An Interview with Caroline Ryan

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The first in a series of interviews with staff members of the Office of the U.S. Global AIDS Coordinator, responsible for the U.S. President’s Emergency Plan for AIDS Relief  program, Science Speaks sat down with Caroline Ryan, MD, MPH.  As Director of Technical Leadership at OGAC, Dr. Ryan has been a long-time key architect of PEPFAR’s implementation, first joining the office in the fall of 2004. She spoke with John Donnelly about how she became involved and why she has stayed for seven years.

Caroline Ryan, MD, MPH

What does that mean in layman’s terms?
Program services have two functions. One is supporting country programs. That means supporting the countries, in 2007, in writing the COPs (country operational plans), and dealing with whatever happens in the countries. We have country support team leads at OGAC. They are in charge of two or three countries and their roles are to be available to answer any questions, or to go out for visits and help with any issues.

The other part of my work is coordinating the work of the 17 technical working groups.

Do you really need 17?
We really do. It sounds like a lot. What the Technical Working Groups do is bring together all the expertise that exists in the U.S. government in specific areas, for example male circumcision or PMTCT, prevention of mother-to-child transmission. The experts come from multiple agencies: U.S. Agency for International Development, CDC, Department of Defense, National Institutes of Health, Health Resourses & Services Administration and the Peace Corps. It’s really important to have those experts come together. They are our internal advisory bodies on those issues. We also work closely with the World Health Organization and the Gates Foundation, among others.

What has kept you working on PEPFAR programs for this long?
When I first started it was very, very exciting for those of us in the field to have resources and to have the privilege to set up systems and policies. That was a real honor. It was the most exciting and amazing time of my life. It was very clear what our vision was. We had very clear metrics and we were funded to achieve those. We saw that the numbers for testing and counseling in Nigeria were falling, we would ask why and  send a team to Nigeria to work with them.

Now, I have come full circle, following up on the ABC guidelines and being involved in writing our new prevention guidelines. It is a really exciting time because we have a good arsenal of interventions to prevent the transmission of HIV. But if we are going to do any intervention, we want to make sure we have strong evaluation so we can tell five years from now what we should add to our arsenal. We need to make sure we are having a response proportional to the epidemic, using the toolkit that has the most impact, and not losing opportunities.

What are you most excited about?
Male circumcision. This is a great opportunity to have an impact in countries where there’s high prevalence of HIV and low prevalence of circumcision. I always say, ‘Twenty minutes, $20, and you have a life-long impact of prevention.’ It can’t be used alone, of course, but it certainly is very cost effective. The technical working group that focuses on male circumcision is an amazing group. We have a very close relationship with UNAIDS, World Health Organization, Gates Foundation, and the Global Fund. Everything we do we plan as a group, not just as individual agencies.

That has been very exciting. We’ve been looking at the modeling, looking at cost prevention, supporting both mobile and stand-alone services, and looking at what we are trying to do with what we call ‘mop-up.’

What does ‘mop-up’ mean?
It means circumcising the men who weren’t circumcised when they were adolescents or babies. As a donor, you want to do something that has an impact and leave behind something sustainable. So we are putting in place a service for adolescents for a short period of time, while also setting up a service to circumcise newborns. It’s not expensive to start the newborns’ program, the programs become part of the health systems. Then you don’t have to be concerned about stand-alone adult circumcision programs for the rest of time.

We’ve done close to 600,000 circumcisions in about two years. Tanzania and South Africa are really on the rise. They are revving up in Swaziland now, too. The paradigm has shifted and everything is taking off. If we have a device soon that made the whole procedure easier, that would be a game changer.

Do you have any promising candidates for a new device used for circumcisions?
We have two devices tested that have promise. One is Prepex, and the other is Shang Ring, which is out of China. Both are in trials now and both are promising.

Could one of them be ready in a year or two?
We are hopeful.

Could it eliminate the need for a doctor to perform a circumcision?
It could.