Interview with Craig McClure

Craig McClure is executive director of the International AIDS Society.  He has played a central role in AIDS advocacy and policy, working for UNAIDS, IAVI and for a number of HIV/AIDS development programmes. He talks to LWW's Ranadi Johnston about the responsibility of HIV researchers to general healthcare in developing countries, AIDS awareness, and future directions of HIV/AIDS research

Ranadi: Why is it important that HIV researchers contribute to building health systems?
Dr McClure: Given that there has been a dramatic increase in financial resources to fight HIV in the last five or six years, there has been criticism in the past couple of years that HIV is receiving too much money and of course those of us that work in the field know that it's not enough money, and yet we are also aware that it is a fairly substantial proportion of the resources devoted to global health worldwide so it's important that as we scale up treatment and prevention programmes in developing countries that we work to ensure that those programmes contribute to the strengthening of broader systems. So for example an HIV treatment programme ... also facilitates access to TB services, that it improves sexual and reproductive health services, that it improves primary care so that people coming forward for HIV testing and HIV treatment are also able to access better health services overall than there were before.
So that means that ... research related to the implementation of HIV programmes in developing countries look at how those programmes are contributing to strengthening health systems, or in fact whether some of them may be detracting from other health services, so that we can find the best models for ensuring that those new HIV programmes are also contributing to better health systems. There's evidence of course that in most cases they are, but we need more evidence of that. 

We know through the Global Fund's evaluation of its financing programmes in the last five years that its monies are being used in addition to purchasing drugs, purchasing condoms, purchasing clean needles and syringes for HIV prevention, that they're also been used to train health workers, to build clinics. So the expansion of health capacity generally, in order to provide HIV treatment services is contributing to health systems strengthening. But we need to know much more.

Ranadi: What do you consider the greatest challenge facing the HIV/AIDS community when it comes to applying the knowledge to the field/to patients?
Dr McClure: The greatest challenge to implementing the evidence? I guess on the health system capacity side of things, one of the greatest challenges is the number of trained and paid health workers. And that's not just specific to HIV, but specific to the provision of healthcare across the board in developing countries. So that's an enormous challenge. And one that the larger financial mechanisms like the Global Fund or the US PEPFAR programme are trying to address.
On another side of things one of the great challenges to implementing the evidence is ensuring that people are aware of the evidence that exists. So the conferences, promoting through journals, and other ways that evidence is accumulated is important. But for many of the people working in remote areas that's still not that accessible.
And we have an ongoing challenge that remains remarkably 25, 26, 27 years into the epidemic, which is that there are still denialists out there who challenge the evidence that exists, particularly amongst communities where there is ignorance. Concrete examples of that would be last year's pronouncement by the Gambian prime minister that he had found a cure for AIDS in a dream. He began to take patients who did have access to antiretroviral therapy off it in order to provide his "cure".

In South Africa the ongoing challenge of Matthias Rath and his promotion of vitamins as a means to control HIV. So a lot of misinformation is one of the challenges that we continue to need to confront.
On the social side of things the issue of stigma and misinformation is a huge challenge throughout the world because it prevents people from coming forward for HIV testing, and being able to access the services that are expanding.
So there are countries, for example, where you would expect that given the prevalence of HIV, as services are scaled up, there would be enormous waiting lists and people lining outside the door for treatment. And yet in many cases they're not, because people aren't coming forward for testing, because they're still afraid of the consequences of an HIV positive result - which could be disenfranchisement from their communities, from their families.
And so addressing that stigma of HIV; and the discrimination against some of the communities that are most at risk of HIV infection particularly in concentrated epidemics like men-who-have-sex-with-men, drug users, and sex workers; - addressing those issues so that those communities can feel comfortable accessing health services - getting tested, getting treated, is an enormous challenge.

