Q&A: The director of the Gates Foundation's HIV program on what's needed to accelerate efforts

Last week, Melinda Gates said HIV is one of the top five priorities of the Bill & Melinda Gates Foundation, and she predicted that those five issues will continue to top the list in 10 years time.

Sub-Saharan Africa is home to 70 percent of the world’s population living with HIV, and these countries see an estimated 1.2 million new HIV infections each year, a number that could grow as more young people reach the age of risk for sexually transmitted HIV.

Devex caught up with Emilio Emini, director of the HIV program at the foundation, to check in on the progress that has been made in the prevention, diagnosis and treatment of the disease, as well as what more is needed to control the epidemic.

Emini spent 32 years in the pharmaceutical industry before taking on what he jokes is his retirement job. But amid growing concerns about the future of funding for HIV, he admits he now has his work cut out for him. His focus now is on how to accelerate momentum on lowering the incidence of infection. Here is Devex’s conversation with Emini, edited for length and clarity.

The stated goal of your HIV strategy is to accelerate the decline of HIV infection worldwide. Let’s start by looking what the data tells us in the countries where the foundation focuses its efforts. What does it tell us?

Even though there has been really significant impact over the past 10 to 15 years on lowering incidence of new infections, the biggest impact being mother to newborn transition, we’re really at a place where in certain populations the incidence of new infections is flat.

It has been flat for the past five years or so. So it is not going further down. Or if it is, it’s decreasing very slowly.

On the other hand, we’re faced with a sort of ironic situation. Because of all the advances in public health that have occurred, particularly for newborns over the past 10 to 15 years, we now have an increasing number of individuals who are beginning to enter that age range when they can become susceptible to HIV infection… If we don’t have an impact on the incidence embedded in what we’re doing now, 15 years from now we will have more people with HIV than we had 15 years ago.

So how can we impact incidence? That happens in two ways. The first is by getting more people on fully suppressed treatment who are infected, because we know that prevents transmission of infection, but we also need to focus on prevention. How do you protect the uninfected from acquiring infection?

You’ve emphasized the need to develop new tools while also understanding the populations you want to use these tools. Can you expand on that?

If you’re developing a product without understanding who is going to use it, who is going to pay for it, and how is it going to be delivered ... You wind up with a product no one uses. It could be very useful, but no one uses it.

When one does development, you focus not just on technical development, which is “Does the product do what you actually want it to do?” but also on understanding who you’re going to deliver it to and adapting the characteristics of the product to the needs and requirements of the end user. The pharmaceutical industry has become sophisticated in terms of how it does that … But we’re talking about an order of magnitude difference in difficulty here. These are populations that are underserved, these are populations that really need to be deeply understood, and a lot of that information just as of yet is unavailable.

Our catalytic roles is in supporting the work that’s being done to understand these high prevalence, high incidence populations ...  then we will fund the research and development work required to develop these novel interventions. In the end, we the foundation are not going to be the organization that will deliver these interventions in the long term. That’s the role of government. That’s the role of delivery organizations.

What we’ve catalyzed is an understanding of the population. What we’ve catalyzed is an understanding of what we need to do. What we’ve catalyzed is the development of the new products or the new interventions, whatever they may be.

And ultimately that knowledge and those products have to be delivered consistently and that is somebody else’s role.

In their annual letter out yesterday, Bill and Melinda point to the way data drives the foundation’s work on global health. How does that work within the HIV program?

As we try to do better, we have to do it in a way that allows us to learn. Because you learn from your failures. … By definition, you’re not going to get to where you ultimately want to go, but then if that’s the case, you use that as an opportunity to learn. 

You ask: Why is that the case? What is it about these populations that I’m trying to protect, so to speak, that, using the existing tools, some of which are incredibly efficacious, I’m not getting to the level of overall population effectiveness I need?

So then you can use that information to say: Okay so what new tools do I need to develop because my existing tools won’t get me where we want to go? And that’s what we do.

You do the best you can with what you’ve got, you learn from it, and then you use that knowledge that will get you further to where you want to go in the future.

As you look ahead, what more do you hope to see in the fight against HIV to ensure that the world controls the epidemic? And any messages for our Devex readers?

The struggle against this epidemic is not something that’s going to end tomorrow. It’s a long-term effort... It’s going to require sustained very high level of financing at a level that philanthropy, and that includes the Gates Foundation, simply can’t fill.

It’s only governments that really can move that kind of financing … There’s always this struggle between donor financing from the rich world, and financing that needs to be picked up by developing countries … But government funding — particularly in the current stage we’re in now — from higher income countries continues to be critically important.

A level of coordination and common understanding is fundamentally critical and it’s a struggle in our field… Often times a lot of efforts go into developing knowledge, developing data, developing products, but it’s not coordinated across the different disciplines.

We can in fact control this epidemic. But there is danger we can lose control of the epidemic … We need to accelerate our efforts.

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