Ezekiel “Zeke” Emanuel, MD, PhD, Special Advisor for Health Policy at the Office of Management and Budget, is currently on a two-week trip in Africa to look at various health programs. Earlier this week, he and other U.S. officials visited an HIV prevention program in Mojo, Ethiopia, called the TransACTION project, a five-year, $40 million USAID-funded initiative that started last year. Led by Save the Children, with technical assistance by AED and Population Services International, the project will eventually bring an assortment of HIV prevention tactics into 110 urban and roadside communities in Djibouti, Ethiopia, Sudan and Kenya. This is the second of a two-part interview with John Donnelly. In this post, Emanuel talks about the importance of matching prevention tools with the specific dynamic of HIV transmission in a community.
Q: Can you describe what you saw in this HIV prevention program in this roadside community a couple of hours outside of Addis Ababa?
A: Mojo is a town on the Addis-to-Djibouti trucking corridor. It’s a classic situation where you have truckers going along this route and you also have, in the communities, sex workers, day laborers, small businessmen, all in all a very transient population. Truckers stay about six months in any locale. There also are rumors of trafficking in girls, luring them in as prostitutes. You have a big challenge here on all scores.
Because of those challenges, you have some problems in collecting data, and trying to figure out prevalence is hard because you have a very unstable population that is difficult to track. We met with people in the communities, and we met with two sex workers who are educating colleagues about getting tested for STIs [sexually transmitted infections] and voluntary HIV testing. If they go to a clinic, the sex workers can bring a voucher and it gives them free HIV testing and free drugs at a pharmacy.
Q: What is your assessment about whether this kind of prevention program will work?
A: It’s early in the model and we don’t have a lot of data about success. We are seeing, though, already issues related to women who are more willing and eager to take tests for STIs and take medication for that, but they are more hesitant about getting testing for HIV. The reason apparently still has to do with the stigma around the disease.
Q: What is the most critical piece to this prevention program that directly targets highly at-risk populations? Is it the peer-to-peer work with sex workers, as is seen in many parts of the world? Is it the need to have a comprehensive approach with community acceptance?
A: It’s early days and there’s not a lot of proof in the pudding. But you have a multi-layered approach here with community involvement, peer-to-peer counseling. It may be the way to go. Sex workers can get examined for STIs, and if they need treatment, it wouldn’t cost anything. This can create a support network, and I think this is going to be a situation where social norms matter, and they can see this as a positive thing for their own health.
Q: Robert Hecht at Results for Development has written about the need for countries to do a much better job in spending money only on proven preventions and making sure they match prevention tactics to the specific transmission patterns in a region or community. Why hasn’t this happened more widely?
A: I’m a big believer in that philosophy, as is Eric [Goosby, Global AIDS Coordinator]. At PEPFAR [the President’s Emergency Plan for AIDS Relief], we are definitely going to focus on that more and develop the interventions that work best in that community.