Looking toward Vienna: Peter McDermott

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`A Scandal’ – Children Issues Not On Agenda

Peter McDermott is the Managing Director of the Children’s Investment Fund Foundation (CIFF), one of the largest charities in the United Kingdom. He previously had worked at UNICEF for 21 years, serving as Chief of the HIV/AIDS section in the program division at UNICEF headquarters in New York, as well as holding positions in Africa and Europe. After the Pacific Health Summit in London last week, where he laid out an ambitious agenda for advancing efforts to prevent the transmission of HIV from mother to child and to treat HIV-positive children, John Donnelly interviewed McDermott about his expectations for the International AIDS Conference in Vienna, starting July 18.

Peter McDermott, Managing Director, Children's Investment Fund Foundation

 

McDermott said he will reply to any questions posed in the Comments section and that he welcomes any suggestions for CIFF’s work in these areas.


Q: What are your goals for the AIDS conference?

A: My mind goes back to the AIDS conference where Stephen Lewis was chairing a session with Bill Clinton and Bill Gates, and one of the themes was we would address and eliminate the transmission of HIV from mother to child. That was four years ago. There’s an element of, `We’ve been here before.’ But there’s never progress in the interim. We need to be very sober about what we are trying to do, a little less self-congratulatory, and a little more self-critical.

Q: So what’s realistic?

A: Going in to Vienna, CIFF is very pleased we have made progress globally on PMTCT (prevention of mother to child transmission of HIV) but we haven’t done enough with the resources spent to date. It’s not just about harnessing more resources but using them more effectively.
I see three challenges – a conceptual challenge, a challenge of delivery, and a challenge of measurement and impact.

Within the conceptual challenge, the vocabulary we have used – prevention of mother to child transmission — has been useful shorthand, but now it’s a burden. We medicalized the problem and made it a drug issue about single-dose nevirapine. There’s really been an underinvestment in other interventions, such as preventing infections and preventing unwanted pregnancies and also care and support and treatment of mothers and children. We need to get back to a more comprehensive agenda. We need to get into a more family-based care system.

There have been a significant number of delivery challenges for far too long. Even the distribution of single-dose nevirapine — in and of itself a sub-optimal regimen – we’ve found that mothers have not always taken what they are given. Unless we get more pregnant mothers into the entry of the PMTCT cascade, it doesn’t matter what regimen we make available because you need large numbers of women to be an effective delivery strategy. Then you need to follow up on them.

And the third point, we are measuring the wrong things. We shouldn’t be looking just at how many women are getting new drug regimens, but also have many are using them. We need to make sure people are surviving. One of biggest challenges is that we now have more than 250,000 children on ARVs, but in some countries we have no idea of how many are alive and well. There’s no point doing this unless we know there is long-term survival.

Q: So will there be a shift toward addressing these challenges in Vienna?

A: As in the previous AIDS conference, the absence of children on the main agenda is a scandal. There are no other words for it. Elaine Abrams from Columbia is on one plenary session on mother-to-child-transmission, and that is welcome, but the issue will not see much air time in Vienna. Pediatric AIDS agenda also is conspicuous by its absence. There’s a two-day pre-conference symposium on children, but not much else.

What we should be doing is put PMTCT and pediatric AIDS both under the pediatrics agenda and make the programs more closely aligned. So in a hospital, there should be one clinic for mothers and children, a one-stop shop. We need to look at this issue as family care rather than disease specific care.

Q: What’s important to your foundation at this conference?

A: We have four areas we’re looking at. The first is we still haven’t managed to get significant, sustained uptake of cotrimoxizole for children – it’s a very cheap antibiotic and the impact on mortality will be very dramatic. Two, the Clinton Foundation and UNITAD and others have done a lot in bringing down the cost of pediatric drugs, but the fixed-dose combination drugs to market really haven’t been brought to scale — we need to push it.

