A Career Defined by AIDS

The Ugandan physician and global health champion Alex Coutinho talks about his career in HIV/AIDS and his belief in the importance of a vaccine.

By Kristen Jill Kresge

Alex Coutinho speaks with authority and conviction. His authority comes from more than three decades of working as a physician in Uganda battling HIV, malaria, and tuberculosis (TB); implementing programs to improve maternal health; and most recently, applying the lessons learned from battling HIV in East Africa to scale up services for treating non-communicable diseases and neonatology, among other areas. His conviction to end AIDS comes from the personal experience of losing friends and family members to this horrid disease.

Like many others, Coutinho’s early career was defined by a virus. He graduated as a doctor in 1983 just as HIV and its deadly consequences were coming to light in Uganda. He served as the executive director of The AIDS Support Organization (TASO), a non-governmental organization established in 1987 and based in Kampala, Uganda, which provides HIV prevention, care, and support services throughout the country. During Coutinho’s tenure as executive director, TASO’s budget grew from US$3 million to $22 million annually. TASO currently provides antiretroviral (ARV) treatment for more than 50,000 HIV-infected individuals across its 11 service centers throughout Uganda.

After TASO, Coutinho was executive director of the Infectious Diseases Institute (IDI) in Kampala, where he oversaw an extensive research portfolio and the Institute’s programs to provide training in HIV, malaria, and TB. Coutinho was also a founding board member of The Global Fund to Fight AIDS, Tuberculosis, and Malaria, and joined IAVI’s board in 2008, becoming its chair in 2013, a post he recently vacated.

In 2013, Coutinho was awarded the Hideyo Noguchi Africa Prize from the Japanese government for his “pioneering efforts to expand access to life-sparing medicine for people infected with HIV.” He won the ¥100 million prize in the medical services category, alongside Peter Piot, winner of the medical research award, who now serves as the director of the London School of Hygiene and Tropical Medicine.

Now, at age 57, after trying out retirement for a short time, Coutinho is working with Partners in Health in Rwanda to scale up services in oncology and non-communicable diseases at the organization’s sister organization, Inshuti Mu Buzima.

Through all of this Coutinho remains passionate about the need for an HIV vaccine and committed to living and working in Africa. His deep voice and his hearty laugh resonate over phone lines and through conference halls. He is direct but immediately likable. His knowledge, experience, and compassion come through effortlessly. He commands a global stage, speaking recently at AIDS 2016 in Durban, South Africa, but his concerns remain local. “I chose to be based where the problem is,” he says.

On the occasion of his recent departure from IAVI’s board, Managing Editor Kristen Jill Kresge spoke with Coutinho about his decades-long career battling HIV.

What was it like when you first started working as a young doctor in Uganda and people were first realizing what HIV was and its dire implications? How did this time help shape your career?

It was back in 1982 when I saw my first case of HIV—even though I didn’t know what I was seeing—in Uganda, in the cancer wards. Then in the next couple of years after that we started seeing a lot of people dying in the wards, and even some of my own friends getting this strange disease. It wasn’t until 1984 that we realized that this was HIV.

In Uganda, I was there right from the very beginning. I graduated as a doctor in 1983, and for 33 years HIV defined who I was as a doctor. But, also, HIV was killing my friends, it was killing my own relatives, and I was feeling pretty helpless. In 1986, I started going around the country trying to educate the population, educate young people, about what HIV was. At the time there wasn’t any effective treatment or any effective prevention, so it was a bit frustrating.

We were talking about the vaccine in 1986 as being 10 years away. Of course, 30 years later we don’t have a vaccine, and they’re still saying it’s 10 years away. So it is really frustrating for me as a doctor. We had antiretroviral therapy in Africa in 2001 and it made a big difference. But even then I knew this was not the total solution. The total solution needed to include both treatment and HIV prevention tools.

So when I was approached to go to Lake Como, Italy, to a meeting IAVI was holding in Bellagio in 1994 to sort of regroup after more than 10 years of knowing HIV was the cause of AIDS, I was one of the external people to give my perspective about what IAVI was trying to do to drive the urgency for a vaccine.

Then, when the opportunity came for me to join the IAVI board, I was ready and I wanted to contribute. I believed then, as I still do now, the importance of getting a vaccine, because regardless of what other technologies exist, we know that without a vaccine this is not going to work.

It was during your time at TASO that there was really a sea-change in the way people viewed the viability of ARV treatment in Africa. This of course came after the 2000 AIDS conference that was held in Durban, South Africa. What was it like during that time?

Well, there was a lot of optimism. We never really believed that we would be able to get treatment at those kind of prices, and in a way, the change was very sudden. One year the likelihood of getting treatment was not there, and then within a couple of years, The Global Fund, etc. were created, and suddenly the question wasn’t whether we would get treatment, because there was money for treatment. The limiting factor was not about money. It was getting capacity.

We were under a lot of pressure because people were dying every day. People whose immunity had declined, and at that time we didn’t have viral loads, but we could measure their CD4 counts. We saw CD4 counts of four or 10, and we knew these people were going to die if the antiretrovirals were not in the stores.

