Interview with Professor Hoosen Coovadia

Professor Hoosen Coovadia, Victor Daitz Professor of HIV/AIDS Research, and Scientific Director of the Doris Duke Medical Research Institute, Nelson Mandela School of Medicine in Durban, South Africa is recognised worldwide for his groundbreaking research in perinatal HIV transmission. 

Ranadi: What do you think have been the most significant advances in HIV and AIDS research particularly in the paediatrics field, in recent years?
Professor H Coovadia: In recent years there have been primarily two major advances for treatment.  There has been considerable evidence that the initial fears (that) antiretroviral treatment for children in developing countries would be just riddled with difficulties and that has not shown to be so.  The results from developing countries for HIV positive kids under treatment have been really good.  They've been good in outcome, good in adherence, etc so that I think has been critically important. It's an important principle which has been established.

The second is the CHER study which established that for babies who are HIV infected ... you have to start treatment very early, probably under 3 months.  The implications for that are not only for the development and growth of the baby but also for the provision of services which allow the detection of HIV very early in infancy.  It's simply not possible at the moment in many parts of the developing world.  It means that, in addition to all the other reasons for scaling up (medical) services, this is really important for babies - that's the provision for diagnosis of HIV, usually with PCR tests. It also reminds us that we need to improve diagnostic tests for young babies, especially those which are affordable and sensitive, specific and easily applicable in a poor environment.

Then the other big issue is that more drugs have become available which can be used by children ... mostly in the developed world.  There are better forms of regimens available for the prevention of mother-to-child transmission and therefore transmission in women who don't breastfeed can be reduced to about 1-2% which is really quite phenomenal when you think that without treatment transmission is about 25-35%.  So that's a huge advance.

The next issue which in my view has been bedevilling the whole mother-to-child transmission is a question of solving breastfeeding transmission.  The single biggest advance, including prevention and treatment has been the in-principle demonstration by at least two good studies, randomized control trials, which show that giving antiretrovirals to babies, specifically nevirapine, can reduce mother-to-child transmission considerably for about 14 weeks.  Whether we can do that for 6 months is not known.  Certainly the principle that you can use antiretrovirals in babies, while babies are breastfeeding, has been established.  There's a question now of fine tuning it so that we can reduce transmission for the period that breast-feeding should be exclusive ..., and that is for about 6 months - that hasn't been shown.  The second intervention for breastfeeding is provisional of HAART, highly active retroviral treatment.  There are a number of observational studies which show quite clearly that HAART is immensely successful.  Unfortunately we don't have properly conducted randomised trials.  There are about three coming up, one pretty soon in the next 6 months, and another a little later, which will answer this question of the use of HAART. So we have to await these studies but certainly the observational studies show that you can reduce breastfeeding transmission also to about 1-2%

Ranadi: What do you consider have been the major recent set-backs?
Professor H Coovadia: I think most people agree that despite all the things we know about treatment, the availability and access to treatment, for ARVs in particular, but also the sustainability of additional auxiliary measures, in particular cotrimoxazole, has been totally inadequate globally.  ... The proportion of children who are actually on treatment is a minor proportion to those who actually need treatment worldwide. ... we need scaling up of services, (to combat) inadequate access to treatment. For prevention, it's the same ... . We do know that of all the HIV positive pregnant women who should be getting simple measures like nevirapine and AZT ... it's available to ... less than 40% of women who need treatment for prevention of mother-to-child transmission. ... So that has been a major problem. 
So we have research which needs to be implemented. We know many things which need to be done to prevent mother-to-child transmission, how to treat babies, but we need to implement this. And this means to scale-up the health services and also to make it more efficient by integrating.  And this is for both treatment and prevention.

Ranadi: So would you say that this is an area of science where there is no conflict between prevention and treatment?
Professor H Coovadia: Not yet. .... Mothers are trooping around from a prevention service to a treatment service, to a charity service and it is costing efficiency, it is ineffective.  It is inappropriate to subject mothers, especially in the developing world, to inconveniences which may not just be inconvenient but also costly.  To me that's the gap between prevention and treatment at the service level.

I want to add that with (regards to) prevention of mother-to-child transmission, there was a WHO recommendation, which I think really was a very good one, they said ... start before the mother gets HIV in the first place.  It's obvious - you don't even need a study.  If we reduce the number of HIV infected women we will have fewer problems. There are three studies which show that if you concentrate your efforts also on the idea of trying to reduce the incidence in HIV in young women of child bearing age, you will reduce mother-to-child transmission.  There are studies which show that you can concentrate your efforts on keeping HIV negative women negative. And the benefit of that is not just for mother-to-child transmission but also for reducing HIV spreading, which in fact is a key aim for all intervention is to confront the HIV epidemic.

Ranadi: What do you think is the greatest challenge when it comes to applying the knowledge you've gained to the field?
Professor H Coovadia: I think application of knowledge.  We know how to reduce mother-to-child transmission with the drugs that are affordable but most, not all, but most developing countries haven't yet implemented them.  We've known about them for the past three or four years now.  We've known about nevirapine for even longer, and even that, ... is not available to everyone.  So I think there is a real lag between understanding and implementation.

Ranadi: What's holding them back?
Professor H Coovadia: Well basically it's government inertia, or the bureaucracy, or the delays intrinsic to government which results in these lag times.  Some governments like Botswana and some provinces in South Africa like the Western Cape, Thailand are pretty good.  But most of them are not.  I think it's a combination of factors within government. Some are just too inefficient.