Ranadi: 20-30 years ago, when HIV/AIDS was first discovered, there was a lot of public awareness. Do you think that has died down a bit, that people have become more blasé with the passage of time?
Dr McClure: I think that overall, in lower and middle income countries, in developing countries there are more programmes for HIV awareness/HIV prevention than there ever were, because of the resources that have become available in the last six years are many, many times the resources that were available before. But I think it is an issue particularly in highly developed countries.
One factor, I think that has influenced that is that we do have virtually universal access to treatment in rich countries.

So we don't see, in our countries, in the way that we did ten years ago, people who are visibly sick, people who are dying. And again particularly amongst gay and other men-who-have-sex-with-men in richer countries we don't visibly see sickness and death in the way that we did ten years ago.  I think that's the same for injecting drug users.  (These are) really the groups most affected in higher income countries.  So I think, because of that, there may be less fear of the consequences of HIV infection. Certainly we are seeing, in gay communities in urban centres in highly developed countries, less programming on condom use, less public awareness. And I think we need to step up that campaign because I think there's maybe the general feeling that the consequences of HIV aren't so bad anymore.

Maybe that's true to a certain extent; it's not a death sentence anymore for someone in a richer country to be diagnosed as HIV positive. But I think we are not doing enough to educate people about the challenges of living with a chronic condition, taking pills every day for the rest of one's life, dealing with, in some cases, the side effects associated with that medication, the challenges of remembering to take it every day.
So I do agree with you that there is less attention in richer countries to HIV awareness and that we need much more attention. Particularly in the communities most affected. I think targeted HIV prevention programmes really need to be strengthened, again awareness raising programmes, particularly with young people in those communities in richer countries. But again I do think in the poorer countries there is more programming than there was ever before. So hopefully that's not the case.

Ranadi: Do you think there is conflict between prevention and therapy?
Dr McClure: It's interesting because the big buzz at the moment - you probably saw the Lancet article earlier this week which generated a lot of interest - which is modelling the potential impact of treatment on prevention.
In a country with an epidemic the size of South Africa, which is the model they used, if everyone was tested every year and immediately put on treatment if they were HIV positive, you could virtually eliminate your epidemic in ten years and make a major dent on it in five years. Now of course there are huge factors that would need to come into play around the implementation of universal testing and the protection of human rights and etc etc. But I think we are seeing prevention and treatment coming closer together.

In Mexico at the International AIDS Conference there was a lot of discussion about maximising the potential preventive benefits of treatment at a community level. Now the problem is that you don't see that benefit if you've only have 30, 40,50, 60, 70% access to treatment. There is ... another modelling exercise that was published about a year - a year and a half ago, that said that unless you have 80% treatment coverage, you really wouldn't see an impact on reductions and transmission. But we're using treatment already for preventing mother-to-child transmission. It's used as post-exposure prophylaxis for health workers and for sexual transmission, and sexual exposure to HIV. There are a number of studies looking at using antiretrovirals and pre-exposure prophylaxis. And then there again is much more talk about the potential impact of the treatment of chronically infected people with HIV, if enough people were treated - the impact on transmissions.

I actually don't think there needs to be a conflict between prevention and treatment at all. And of course we need to keep all the other interventions for prevention going condom use, needle and syringe exchange, methodone treatment for opiate addicts etc etc etc. And we need to continue our research on microbicides and vaccines. But I think, certainly for the IAS and many others in the field, that there's great interest in trying to marry, or bring together prevention and treatment and get the best preventive impact out of treatment that one can.

Ranadi: A lot of the current research seems to be based on preventing virus replication. Where do you think the next generation of therapies will come from?
Dr McClure: There are a lot of interesting things going on in Basic Science. Robert Siliciano presented a plenary in Mexico - his group has looked at whether the current therapies that we have, used appropriately, are completely preventing viral replication. And the work from his group suggest that in fact they are; that we have potent therapies now, with very few side effects, that when combined appropriately, and taken regularly, virtually eliminate viral replication. And so the problem that remains are the cells infected with HIV that remain dormant for many, many years.

