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Often, the easiest answer is for policy advisors to just roll out a [new policy]. So you can say, "We'll roll out nevirapine," and then AIDS activists can congratulate themselves and say, "We pushed the government into this"; researchers can congratulate themselves and say, "Wonderful initiative -- we did all the work." Government can stand up and say, "We're really doing something in AIDS now" -- and at 2 years old, the kiddies are still dying, and everyone's lost hope. That's not saying we shouldn't intervene. Once we know the results [of South African trials of this regimen], we'll go back to the minister for her policy decision, which may be that we need more clinical trials, or it may be that we'll roll out a new policy.

That almost seems to be in conflict with the urgency of what's happening in terms of infections.

What I want to avoid is self-perpetuating publication of papers. Science can either produce more publications or it can impact on the social reality of people infected. You have to have some solid evidence about what you're doing. The danger of rolling out public health policies based on anecdotal evidence is that they're very difficult to reverse. I think we can be quite loose and make best guesses, but good political decisions are underwritten by good science.

Still, at this conference, some researchers have been surprised by your hesitation to recommend ideas, like the $4, two-pill nevirapine regimen, that might work, have been proven to work in other African countries.

They're entitled to their opinion. We're waiting for the SAINT [South African Intrapartum Nevirapine Trial] study, which will provide important information specific to South Africa. In addition, we're looking at the total picture -- trying to understand reducing transmission in the South African context. I don't dispute that nevirapine lowers transmission, but we have to deal with the problem from a holistic perspective. Treatment might be important, it might not be. Perhaps it's more important to improve the child's quality of life [such as clean water, food, shelter].

On the last night of the conference, you met with thought-leaders in research, many of whom had extensive experience in using simpler drug regimens, and there was near unanimity about the feasibility of testing whether a simple combination of ddI and hydroxyurea can help reduce death in South Africa. Is that something you'd like to see implemented?

A whole process will hopefully start out of these meetings. It needs to be discussed whether we should do studies of therapeutic interventions in adults. Therapeutic interventions -- that's new. [South African policy has officially focused on prevention, emphasizing vaccines.]

It's clear that treating the virus can help stop transmission. We know that when women have fewer copies of the virus in their blood, they are less likely to pass it on to their babies. A Ugandan study presented here showed that people with lower viral load don't pass the disease on to their sex partners. Some people might say that, given the gravity of the epidemic, large-scale treatment trials should be started as soon as possible -- say in the next six months.

Let them [the critics] put it in place in the next six months. AIDS is not only a South African problem. Everyone should be working on it. It's not just what am I going to do when I get back -- it's what is everybody who I talked to here going to do.

Are there things that you saw here that were compelling, that you'd like to act on?

For years I've heard things that were compelling. The problem with transformation is that there's many, many, many things that are compelling. Priorities have to be traded all of the time. It's almost like managing chaos theory. I think we must do something and do something quite quickly. Whether this is the right strategy -- setting up trials and setting up networks -- I don't know. The political leadership of our country will have to make decisions given all their other priorities. AIDS is one of our problems. I think it's a very big problem. But in fact, the evidence that's coming out of Africa at the moment is that many, many women are concerned about getting access to clean water, medical care for their kiddies. I don't know how to prioritize. If political principals prioritize what we do differently, I'm not going to fight them.

Where do you go from here? Are you hoping to have a formal international advisory committee come out of this?

It should. But if I did everything formally, I wouldn't be here. The danger is that I go back home, send in a report, another crisis pops up somewhere else, I focus on that, and then suddenly wake up and find out I'm not registered in Durban [at the World AIDS Conference, July 2000] either. In South Africa we're passing 120 pieces of legislation a year to turn ourselves from an apartheid-based system into a democracy. That focus on transformation does mean you can't focus that easily on everything else. It's our reality. We can't shift it.
salon.com | Feb. 4, 2000

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