Third, the loss to follow-up issue – the issue of initiating a lot of children on treatment, but we don’t know what is happening to them. And four, we come up against a brick wall identifying exposed children; we don’t have a good point-of-care diagnostics tool to identified whether the children are infected – that is the unfinished agenda.

6 thoughts on “Looking toward Vienna: Peter McDermott

  1. Rena Greifinger

    Thanks so much for your candid interview. Your passion shines through. Children and youth consistently remain under the radar at these large-scale conferences. They become token issues, rather than spotlighted ones, and it is infuriating that 30 years into the epidemic, there is still little focus on long-term care for perinatally infected youth. I work with a group of youth in the U.S. who have full access to treatment, but continue to struggle with adherence. Many have suffered opportunistic infections. Everything about being a young person goes against the concept of adherence and until we can concentrate our attention and dollars on that, both here and abroad, we risk losing everything that we have worked for in the PMTC world.

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  2. Kwaku Yeboah

    Peter,
    You are right on point. As a way forward I will think that there should be a way to engage stakeholders representing different groups affected by the epidemic such as child advocates. Such engagement with the scientific ommittee could address some of these glaring issues.
    Having said that I also think that the bottom line in having programs reaching children and young people is engaging national governments and their implementing partners to ensure that there is equity in resources to deal with different groups that can impact on the epidemic. National programs should be supported in monitoring outcomes other than the conventional indicators

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  3. David Hughes

    Once again Pete lays out a very clear path of what needs to be done. The man is brilliant about conceptualizing achievable goals and as always he does not stop at the inputs and outputs, but looks for effective and life improving outcomes. Hopefully children (who are the future we need to strive for) will be a focus in 2012 and that Pete will be seen as one of the heros leading for a better life for children, especially those infected and at risk of HIV infection.

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  4. Suzi Peel

    Thanks Pete and John for raising these key issues – again.

    We must be part of AIDS 2012, and ensure that all aspects of Children and AIDS get into the Call for Abstracts. It is at the earliest stages – when the list of abstract submission categories is defined – that a Conference sets its tone and priorities.

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  5. Peter McDermott

    Many thanks for the various comments. Forgive the delayed response, I have been travelling extensively and in fact arrived in Vienna today for the conference.

    Rena,

    Thanks for your comments. Yes, after thirty years it is a struggle. You also raise a really good point that you have , in the US as in a number of countries been working with youth who have been infected for a number of years and face the challenge of adherence, etc. I am not sure we have spent enough time learning from these experiences which will be vitally important as we are clearly going to have a whole new generation of infected young people in the south.

    Kwaku,

    You have made an excellent point. We , as a community, simply haven’t done enough to engage other groups in particular national governments. There are some notable successes like Botswana and others but there are too few. The scientific and prevention communities puzzle me as we have had very limited success in making children infected and affected with AIDS a mainstream focus for them. We have exceptional individual leaders from these communities but the scientific and prevention movements themselves have never accorded children a high priority.

    David,

    Thanks for the complements, but the failures of action are also apparent, and the successes we have to date are the result of the hard work of many including yourself.

    Regina

    I did not want to denigrate the work done on trying to put children more centrally on the global AIDS conference agenda. Indexed the work of the CABA coalition and other child focused groups are responsible for the success to date, along with initiatives like the Joint Learning Initiative etc. The road map on what is happening at the Vienna conference is invaluable, as is the two-day pre-conference meeting which starts tomorrow. However, we need to be both honest and realistic; children are not accorded a priority when plenary sessions are made, in fact Prof Linda Richter’s plenary speech at Mexico was the first and only one specifically addressing children in any conference to date.

    Suzi,

    Great to hear from you. Absolutely right.

    Thanks to all for the invaluable comments. I am very much looking forward to the next two days where we do specifically focus on children, and kudos to the CABA group who have made this meeting harder nosed on evidence and impact. As a community we need to make sure we invest in interventions that are evidence based, measurable and can clearly demonstrate impact s

    In appreciation for your comments

    Pete

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