25 November 2009

Q&A with Ambassador Eric Goosby, U.S. Global AIDS Coordinator

Dr. Goosby Answers Questions from the Global Community on Facebook

Ambassador Eric Goosby, U.S. global AIDS coordinator

Ahead of World AIDS Day on December 1, we asked people on Facebook one question: What do you want to ask the U.S. global AIDS coordinator? What follows are your questions and Ambassador Eric Goosby’s responses.

Q&A with Ambassador Eric Goosby, United States Global AIDS Coordinator

Question:

I would like to know more about HAART for children ... especially newborn babies; the introduction and escalation of rehabilitative services and step-down care for children, especially those orphaned.

Ambassador Eric Goosby:

HAART is a very successful AIDS therapy program that stands for Highly Active Anti-Retroviral Treatment. It’s a term that was coined in 1996–97 when the discovery of Protease Inhibitors with Ritonavir and Saquinavir was first obtained by Roche Pharmaceuticals. That triggered an era where anti-retroviral treatment went from being largely ineffective for periods greater than 18 months to being remarkably effective for an undetermined length of time. We now know these highly active anti-retrovirals have the ability to suppress viral replication really indefinitely as long as the person can take the medication and tolerate it. And that has stopped progression in the individual, dropped their infectivity, and allows them to go back to a normal life.

As for children, in the last two years, the [medical] literature has supported using three-drug anti-retroviral HAART therapy about a month after birth. What happens is their brain and growth development stays on a normal growth curve. The program also starts them on Co-trimoxazole, which is a medication that stops common infections. We now have followed children long enough to see some of the children started on HAART in the late 90’s [thrive]. Actually, a close pediatrician friend of mine has had his first child HAART patient actually starting medical school.

Question:

4.6 million people have HIV in Africa; less than one-quarter get antiretroviral therapy. What are [you] doing about this problem?

Ambassador Goosby:

Well, those numbers actually underreport the AIDS burden in Africa. There are 33 million people on the planet with HIV; 27 million are in sub-Saharan Africa. Of those 27 million, PEPFAR has supported treatment of about 2.1 million.

What we’re doing is working with our partner countries to identify HIV-positive people. We then take the HIV-positive person and put them into care and provide services that would include HAART therapy. We’re also working very aggressively to scale up our efforts to prevent people from getting infected. Prevention activities are difficult because you have to convince people not to participate in high-risk [sexual] behavior and that message has to be reinforced every day. Prevention strategies have to be constant, repetitive, and persistent for years to maintain the impact. It’s quite different than treatment.

Question:

Why do U.S. pharmaceuticals [companies] refuse to give [drug] patents to African counterparts to enable them [to] reduce the cost of ARVs here [in Africa] while they gave [them to] their European, Asian counterparts? Is there a racial twist [factor] or are they profiting more from Africa than anywhere else?

Ambassador Goosby:

Pharmaceutical companies are generally, in fact almost exclusively, for-profit. It costs hundreds of millions of dollars by any standard to develop one drug and you don’t know if it will be effective. The first anti-retroviral, saquinavir, ritonavir, that came out in 1994–96 took eight or nine years of research and development to develop. So, the development and manufacturing of new pharmaceutical agents is a risky business. Most attempts fail.

However, there are now many examples of pharmaceutical companies that have engaged with generic manufacturers, mostly in India, some in sub-Saharan Africa, that produce a generic form of drugs patented by Western companies. They in fact work with the generic companies to manufacture drugs that are effective and safe and sell to markets that can’t afford the non-generic drug prices. For example, for the HAART therapy I mentioned, the average cost is $9,000 to $12,000 a year. We’ve been able with generic manufacturing and with competition to get the price down to about $400 for first-line therapy in sub-Saharan African settings.

Question:

[Don’t you think] more aggressive campaigns as regards preventive measures should be emphasized?

Ambassador Goosby:

I can’t argue against that. Prevention is a critical component to responding to an AIDS epidemic. The truth is we’re spending millions on prevention. The issue is their effectiveness. The problem as I alluded to earlier is that to sustain the prevention message you have to be repetitive and targeted in getting it to those who are participating in the riskiest behavior [such as unprotected sex and sex with multiple partners]. Most governments and prevention-focused NGOs engaged in prevention messaging have difficulty because of limited healthcare resources that make it hard to sustain that kind of constant messaging.

Also, people are complicated and to change behavior is even more complicated. When you get into sexual behavior, you’re in an area of major conflicting messages and motivations that determine whether the person stays safe or is unsafe.