Sten Vermund, MD, PhD, professor of medicine and director of the Institute for Global Health at Vanderbilt University School of Medicine, sits on the Scientific Advisory Board (SAB) to the President’s Emergency Plan for AIDS Relief (PEPFAR). The SAB met for two days last week in Washington, DC, reviewing the current portfolio of PEPFAR-funded initiatives, the funding situation, and garnering SAB recommendations for PEPFAR priorities moving forward in the areas of care and treatment, prevention, and health systems. After the meeting Science Speaks spoke with Dr. Vermund, who also sits on the Center for Global Health Policy Scientific Advisory Committee, about the proceedings and his perceptions.
Of the SAB recommendations you heard today for priorities moving forward, what are the two or three that you found most compelling?
- A coherent medical informatics system for both clinical care and strategic information management is overdue in PEPFAR. The committee recognized this and made the recommendation to sympathetic leaders at the Office of the Global AIDS Coordinator (OGAC). The present system is no system at all and demands that governments adopt many different approaches developed quickly during the emergency response.
- The need for high impact public health evaluations was acknowledged, and the joint use of antiretroviral therapy (ART) to both prolong life and to reduce community transmission was deemed a top priority for operations research investment.
You raised concerns about macro level ethical issues, can you elaborate on that?
If the U.S. (in PEPFAR) or the global community (in the Global Fund for AIDS, TB and Malaria) helps some of the world’s most resource-limited nations put millions of their citizens on ART, neither can step back and simply say, “Sorry, no more money or technical assistance!” We have an ethical obligation to continue ART support as we help countries capacitate to manage such programs themselves. It is unethical for us to get out of the ART business under the guise of saying “the emergency is over, good luck to you.”
Toward the beginning of the meeting when discussing research prioritization you said, “Underfunded research may be a waste of money.” Can you explain what you meant by that?
Historically, program monitoring and evaluation has been done at a very low investment level such that we do not know in fact whether our programs are working well or not. Such a level of support for programmatic research does not inform us of what is going well or poorly in programs and how to fix it; hence, such underfunding spends money to no good effect.
Charles Holmes, MD, MPH, chief medical officer at the Office of the Global AIDS Coordinator, spoke about loss to follow up during his presentation. He showed somewhat positive data from Mozambique in that regard. What has your experience been on the ground with those who test positive for HIV but have a relatively high CD4 count and are not put on treatment. What happens to these folks? Do they fall through the cracks or come back?
Both persons with higher CD4 counts and persons on ART with low CD4 who are starting to feel much better on ART are lost to follow-up at higher-than-acceptable rates. Considerable community work is needed for the kinds of support systems to maximize the likelihood that poor rural or urban persons perceive the need for, and are able to access, services.
How likely is it for one of these patients to experience an asymptomatic CD4 count drop below 350 or 200? Would ARV intervention once they do begin showing symptoms be too late?
It is common for persons to be relatively asymptomatic and drop to a low CD4 count without much clinical indication. That is precisely why HIV testing and counseling programs are needed for at-risk persons.
Is your perspective of information gleaned from the Mozambique evaluation as positive as Charles Holmes’? Are there pros and cons to the push toward greater efficiency in PEPFAR?
Our own experience in rural Mozambique is to suggest that rural farmers and spouses do not access chronic medical care at high frequency for many years. There is simply no tradition to do so. Once symptomatic persons start to feel better, or once they perceive the cause of their illness (often seen as a spiritual cause) having been lifted, loss to follow-up is common. We are working diligently through structural changes in the clinics and intensive community work to enhance follow-up in these low-resource rural areas.
What is your opinion on where the Centers for Disease Control and Prevention (CDC) fits into the Global Health Initiative? What is CDC doing to implement GHI on the ground?
CDC has tremendous field expertise in public health systems deployment, especially dating back to the smallpox eradication era. Their role here was justified given the magnitude and fast timetable of the emergency response, providing very strong support alongside the U.S. Agency for International Development (USAID) to sponsor deployment of a vast clinical and public health enterprise. CDC, as with USAID, provides resources and coordination for its partners in dozens of countries.
In the case of Mozambique, has the effort to support greater integration through GHI and greater in-country dialogue across sectors been visible? Or is it too early to say?
It is too early to say.