The next in a series of interviews with staff members at the Office of the Global AIDS Coordinator, Science Speaks interviewed Senior Technical Officer Bill Coggin. As co-chair of the interagency TB/HIV technical working group, Coggin works on the PEPFAR’s annual TB/HIV guidance and technical considerations for the field, as well as technical reviews of the annual Country Operational Plans (COPs). He is also the technical officer for supply chain management responsible for the PEPFAR pooled procurement mechanism. In this interview, Coggin speaks to the way he got involved in global health, HIV/TB program funding priorities and how PEPFAR continues to squeeze the most out of every dollar it spends.
How did you get involved in AIDS?
My introduction to international public health was in Zaire – which is now the Democratic Republic of Congo – where for three years I was working as part of the Peace Corps as a community public health worker in a rural health district of about 50,000 people, combating communicable child diseases, working on immunizations, malaria and diarrheal diseases. That was the hook that sent me on a path to international health work.
Then I joined the U.S. Centers for Disease Control and Prevention (CDC) in 1990. My first assignment there was TB and HIV during the resurgence of TB in the U.S. at that time – I was assigned to the New Jersey Department of Health, working mainly in drug treatment centers and prisons. At that time, TB/HIV collaborative activities as defined by CDC were really to test intravenous drug users and prisoners in crowded conditions and provide isoniazid preventive therapy (IPT) both in the prison settings as well as in the methadone maintenance centers.
Despite the differences in the magnitude of the TB epidemics here in the United States and in Africa – there were many similarities between approaches and challenges to combating them. First, TB is a disease of poverty affecting the disenfranchised – and many of the lessons learned abroad apply domestically and vice-versa. Second, the need for maintenance of effort and resources for sustained public health programming to combat TB is clear both in the U.S or abroad. The resurgence of TB in the United States was related to the emergence of HIV in 90s as well as defunding of TB programs thinking, in complacency, that TB in the U.S. was no longer an “issue.” And the third link – of all the TB cases in U.S. 60 percent are foreign born – so there is a direct interest in what we do to support global health overseas that ties back into our domestic public health and security.
What do you consider the most important aspects of your job – can you describe your work for me? What are you working on right now?
I’m the senior technical advisor for TB/HIV at OGAC. A lot of what we do at OGAC as a coordinating office is work with implementing agencies of PEPFAR. For example, heading up the TB/HIV technical working group is the U.S. Agency for International Development co chair, the CDC co-chair and myself. We do the Country Operational Plan (COP) guidance technical considerations, and we provide technical assistance to PEPFAR teams according to the need. Our technical working group serves in that function where needed. We provide technical review for COP submissions that will come in, applying a lens to those technical practices that have been defined in the guidance.
We’ve been given our marching orders with some key directional shifts, pivots in focus, and we are having a lot of discussions around how to implement these shifts. Basically this entails looking at the PEPFAR footprint, which countries are best-poised for building government ownership and taking financial and/or management responsibility for their own HIV response, areas of redundancy that we need to eliminate, etcetera. The key point that Ambassador Goosby has stressed is that our programs must focus on high impact interventions. Interagency negotiations and dialogues take place to look at these programs through that lens to ensure they are shifting as appropriate.
There are seven priority areas set forth in the COP guidance, one of which is TB/HIV, and we use the guidance as a key advocacy tool to help encourage programming along those lines.
We have been programming additional funding for TB/HIV. We are initiating a very targeted “three I’s” (intensified case finding, IPT, and infection control) activity in a small subset of countries, including lab strengthening and early antiretroviral therapy (ART) for TB patients. This money has been committed by U.S. Global AIDS Coordinator Ambassador Eric Goosby in recognition of the unique position that PEPFAR is in to address the co-epidemics, as with support from Congress.
You are the country team lead for Haiti and were in 2010 when the earthquake struck. What was that experience like? What is going on with the HIV epidemic there now?
I’ve been working on the Haiti PEPFAR program since October 2009 – almost two years. My intro to Haiti was part of an interagency team to do an assessment of overall U.S. health programming in the country. Secretary Hillary Clinton had a strong interest in looking at the U.S. government assistance in Haiti and looking at where our programming was getting it right/wrong, not only in health – but also energy, safety and security, and agriculture. Out of that process grew a new Haiti U.S. strategy that was about to be released at the time of the January 2010 earthquake and since then that strategy has had to be revised to reflect the new realities and challenges in Haiti. This strategy focuses on health systems strengthening. We have a long history of investment in Haiti, including NGO-delivered services, and there is a now a concerted effort to support the Minister of Health (MOH) to build its capacity to guide, direct and monitor all of the partners on the ground, and that’s critical after the earthquake even more than before.
