Dr. Michael Merson currently serves as director of the Duke Global Health Institute, but his experience in global health goes back years. In 1990, he became director of the World Health Organization’s Global Program on AIDS, charged with managing the global response to the burgeoning AIDS pandemic. This summer he wrote an article in the journal Health Affairs evaluating the key U.S. AIDS relief program, the President’s Emergency Plan for AIDS Relief, started by President George W. Bush. The Chronicle’s Julian Spector spoke with Merson about the development of AIDS treatment, his work in the field and the global response to PEPFAR.
The Chronicle: What was the state of AIDS treatment when you become director of the WHO’s Global Program on AIDS in 1990?
Mike Merson: Let’s remember that the first reported case of what turned out to be HIV was in 1981 and the virus was discovered in 1983 and we had an antibody test that detected it in 1985. By 1990, we’re at the end of the first decade and still learning how big of a problem it is. There is of course an increased awareness —particularly in the U.S.—because that’s where a lot of the initial cases were discovered, and a growing awareness in other parts of the world. Although it was nine years into the epidemic, not that many cases had occurred by then. It was in the millions, we don’t know exactly, but let’s say between five and 10 million. We were just learning about how widespread the disease would be.
At that time the WHO program was starting and one of the real issues we had to deal with was raising awareness and dealing with the myths of how it spread. We knew by then it was primarily spread by unprotected sex, contaminated blood and therefore by injecting needles that were contaminated and mother-to-child transmission.
One of the real issues we had to deal with then was stigma. There was a tremendous amount of stigma in being HIV-infected and having AIDS. Part of that was the way people with AIDS looked. They lost weight.... When you have a disease that makes people look [that way] and it’s caused by behaviors like unprotected sex, like drug use, you wind up having quite a bit of stigma.
And we didn’t have treatment. There was no effective treatment before 1996. Not everybody died quickly, some people were still alive, like Magic Johnson—long-term survivors— but it was deemed to be something that was fatal.
The program that I ran at WHO, we had about 500 people working in about 80 countries around the world, based in headquarters in Geneva. We were mostly working with the many countries in the world that were beginning to face the disease and planning programs. There were also research efforts around development of a vaccine and development of a drug—and dealing with the media and providing information about the disease and how it was transmitted. It was the largest health program ever mounted by WHO. In 1995 the WHO program, as it was, was shut down, and UNAIDS [Joint United Nations Program on HIV/AIDS] came into being and became the main United Nations program coordinating a global response. UNAIDS was a joint program of 10 UN agencies including WHO.
TC: How has public awareness and the global health community’s understanding of the disease evolved since you entered the field?
MM: Probably the biggest change was the discovery of antiretroviral therapy in 1996. It’s triple therapy—three drugs. If you give it three drugs, you’re less likely to develop resistance to the drugs. The discovery of the drug was a big breakthrough because it allowed people to live longer and it meant that if you had AIDS, it wasn’t necessarily going to be fatal. It took away a lot of the stigma and allowed us to give more hope to people who had the disease. We recently learned antiretroviral therapy can also prevent mother to child transmission—if you give it to the mother in time and to the baby.
TC: Do the drugs offer a solution to the pandemic?
MM: No, if we got into a situation where people took drugs all the time, we would get into resistance and the drugs would become much less effective. We can’t rely on drugs and treatment to stop this epidemic. We need a comprehensive approach to prevention. We need to use condoms when you’re having multiple partners, [but] first of all don’t have multiple partners. The fewer partners one has the less risk of any sexually transmitted disease. We also know that male circumcision protects men from transmitting and protects women from getting the disease. It’s important to check all pregnant women for HIV to prevent transmission to the child. We also know we need to get everybody infected on treatment so they are less likely to transmit the virus to someone else. We call that comprehensive prevention. Prevention of HIV is not one thing. It’s a multiple approach.
TC: What characterizes the U.S. approach to AIDS policy?
MM: In 2003, President Bush announced PEPFAR in his State of the Union address. It was a five-year emergency plan to respond quickly to the spread of HIV, particularly in Africa but not only in Africa—in the countries with the most disease. It tripled our foreign aid for Africa, focused on treatment with antiretroviral drugs, on prevention using “ABC”—abstinence, be faithful, use condoms—and providing care for orphans and vulnerable children. It was a fairly comprehensive five-year program, $15 billion over five years. It was a bipartisan program, supported by the Democrats and Republicans.
That was through 2008. The program remains very popular. In 2008, Congress decided to give more money to the program. President [Barack] Obama has been a big supporter as well as President Bush was. President Obama started something called the U.S. Global Health Initiative in 2009, in which he greatly expanded government support for AIDS, malaria, tuberculosis, child health, maternal health. PEPFAR was part of that program. President Obama has very much continued the leadership that President Bush started for AIDS treatment and prevention.
TC: How successful has PEPFAR been?
MM: The U.S. government is not the only entity providing support for HIV—there’s the UN, the Gates Foundation, the British government, the European Union.... It’s hard to say that the U.S. government’s is better than anyone else’s support.... In general the support from all sources including PEPFAR has put about 6.6 million more [people] on antiretroviral treatment in low and middle-income countries. That’s a twentyfold increase since 2001. A lot of that has to do with PEPFAR. We know that the number of new infections of HIV has declined by about 20 percent since 1997. We know the number of deaths has declined by about 20 percent since 2005.
The epidemic is far from over. For every person who dies of AIDS, there are about two new people who are infected in the world. We have a long way to go to get it under control, but things are better. That’s due to global response, but PEPFAR has played a major role in the global response. We should be proud as a country that we’ve had a role in that.
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