So there was a lot of exhilaration as antiretroviral therapy kicked in, but there was also a lot of anxiety in trying to save as many as we could, and that wasn’t happening because of systemic challenges in getting things moving.

This past July, after 16 years, the International AIDS Conference returned to Durban. Things are vastly improved since the last Durban conference in 2000 but still less than half the HIV-infected people in the world who are in need are getting treatment. How do you view the current situation?

I think Durban in 2000 was a landmark because it was really at that conference that the possibility of treatment in Africa was the greatest, and where Africans were saying and demanding that this is not acceptable. Sixteen years ago there were maybe 800,000 people on treatment, most of them outside Africa. Today, there are 17 million people on treatment, most of them in Africa. That alone tells you how far we’ve come, so the glass is half full. But the glass is also half empty. There is another 20 million people and counting who need to get on treatment. So this should be celebrated, but we also have to recognize the soberness of how half the world has treatment and the other half doesn’t.

You were a plenary speaker in Durban this year. What was it that you emphasized in your talk?

I was part of a plenary that looked at what health systems are needed to achieve universal access. Starting from today, what do we need to get so we can get people on treatment, and what can we do to make sure that the 17 million on treatment stay on treatment and how do we make sure that they don’t fail treatment, don’t develop resistance, and don’t need secondary treatment.

The longer HIV-infected people are on treatment, there is also a greater likelihood that they will develop non-communicable diseases, such as heart disease and cancer. What is your perspective on how important that issue will become in Africa and how already strained healthcare systems will manage this additional burden?

Well, technically, it’s a good problem to have. I call it a good problem because the only reason it’s become a problem is because people are now living longer. Previously, we didn’t see this connection between HIV and non-communicable diseases because people died—there was premature death. But now as people stay on ARVs for five, 10, 15 years, people grow older, and non-communicable disease and oncology/cancer start rearing their heads.

And yes, it generates significant challenges in terms of managing one chronic disease and then adding another chronic disease. But it’s really a reflection of the success of getting people on treatment and keeping them alive. I think the opportunity is to develop a system that can be used for chronic diseases, whether they be oncology, non-communicable diseases, genetic diseases, or HIV. It’s really getting a chronic care platform that builds in the complexity of life-long management of disease.

Or in the case of HIV, lifelong management among people who are healthy. You’re really telling them, based on the lab tests, you are unwell and you need to take medication for the rest of your life because your lab tests say you’re HIV positive. That’s very different from someone who is sick or has been dying and they understand that, ‘Wow, I was nearly dying, and now I need this medication.’ That’s a major challenge we are faced with.

Going back to vaccine research, have you seen the interest in or the momentum toward a vaccine change over the years?

I think there’s a tight audience that understands the imperative for HIV prevention generally, and the fact that a vaccine is essentially the pinnacle of what we’re looking for. But I think there’s also a fair percentage of people that say, look, it’s unlikely that you’re getting a vaccine in the next 20 years, and in the interim, we have treatment that’s prevention. There are all these other prevention approaches and many of them involve antiretroviral therapy, such as preventing mother-to-child transmission and PrEP [pre-exposure prophylaxis]. So in some groups I feel there is almost a sense of giving up on the vaccine and feeling that the other alternatives are just as good, which I don’t agree with. I think they are complementary.

So what are you doing these days?

Well, I have retired. But after a year I discovered that golf and traveling are not sufficient substitutes for an active mind in global health. So I went back to work, and I’m the Country Director for Partners in Health in Rwanda. My work is essentially about large scale, scale up for conditions other than HIV. It’s essentially taking the lessons from HIV and using them to scale up access to oncology services, neonatology, and the treatment of non-communicable diseases. So I guess that’s what I’m up to.

So is this the first time in three decades or more of your career that you’ve not been working directly on HIV in any way?

When I was working on HIV at IDI, we also did maternal and child health. I was leading the project in one of the districts where we were scaling up maternal and child health programs and were able to reduce maternal mortality. And of course, in working with HIV, we were also strengthening health systems across Uganda. So it’s not the first time, but it is the first time to use these approaches to scale up services in oncology, neonatology, non-communicable diseases, and mental health.

Was it important to you to stay in Africa throughout your career and make a difference there?

Well, global health can be practiced anywhere in the world. All the players, whether they be in New York or Geneva or London are important. In my case, I chose to be based where the problem is. I chose to be based in Africa where many of these issues, like HIV and so on, are having the greatest impact. So my primary ambition was that when I attended global health forums and global meetings, my contributions were validated by the front-line experience that I had. Some of the discussions I would listen to were very theoretical, and I was then able to intervene and sort of say, listen, yes, this sounds okay on paper, but the truth be told, it’s not as straightforward as this. And so my experience was that working from Africa gave me much more credibility—made me much more of a credible spokesperson for Africa than if I had been based with UNAIDS [The Joint United Nations Programme on HIV/AIDS] in Geneva or at any other place.