Up Close With Dr. Gayle

In August, Helene Gayle, MD, was nominated by President Obama to be the chair of the Presidential Advisory Committee on HIV/AIDS. Gayle comes to the post as president and CEO of CARE USA, an international humanitarian organization that fights global poverty, prevents the spread of HIV, and increases access to sanitation, clean water, and education. Previously, Gayle spent 20 years at the Centers for Disease Control and Prevention, where she focused primarily on fighting HIV. She was also the coordinator of the HIV/AIDS division for the U.S. Agency for International Development, and she directed the HIV, TB, and Reproductive Health Program at the Bill & Melinda Gates Foundation.

From her CARE office in Atlanta, Gayle spoke to Advocate.com about her new position.

Advocate.com: Dr. Gayle, how do you feel about your appointment?
Helene Gayne: I feel very honored, because in positions like this, people say you have something to offer -- so I am honored to be asked [to serve]. But, I am also pleased that it looks like this current administration will put a high priority not just on the global epidemic, but on the epidemic here in the United States. In many ways, we have done a good job overseas, but I am excited that we appear to be ready to do what we've done beyond our own shores here in our own country.

The council is currently co-chaired by Sen. Thomas A. Coburn, MD, who gained notoriety for opposing safer sex as a way to combat HIV/AIDS. How do you feel your leadership chairing the advisory council will change its focus and mission?
I think that the president spoke during his campaign about having a national AIDS strategy, and that we need a truly comprehensive AIDS strategy, which is something we didn't really have in the previous, or any past, administration. We have multiple agencies working on HIV, and there are agency strategies. When I was at the CDC, we had an agency strategy -- but we didn't really get to look at how to tackle HIV as a nation: with an integrated strategy that engages all agencies, resources, communities, and the public sector as well as the private sector. Asking for a national strategy will engage communities broadly and lead to change. It's a great commitment to our nation, particularly when we have done so much in the global community through PEPFAR [President's Emergency Plan for AIDS Relief] and our contributions to the Global Fund. Of course, we still need to continue our global work, for most [HIV] infections continue to happen outside of the United States.

I'm also optimistic because a lot of the comments coming from this administration are about prevention and not just treatment, which is something previous administrations have not always focused on.

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Even by his critics, President Bush is roundly applauded for his commitment to AIDS in Africa. What are your thoughts?
That came about by having a great strategy focus. Some if it was about resource allocation, and some of it was about knowing where infection was occurring. It was a comprehensive approach. We always need to know how infection is occurring -- by communities, by routes, and making sure we are matching our response to the epidemiology. We have to understand where [HIV] is occurring, who is most affected by it, and we have to deploy our resources strategically. Most importantly, we need to make sure we always have science behind everything we do, and to make sure that our work is evidence-based and meeting the greatest need.

I live in New York City. Are you familiar with the Bronx Knows Campaign under way here? The Bronx is attempting to learn the HIV status of all of its adult citizens, something no city in America has done. If it were its own city, the borough of the Bronx would be among America's 10 largest. What do you think of this?
I think it's great. I've often said that it's unfortunate that in a country like ours that has access to HIV testing, there is still a large proportion of people unaware of their status. Knowing [the public's] status is important for prevention, but it's also important for treatment and in directing people to the appropriate services. Programs like [the Bronx Knows] are important for communities to have a better idea of what the epidemic is doing in their own backyard. It grounds both prevention efforts as well as treatment. Programs that test in a nonjudgmental, rote way help reduce stigma, reduce mystery, and are a key component of an overall [HIV] response.

As you probably know, The Advocate readership is made up largely of gays and lesbians. As a gay man myself, what can you tell me about how you personally understand this disease that so deeply affects our community?
I have been personally involved in HIV work for over 20 years... or is it 25? You give up counting after a while. But clearly, the community most affected in the beginning was the gay, or MSM [men who have sex with men] community, and in many places, it still is. It's hard today especially for urban MSM of color. The demographics have shifted some, but nonetheless, it is an epidemic that is having a huge impact on the gay community.

