Robert Clay

IMPACT: This year marks the 30th anniversary of the first diagnosis of HIV. What do you think have been the greatest successes and failures in the last 30 years in efforts to fight the disease?

ROBERT CLAY: Without a doubt, the greatest success in efforts to fight HIV has been the rapid expansion of access to life-saving anti-retroviral treatment (ART). After seven years of ART scale up, about 5 million people are on treatment in poor and middle-income countries around the world. This is an incredible success story. ART is not just saving lives, it is preserving the social fabric for families and communities. But there are more than 33 million people living with HIV who will eventually need treatment and about 2.6 million new infections each year, roughly double the number of new patients who initiate ART. The math does not add up. We will never get ahead of the epidemic unless we turn off the tap of new infections.

So our greatest challenge lies in prevention. While we have had some successes in prevention, especially in concentrated epidemics such as in Brazil, India and Thailand, when it comes to the generalized epidemics in Southern and East Africa that bear the greatest global burden of disease, the progress is mixed. In my own view, however, it is not that prevention has failed in generalized epidemics, but that it has not been fully tried, at scale, with a systematic, data-driven approach and interventions of adequate coverage and quality. We must intensify our prevention efforts, and we must do better than we have done over the last 30 years.

IMPACT: What HIV prevention interventions do you consider the most challenging to achieve impact with, and why?

RC: The broad area of structural interventions remains largely underdeveloped and is a major gap in advancing combination prevention. I’m speaking especially with respect to generalized epidemics. There is a better understanding of the role of structural interventions in creating an enabling environment to address the needs of most-at-risk populations in concentrated epidemics. There are indications that intervening structurally in generalized epidemics could have a big pay-off. Take for example the World Bank-funded study of cash transfers for young women in Malawi. Although the results have yet to be published or replicated, the cash payments appear to have altered the context of risk by influencing the young women to choose younger male partners who were less likely to be HIV-infected, thereby reducing HIV incidence by about half.

IMPACT: How is your office contributing to efforts to build the evidence base for behavioral prevention interventions?

RC: There is already substantial evidence from intervention research, both domestically and internationally, that behavioral prevention interventions work to reduce HIV risk behaviors. As part of USAID’s agency-wide mandate to reinvigorate evaluation, the Office of HIV/AIDS is planning to further increase support for rigorous impact evaluation to further expand this evidence base. In the future, however, I expect evaluation efforts to give greater emphasis to assessing the impact of “prevention packages” that include a combination of biomedical, behavioral and structural interventions, recognizing the importance of both the contribution of individual interventions, and the interactions and synergies between them.

IMPACT: USAID values integration across health areas to more efficiently meet global health goals. What key integration approaches should implementing agencies launch and scale up under the Global Health Initiative?

RC: USAID, as the premier development agency, has always advocated for integration as an essential strategy to address the health and development needs of the populations that we serve. We advocate for smart integration which requires a strategic review of different program(s) to identify opportunities, fill gaps to increase efficiency and effectively meet the needs of clients. USAID does not use one specific integration approach; rather, we adjust our approach based on the different contexts and needs for each country. Most recently, PEPFAR, with USAID as a key agency, released integration guidance to support the linkage of prevention of mother-to-child transmission with maternal, newborn and child health services.

IMPACT: Much of the reform effort underway at USAID seeks to promote local capacity building and local ownership of aid programs. In what ways will these reforms impact funding for and implementation of HIV/AIDS programs in particular?

RC: USAID, as a key implementing partner of PEPFAR, has focused on enhancing local capacity in many ways, including providing support for technical assistance to local organizations and encouraging the longer-term sustainability of such programs, providing skills to seek future funding, and by linking them with government partners and programs. Under the new USAID Forward reforms, USAID would continue to support the growth of local organizations, working collaboratively with external partners or building the capacity locally to provide technical assistance to enhance institutional capacity. USAID programs would also continue to work towards shaping local programs and policies to monitor and evaluate effective and sustainable local partners and programs.

This interview has been edited for length and clarity.