So the research right now in that area, towards eradication of HIV infection, is looking at ,'How could we unleash those latently infected cells without causing a massive immune response that would kill the patient' - (because) current things like interleukins can turn on latent cell but when you do that the immune response is so massive that it kills the person. So research is looking into ways in which those latently infected cells could be activated so that the currently available therapies could eliminate HIV once and for all. And that's very exciting.

There's also a lot of Basic Science right now that is looking at the host, or the infected person's immune response in the very very early stages of infection - within the first few hours and the first few days of infection. What HIV does in those first hours, first days, of infection that deregulates the immune system. And then if we can figure out that much better, then the next step would be to stimulate those aspects of the immune system that could prevent deregulation by HIV. And that would lead to the preventive HIV vaccine which I think is the long term goal of Basic Science.

Ranadi:  What about the guy in Berlin with Leukaemia treatment - do you think that's an area for further study?
Dr McClure: Well the guy in Berlin had Leukaemia, so he needed to be treated with bone marrow transplant in order to treat the Leukaemia. And so the very clever medical researcher involved used the delta32 double deletion stem cells of a bone marrow transplant and by using stem cells that had the double genetic deletion which really protects against HIV infection - that a tiny minority of people have - he was able to stop HIV completely in the person.
But it was vastly expensive and also very dangerous therapy that you would only give to someone whose life is threatened by a cancer like leukaemia. It's very very interesting of course - but the potential for using that on a wider scale - I don't really see (that there's) much possibility.

Ranadi: Is there anything you'd like to add before as we round off?
Dr McClure: For us at the IAS, all areas of research are important, but I think it's critical that we understand much better what we're doing as we roll out treatment and prevention services worldwide. We have to be strategic with the resources that we have; so that we don't make the same mistakes more than a few times, so that we learn from the best practise that's going out there as these programmes are rolled out in different ways around the world. I mean there are programmes with NGOs, with faith-based organisations, through the public sector, through the workplace.

And people are doing it in very different ways. We need much more research to understand better, as the programmes are implemented, what's working, what's not working, how to maximise the impact on health systems overall, how to maximise the impact of treatment on prevention. These are answers that are critical to understand because we want ultimately to turn the tide on the epidemic - not to be in the mode that we are right now, which is 30% access to treatment, prevention programs that really are not working as well as they can. We've got to use the resources we have while we have them for the epidemic.
Otherwise, ten years from now, I suspect, perhaps even sooner, donors will get fatigued, they'll move on to another issue and we'll be left with a chronic HIV epidemic for hundreds of years. So understanding better what we're doing now as we roll out these new programs in developing countries is so critically important in order to really make a difference.

Ranadi: Do you think it's doable?
Dr McClure: I think it's absolutely doable. We have all the tools we need to prevent and treat HIV and we need to bring treatment and prevention together. We need to make maximum use of all the tools we have. I think far too often people say, 'Until we have a preventive vaccine we're really not going to end this epidemic'. It's simply not true. If we use all the tools that we have we as effectively as we could, we could turn this epidemic around in I would say optimistically in the next 10-15 years. If we really continue to push what we're doing now and continue to push in a much stronger way to understand better what we're doing now - what's going well, what's not going well, in 15 years we can turn this epidemic around.

Ranadi: Do you see a successful vaccine anytime in the foreseeable future?
Dr McClure: You know I think one day there will be a preventive vaccine but that day is many many years away. We've learnt a lot in the past 25 years, but mostly what we've learned is the complexities of the interaction between the virus and the immune system of the person who is exposed to and is infected with HIV. And because we've learned how complex that is, we realise that developing a vaccine for HIV is nothing like developing a vaccine for polio, or for HPV, or for any of the other diseases that we have a full protective vaccine from. This virus directly impacts the immune system, not only by destroying it gradually over time, but by completely deregulating the way it works right from the moment of infection. So yes, I think we will one day. But I think it's many years away.