In some ways, [the fight against HIV] has "helped" communities of gay men become stronger, in that it helped those communities to come together around something very important to their very survival. The communities have come together, and become something better. I hope [fighting HIV] can be a force that helps people grapple with prejudices, including homophobia, stigma, and the hallmark of biases... to help rid the unfair treatment toward same-sex behavior in the nation. I hope [fighting HIV] will continue to be a positive force in helping us as a nation understand nondiscriminatory behavior, because it's a matter of life and death.

What initially interested you in HIV?
I am a public health physician. I was at the CDC, which was at the heart of this disease really from the beginning -- and as I began my career I knew HIV was going to be one of the public health and humanitarian issues of our time. It was a disease that we know disproportionately affects populations that are marginalized and stigmatized in society more broadly.

I have always thought working for HIV could be an agent of social change. To deal with HIV, you have to deal with the underlying problems. [Fighting HIV] can be a driver of social change, and you have to tackle the underlying issues affecting the most vulnerable members in our society, as well as around the world. It is a driver for creating a better society worldwide. In many parts of the world where I work [outside of the United States], it's gender inequality that drives HIV -- when you look at women's lack of access to education, employment, and health care. In this country, whether it's among gay men, injecting drug users, teenagers with high rates of STD -- what have you -- there are a lot of things you also have to work on when you work on HIV, that will also change societies and communities.

What do you think about revising the FDA's policy of a lifetime ban on blood donation from MSM donors?
It's the kind of questions that will take a broad community dialogue. We live in a nation with a zero tolerance of risk. There has been a lot of work making the blood system as safe as possible, and there are many people who say, "I'm not an intolerant person, but why argue with what is working?" Many people have no idea there is a ban, or what the effect would be of changing it. To change that policy, you'd need to demonstrate to the population at large that changing the ban wouldn't make the blood supply less safe -- and that we could still keep the blood supply as safe as possible.

Are you in favor of reevaluating the ban?
Yes, but this is an issue that has been on the minds of many, many people for many years, and I hope it can be a part of a broader dialogue, looking at a range of policy issues, as we make sure that policies are keeping up with our technologies, and [with] the epidemiology of where [HIV] is going. We need to continually look at the trend of the epidemiology, to make sure our policies are matching that and our resources are being spent strategically.

At the same time, we want to make sure that the risk [of HIV transmission through blood transfusion] is as low as possible. I want our HIV policy to be as evidence-driven as possible, and to let the chips fall where they may, on either side, of this or any issue. This has not always been the case. Many policies are made with belief, and ideology, but I want our policies to be based upon the best evidence possible.

On a policy issue like this [blood donation], clearly it has a lot of complex issues, and it means having a broad dialogue with all of the stakeholders. But all the parties, and the public, have to understand why there is a policy, and then we can say, "This is why the policy is staying in place, or not staying in place." And it will be in this broad dialogue that an issue like this can get solved.

As you take on this new post, what makes you the most optimistic? The most pessimistic or concerned?
I am most optimistic that there is a strong sense on the part of this administration that this is important work, and that it fits into the broader dialogue of health care and health reform in this country. Now, that's a pretty brisk dialogue right now [chuckling]...but at least it is happening, and it is being talked about.

I am concerned because I have been following this epidemic for 25 years, and this is not easy. It's hard work. Though we have made some progress, we are stalled in reducing the rate of new infections occurring. We need to make sure people with HIV have access to treatment -- but the only way to have a real impact is to impact the rate of new infections.

Prevention is hard work. [Taking on] prevention is always hard, with smoking, or seatbelt wearing, or fighting HIV. And I hope we have the strength as a nation to stay the course, and be able to make the same sort of progress in preventing HIV infection as we have had in extending the life of people living with HIV.