Global health has been at the forefront of the international agenda and the object of fierce debates. Healthcare systems worldwide are increasingly strained, and in developing countries the need to increase the capacity to deliver is urgently felt. The United Nations has considered HIV/AIDS, Malaria and other diseases as a priority, and set its combat as one of the Millennium Development Goals. Of the six million people who die of malaria, tuberculosis and AIDS yearly worldwide, 90% live in Africa.

Currently there are over 33 million people infected by HIV worldwide. Unlike malaria that is restricted to regions where the mosquito that carries the disease-causing parasite lives, HIV has a global distribution despite its prevalence in sub-Saharan Africa (which accounts for 70% of all HIV infections).

The impact of the HIV epidemic in Social, Economic and Healthcare Systems reflects the profound effect it has at the individual and community level. In certain countries infection rates in the adult population are as high as 30%, and despite the effort to understand the factors that drive and sustain such an epidemic, hope for an HIV-free generation in these countries seems a difficult goal to attain in the present circumstances. The increase in life expectancy in Africa, that took years of public health measures to achieve, has been greatly reduced by the HIV epidemic. The disease has also been spreading quickly throughout Southeast Asia and in particular, Thailand and Vietnam, as well as India, China and Eastern Europe. The slowdown in development due to a weakened workforce has a pronounced impact on these regions’ economic growth, and threatens the stability of many governments. Ultimately, epidemics such as HIV/AIDS affect global health and security at large.

Many of the challenges posed by HIV/AIDS and other diseases can be best addressed through strong and sustained scientific research guided by the priorities of each region. The best solution to the HIV epidemic is a vaccine that is efficient and widely available. This has been the main drive in my pursuit of a career in science. I started to work on HIV/AIDS as a volunteer with an NGO in the mid-1990s in Portugal, where the infection was starting to gather media attention. Despite the major toll of the infection in sub-Saharan Africa, the first cases of what would be found to be HIV were first identified in Los Angeles, California in 1981 in five homosexual men. Additional case reports in other cities immediately followed, and from then on the number of cases in North America and Europe kept on increasing, prompting the isolation of the aetiological agent of this syndrome subsequently named HIV. In 1985, a second virus – HIV-2 – was isolated from asymptomatic sex workers in West Africa where this virus was mainly confined. Tests to detect the newly discovered viruses were rapidly developed and made available, and hopes for a vaccine were high. The media was highly involved, highlighted by the fact that celebrities were themselves becoming infected and dying of this new disease that was also rapidly spreading amongst heterosexual men and women. What was eventually to be called AIDS was by the late 1980s a constant presence in the media in the Western world. In the meantime, the virus was silently spreading on the African continent.

The AIDS epidemic came at a time when it was generally thought that infectious diseases no longer posed a serious threat to the industrialized world. Yet the immunodeficiency that characterizes AIDS has fuelled the re-emergence of other infectious diseases, such as tuberculosis. No cure for HIV is in sight and prevention campaigns, despite slowing down the spread of the infection in a few countries, have not stopped the spread of the virus. The development of an HIV vaccine is therefore, imperative, and the fact that 90-95% of all new infections are in developing countries makes HIV/AIDS among the most serious threats not only to global health, but also to global development.

My quest for an HIV vaccine started when I first moved to Oxford in 1998 to pursue a Doctorate in HIV Immunology. We identified a group of people who remained seronegative for HIV despite a long history of exposure to the virus through an infected partner. Understanding the mechanisms behind this apparent lack of infection despite high exposure could provide us with invaluable insight into vaccine design. In 2000 I travelled to West Africa to carry out research in HIV-2. This virus is particularly intriguing; it causes a much slower progression to disease in those infected, and is geographically restricted to West Africa, and to countries that have past socio-economic ties with Portugal. Being Portuguese, this furthered my curiosity. The scientific challenges were many, but so were the broader health and socio-economic ones: at the time there was no HIV/AIDS policy in the country, and most patients did not have access to treatment; stigma and discrimination were a major challenge for health interventions. When I returned to Oxford, I felt restless. The following year I left for Gambia for further research – this time equipped with a camcorder. I was determined to not only complete our study, but also to be able to see and learn more, and to share with colleagues and friends who hadn’t had this experience (through the production of an amateur documentary).

Back in the laboratory, and after completing my Doctorate, I felt even more restless; there was an urgent need to act. I joined a team running a phase-I clinical trial for an HIV vaccine carried out at Oxford and funded by the International AIDS Vaccine Initiative. Different reasons led me to join this team. I needed to discover how much I actually believed that a vaccine that is widely available is a possibility. Our results from the vaccine trial were encouraging, but there was still a long road separating us from a Phase-I trial to potential commercialization (it takes about 25 years to take a vaccine from the initial stages of research in animal and human trials to commercialization and distribution). What I also found out was that I had gained a lot more in terms of experience. Working in a public-private/international partnership gave me a very interesting global perspective on the roles played by the different stakeholders.

Toward the end of the vaccine trial I was confronted with the fact that while we will not have an efficient vaccine within the decade, we do possess the tools to stop the infection from spreading further, through universal access to education about prevention and treatment. Those tools will also stimulate further basic and clinical research. Furthermore, It is essential to ensure that if we do have a vaccine, the infrastructure is in place to guarantee that is becomes widely available.

We now know that a cure is still a distant prospect, and that many vaccine attempts have been tried, but failed. Antiretroviral therapies are constantly being developed, and they have dramatically improved quality of life. Nevertheless, in developed countries where antiretrovirals are more readily available, side-effects and increased rates of viral resistance have been raising concerns about their long-term use. Treatment advances have yielded important new therapies, but the cost and the complexity of their use and implementation puts them out of reach for most people in the countries where they are needed the most. Every year billions of dollars are allocated to tackle the HIV epidemic, yet financial aid alone has been insufficient to achieve sustainable health solutions. Although great efforts to improve the health of the poorest have been made throughout the last decade, these still fall short of the targets set in the Millennium Declaration.

The scale and scope of the health challenges faced by many African countries strains the existing health infrastructure. The scientific and medical technological advances in Africa are still far from reaching their full potential. The lessons I learned throughout the last 13 years have been many, and I have gained invaluable experience from working with NGOs and carrying out HIV research in West Africa. I firmly believe that to meet the great health challenges ahead it is of utmost importance to overturn the brain-drain in healthcare, to stimulate and retain local scientific knowledge, and to think of innovative and creative ways to deliver healthcare in a sustainable manner derived from local solutions and knowledge.

Toward the end of the vaccine trial, I started to think about how to best address the challenges I had come across. I was determined to think through ways of expanding the healthcare infrastructure in West Africa, and in Gambia, in particular. Given the country’s geography and the difficulties in reaching out felt by the field workers, we concentrated our efforts by working with local partners to develop an initiative that would secure universal access to HIV/AIDS education while ensuring the social and financial sustainability of the project itself. A scholarship from the Skoll Foundation ([skoll.org]) and the Skoll Center for Social Entrepreneurship allowed me to do an MBA at Oxford’s SAID Business School to further develop these plans.

In early 2007 we went to Gambia to meet with our local partners. The situation regarding the provision of antiretrovirals had changed dramatically in 2002-2003 with their introduction in the country, and a grant from the Global Fund to Fight AIDS, TB and Malaria. There was a more recent development: the President had just announced he could “cure” HIV/AIDS. We returned to Lisbon a few weeks later, where I am now based.

One of the greatest general lessons I learned has been to never take anything for granted.