Interview with WHO Strategist Kevin de Cock 'Nothing Is as Devastating as AIDS'

Kevin de Cock, the WHO's chief strategist in the fight against AIDS, talks to SPIEGEL about progress in the war on HIV, the blessing of male circumcision and how the international response would be different if infection rates were higher in the West.


SPIEGEL: Dr. de Cock, how much should a heterosexual teenager in Berlin worry about getting infected with HIV?

Kevin De Cock: His or her risk may be low, but it is not zero. In the most affected areas of the world -- and especially in southern Africa, where up to 30 percent of the population is HIV-positive -- any sexual contact without a condom is potentially dangerous. Luckily, that is not the case in Berlin. But still, any sexually active person should be very careful about exposing him- or herself. The message that condoms offer protection has not lost its importance. They protect against HIV as well as against gonorrhea, chlamydia, syphilis, herpes and other infections.

SPIEGEL: How high is the risk of transmitting HIV by means of vaginal intercourse?

De Cock: Most infected people will probably only spread the virus in one out of 1,000 intercourses. But their infectivity can be much higher if they have only been recently infected or if they also suffer from other STDs, such as genital ulcers. HIV is not as infectious as the flu. But since the beginning of the epidemic, more than 60 million transmissions have occurred, and 25 million have died from AIDS, the majority of them in sub-Saharan Africa.

SPIEGEL: In the 1980s, when this virus was new and unknown, there was widespread fear among experts that HIV would sweep throughout the world.

De Cock: And thank God that hasn't materialized, at least not in the West. In Europe, the virus is mostly confined to specific groups: men who have sex with men, drug users who share needles and immigrants from countries with very high levels of infection. In some groups, such as young gay men, infection rates have recently risen again, perhaps because the highly successful treatment options with lifelong antiretroviral (ARV) therapy have turned AIDS into an apparently less dreadful and more manageable disease. AIDS has lost some of its horror for many people. But believe me: It’s not something you’d want.

SPIEGEL: This life-saving treatment is now more and more available to those afflicted with AIDS in poorer countries.

De Cock: The world community has committed itself to working toward universal access to HIV prevention, treatment, care and support. At the moment, three million people in poor countries -- almost three-quarters of which are in sub-Saharan Africa -- are receiving medication. Our original aim was to have three million receiving treatment by 2005, but unfortunately we are a little slow. Another six million people need treatment now but don’t receive it yet. We need to work on this.

SPIEGEL: The cost to the international community for HIV treatment and prevention is now between $8 billion (€5.17 billion) and $10 billion dollars per year. This figure will grow to $20 billion in 2010 and $40 billion in 2015. At the same time, millions in Africa die of easily and cheaply preventable diseases due to a lack of access to clean water and sanitation. Do you see an imbalance here?

De Cock: I don’t deny that there is a lot of premature death in Africa from many preventable diseases. There are obviously other problems in health that deserve more money. But nothing is as devastating as AIDS. AIDS is the leading cause of death in many countries. There are countries in southern Africa that have lost two decades of life expectancy. You tell me another phenomenon that has as many victims, with the exception of massive death in war.

SPIEGEL: Every day, 26,000 children die of easily treatable diarrhea.

De Cock: Yes, African children die in huge numbers from bacterial and other infections; it is awful, and it is not right. But, in a cruel way, society is used to this. With AIDS, it’s different. Young adults die of it in unprecedented masses: breadwinners, parents, well-trained professionals. These deaths rip apart the foundation of society. They occur in the ranks of the military, the police. The doctors die, the nurses, the farmers who produce food for others.

SPIEGEL: Thanks to international aid, there are now clinics in Africa that stock the latest in HIV medication, but they won’t be able to help you if you suffer from other treatable diseases. Are AIDS sufferers becoming the most privileged patients in Africa? You’ll get treatment if you have AIDS, but you’ll be left to die if you suffer from parasites?

The global HIV epidemic
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The global HIV epidemic

De Cock: We have this devastating epidemic in some African countries. And we have these sensationally life-saving drugs in the north. Is it acceptable not to use them in the south? No. It may be an interesting intellectual debate whether AIDS receives too much money compared to other pressing problems, like the lack of clean water and sanitation. But, at the same time, we need to act -- $40 billion (€25.9 billion) is not a lot when you can have such a huge impact on the health of millions of people.

SPIEGEL: These countries will probably never be able to pay for the medications by themselves. Could this therapeutic success ever be sustainable?

De Cock: What is sustainable? In the poorest countries, pretty much the only sustainable thing is the epidemic, if it is not addressed. Eventually, all 33.2 million people who are now infected will need medication, just as those 2.5 million who are now getting infected every year will. The expenditure will be gigantic, and we will face decades of having to deal with this problem.

SPIEGEL: How has HIV been able to devastate southern Africa in this way?

De Cock: The virus has found an ideal situation there. Many men in southern Africa are separated from their wives for massive amounts of time; they migrate over huge distances to earn their livelihood. Survival sex work is much more common than in Europe. More people in Africa have sexual relations that are overlapping rather than serial, as in Europe. These are sexual networks that make it easier for the virus to diffuse through a population. By the way, there is a stereotype that it’s always men who bring HIV into a stable marriage. But that is not always true. Women get infected at an earlier age from older men, and they may also infect their partner later on in a stable relationship. That is why WHO is pursuing an aggressive testing strategy. People should know their status.

SPIEGEL: Has the condom campaign failed in Africa?

De Cock: Condoms have saved countless lives. But they are not the ideal means of prevention. It is very difficult to maintain condom use in stable relationships. People are good at using them during casual sex. But, beyond that, it’s different. That is human nature.

SPIEGEL: All attempts to develop a vaccine have failed. Yet, at the same time, male circumcision has been proven to be a cheap and readily available "surgical vaccination." Circumcised men have HIV infection rates that are 60 percent lower than the non-circumcised because the foreskin contains cells that can be easily infected. The evidence that circumcision works as a protection is at least a decade old, but WHO only recommended it in March 2007. Was that a mistake?

De Cock: We first needed large clinical trials in heterosexual men. We must have secure data to base our health recommendations on. That simply takes time. Three large trials in Africa have recently been stopped ahead of time because it appears that circumcision really has a remarkable effect. I do admit: I myself was skeptical about it for a long time. Now we do recommend circumcision for prevention strategies as well as condoms, the reduction of sexual partners and abstinence for the willing or the very young.

SPIEGEL: Let’s have a thought experiment. If Europe were suffering from an epidemic like the AIDS epidemic in southern Africa....

De Cock: ... then there would be about 50 million infected in a population of 400 million. Just imagine! It would certainly lead to different results than it does now in Africa. AIDS would be the single most important topic in society, dominating everything else. I think there would be large-scale, careful programs, balancing between public health and human rights. HIV prevention would be a priority for every citizen. At the same time, there would be universal access to tests and the best available treatment for everyone. Why should we accept less for Africa than we would at home? We have entered a time when protection against major infectious diseases -- such as AIDS, tuberculosis and malaria -- should be seen as a universal right.

Interview conducted by Marco Evers

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