only clinical monitoring, without CD4 counts, is possible), and switching to second line is often the last option. We are therefore working intensively to help clinicians understand when they should switch the patient, and to provide tools for front-line clinicians to help them make these decisions. Targeted viral load testing of those at high risk of virological failure, based on clinical findings and CD4 counts may be an interesting approach in this context.
You have a great deal of experience in Southern Africa, where improving access to HIV treatment has helped reduce new HIV infections and AIDS-related deaths. In Eastern European countries, however, the number of new HIV infections is still on the rise. How does the situation in Eastern Europe compare to that of Southern Africa?
Perhaps ironically, the situation is probably more difficult in Eastern European countries than in many countries in sub-Saharan Africa where, in general, the societal and political background is now conducive to effective control. The epidemic in Eastern Europe is often driven by intravenous drug use, but governments seem reluctant for political and legal reasons to make effective interventions, such as syringe and needle exchange programmes, available. This makes it far more difficult to mount an effective public health response. Stigma is also probably still more prevalent in this countries, although it also continues to be a problem in many other regions, including Sub-Saharan Africa.
Are there any particular lessons that you can take from your experience in Africa and translate to the situation in Eastern Europe?
I am not a politician, but is seems fairly clear what needs to be done: politicians should start talking about HIV, acknowledge the problem, lead by example and fight stigma, and make the required resources available.
The field of hepatitis C treatment is changing rapidly with the advent of promising new therapies. One of the issues surrounding these new treatments is availability in resource-limited settings. Based on your experience with the roll-out of HIV treatment in Africa, what do you think is needed to ensure the global roll-out of hepatitis C treatment is successful?
That’s a very important question. Can we avoid the 8-year gap we witnessed with HIV treatment, from 1996 when the drugs became available quickly and on a large scale in industrialised countries, to 2004 when governments in resource-limited settings were able to scale up cART? It may be more feasible for hepatitis C as there are fewer patients. On the other hand, finding the people who need the treatment might be an even greater challenge because there are fewer of them. At present the very high costs of drugs are, of course, a problem even for resource-rich countries.
Looking forwards, what do you think the global landscape of HIV care will look like in 10 years’ time?
In 10 years’ time we will know whether treatment as prevention can be rolled out on a massive scale, and I do hope it will be successful at least in some settings, although recent results have not been too encouraging. Combination prevention will have made a difference and the number of new HIV infections will have have declined further, but HIV/AIDS will still be an important public health problem in many populations. The research agenda for the next 10 years also includes treatment approaches that move towards eradication of the virus. I’m hopeful that we will get nearer to such strategies in the years to come. Finally, I hope that successful new approaches will become available to everyone who can benefit from them. In short, the landscape will be different but HIV will still be there.