The very weak health care system that existed in 2010 was devastated by the earthquake, and PEPFAR had been supporting HIV care and support through the MOH and indigenous and international partners. That network was immediately mobilized to play a central role in the emergency response and recovery phase after the earthquake. PEPFAR’s infrastructure including treatment sites, human resources, supply chain and commodities through the supply chain management system program were put into action to distribute first aid and other commodities.
We’re proud of PEPFAR’s ability to respond that way. The cholera emergency that emerged after the earthquake required a lot of coordination and mobilization and once again we were pleased that PEPFAR could again make incredibly important and timely contributions. This is really a tribute to PEPFAR’s implementing agency staffs from CDC and USAID and our MOH and implementing partners.
In terms of the AIDS response, as of the end of last fiscal year, there were 28,000 Haitians on PEPFAR supported ART. Obviously there was a massive dislocation of the population and disruption of care after the earthquake. PEPFAR responded with a massive effort to link patients who were still alive to continuation of services, and lots of groups helped locate these patients. Some of the data from CDC I’ve seen on retrieval of patients during the five months after the quake indicated high rates of successful return to care but with marked declines in HIV testing and new ART enrollment.
How are we doing with testing people with HIV for TB?
Obviously the whole TB/HIV framework has TB entry points and HIV entry points. PEPFAR is really an HIV focused program – PEPFAR is particularly well-placed to advance the “three I’s” through our support for HIV programs. So the “three I’s” have been highlighted as a priority – as they are in this year’s COP guidance and in the PEPFAR 2 strategy – so this is something that definitely has political support.
As for funding, TB/HIV has a $160 million directive and earmark, and we’ve been able to maintain that funding level given the importance of co-infection on combating the epidemic. Beyond that funding envelope, we really work strategically to leverage other funding, for example working closely to make sure programs we support are in sync with those supported by the Global Fund.
What about putting those with HIV who do not have TB on IPT? Are we tracking that?
That’s a big question. IPT suffers as sort of an orphan intervention. What we’re trying to do in collaboration with the World Health Organization (WHO) and others is to highlight the evidence base for IPT, and to support projects for IPT where it’s part of national guidelines. We’re trying to work with civil society to create demand for IPT and the patient information systems are really critical as well – we have lots of anecdotal evidence that TB screening is occurring and that people are starting IPT, but we don’t always have the data to support that. There are recording and reporting issues that need to be simultaneously worked on and improved. Data of IPT reported from countries to WHO are beginning to show slow but incremental improvements; there is still much to be done.
What is the potential for roll out of the Gene Xpert rapid TB test? Can you give us an idea of how many machines have been placed and what future deployment will look like?
We’re really excited about the potential of Xpert to improve early diagnosis of TB – particularly among PLWHA. Ambassador Goosby, Administrator Shah, and Director Frieden have articulated USG commitment to support this technology. So far we’ve developed guidance for U.S. government teams to help them determine how this fits into their portfolios and work through issues with MOH and other partners.
That said we recognize this is not just an issue of parachuting in with machines and cartridges. We need to look at how Gene Xpert is integrated into country lab plans, diagnostic algorithms that need to be changed, how to link new cases of TB that are identified to TB treatment, etcetera. We need evaluation as the roll out proceeds as well. Some of the $20 million I mentioned earlier will be targeted towards Gene Xpert.
We are creating an inventory of USG investments and working within the context of a WHO process that aims to catalog where Gene Xpert is being deployed. No hard numbers are available right now but we are busy collecting those data.
In terms of your role in drug procurement and supply chain management, is PEPFAR engaging in anything new in order to try and reduce ART drug procurement costs? How is that process going and what kind of savings are you seeing?
Incredible gains have been made – last year more than 86 percent of our procurement of antiretrovirals was generic, which really validates the decision in early PEPFAR to create the tentative approval process for generics through the U.S. Food and Drug Administration. We estimated that last year $173 million was saved that otherwise would not have been – resources that can be plowed back into prevention, care and treatment. Further efficiencies are being realized; PEPFAR’s SCMS partner has saved an estimated $52 million by progressively shifting from air freight to sea freight to deliver commodities.