Innovative programming to combat HIV, TB and cholera: A conversation with CDC’s John Vertefeuille

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In this third post in a series of conversations with officials at the U.S. Centers for Disease Control and Prevention (CDC) discussing the CDC’s role in global HIV and tuberculosis research and development, Science Speaks sat down with John Vertefeuille, PhD – the country director for CDC in Haiti. There he leads a team of 55 and manages an annual HIV budget of approximately $90 million and post-earthquake and cholera budgets of $170 million. Below he discusses his time heading the Global AIDS Program in Nigeria, efforts to extend HIV prevention messages to youth in Tanzania with cell phones, and a brief update on current immunization efforts underway in Haiti.

When did you first start working in public health?
I had gone to get a Master’s degree at Johns Hopkins University in molecular microbiology and immunology at the School of Public Health. As part of a required training course, you had to take an epidemiology class. I liked it so much I ended up staying an extra year and taking only epidemiology classes. I took a job right after that at the State of Maryland Health Department and my employer there also worked at Johns Hopkins. She said they would work to create a space for me to get my PhD, so I quickly jumped into a PhD program and actively pursued a career in public health.

I loved the epidemiology method classes and the idea of being able to assess public health challenges and look for ways that we could, in a cost effective manner, with a simplified set of processes, get services out and provide them to a lot of people and impact disease.

You were the head of the Global AIDS Program in Nigeria, which has a relatively low prevalence – something like 4 percent – but a lot of cases because of the large population. Is prevalence still declining? What do you attribute this low rate to? Is this reliable given the low rates of HIV testing there?
The current prevalence in Nigeria is 3.6 percent for adults ages 15 to 49 years. Certainly from the time I was there – I left Nigeria in 2008 – to now we have seen the HIV prevalence declining. You have to recognize there have been some changes in the way surveys have been conducted – I believe they continue to get better. I think the information that is available now, recognizing that the surveys that are done are very robust, represent a reasonable amount of disease that is in the country.

There has been a testing strategy employed for the last several years using a variety of methods – clinical-based testing, fixed-site outside of health facilities, mobile testing – making sure that testing was available in a variety of venues.

You were the head of CDC’s efforts in Tanzania. You all launched an initiative with PEPFAR and Tanzania Youth Alliance (TAYOA) in 2008 to increase internet counseling and risk reduction messaging using cell phones. What was the outcome of that program? Has it been implemented in other places?
The TAYOA concept was a great one and on implementation it really did do a lot for engaging youth. What was very unique was the approaches they took to making youth friendly activities, youth friendly space in terms of their center, and also the hotline that focused on having people available through the mobile phone network to talk about risk factors or where services were available, plugging them into the health system through that mechanism.

It worked very well and there is a general trend toward using these technologies to promote different health activities. What we saw in Africa at that time and what we capitalized on was that mobile phone access really did take off and the technology could be easily used to convey these messages. It was an exciting project. Since its inception, the helpline has received more than one million callers, nearly half of which had primary questions related to HIV prevention.

Can you speak to some specific achievements of the PEPFAR program in Tanzania?   How good is treatment coverage?  What about voluntary medical male circumcision?
I left Tanzania last February, and at that time there was a real impressive growth in the ART program. There was a net increase of 5,000 to 6,000 new patients per month at that time. It may have fluctuated a bit since then, but on average that’s a pretty impressive growth of the program.

The latest report available on PEPFAR indicates that coverage is up to 255,000 people receiving ART in Tanzania. That represents pretty dramatic growth over the last six years. There has been intensive planning with the government to harness PEPFAR funds and leverage them extensively back and forth to continue to increase access to services.

With joint planning and joint costing, there was a productive distribution of labor set up, with the Global Fund (as a general distribution of tasks, not exclusively what it did) focusing on procurement of drugs, and PEPFAR focusing on technical assistance and support of facilities to deliver those (for example management systems, patient flows, renovating and building more than 100 health facilities around the country). It helped the government be in the driver’s seat and promote its country ownership of the program. It allowed for us to use detailed costs for provision of these services and continue outward planning of costs going forward, including how it would affect planning of activities.

Medical male circumcision (MC) was a major innovation in the tools that we had to prevent HIV. [Three randomized clinical trials showed MC to provide up to 60 percent protection for men during vaginal intercourse]. This came out as we were doing our planning in Tanzania in the 2008/’09 period, and we were able to take this new information about the proven effectiveness of MC and overlay that on the statistical information that we had about where in Tanzania the prevalence of HIV was high and the coverage of MC was low.

Doing that analysis, we were able to prioritize five areas of the country for the intervention. I’ve been watching their progress since I left, and they have really been rolling out MC in a major way. We expect that will have a huge impact on transmission in those areas of the country – and transmission rates in the country as a whole will be affected as well. That’s a major success story in progress in the country of Tanzania. Through PEPFAR, the U.S. government (all agencies) has provided more than 146,000 MCs in Tanzania since October 2009, and has a target of 200,000 for the current PEPFAR program year. Note that some portion of the 200,000 is represented in the achievements to date.

Is TB/HIV co-infection a big issue? What about TB screening of HIV patients, IPT?
It’s a significant issue in a lot of countries. Some of the challenges I’ve experienced include Identifying the two ministry of health (MOH) levels responsible for HIV and TB services.

We made a big push in several countries for the co-location of TB and HIV services, so patients have the opportunity to have their TB needs met and also engage in getting their HIV needs met at the same clinic. We strive for universal questioning of HIV patients about the basic TB symptoms to try and identify patients that might be co-infected, and then we quickly try to test them if they have any of these symptoms and get them appropriate treatment.  The approach that we take in several countries is that the government and the MOH are our most important partners – we do a lot of joint planning and see how our programs can fit into the national plan, and build capacity of MOH to respond to national disease threats. These issues were identified with the MOH and solutions were defined and implemented with them as well. The ministries are very intimately involved in that process, and it’s a positive trajectory that yields better results for HIV issues as well as TB.

HIV testing at TB facilities is an important piece, and immediate linkage services. Studies in Tanzania have looked at improving access to the treatment they needed by co-locating the services. What we saw in general was that by co-locating services and streamlining processes to link the services you could really decrease the time it took to get a patient into care for both of diseases, on top of a definite benefit to treating TB in terms of reducing its spread.

Can you talk about any other research projects under way in Tanzania relevant to HIV and TB?
CDC has several evaluation activities that have and are occurring in Tanzania. They range from looking at malaria rapid test kits and their use in different parts of the country, to evaluating different strategies to HIV testing services as they are rolled out. We’ve done several costing studies to look at how to articulate what the costs of interventions are and how we can take steps to reduce those costs. These are in different phases of development or implementation there.

How is the CDC working to help reverse the severe health care worker shortage in Tanzania? (Tanzania has one of the worst physician-to-patient ratios in the world, with just 0.02 doctors and 0.37 nurses and midwives per 1,000 people.)
This was a really exciting part of the portfolio in Tanzania. We tried to improve the situation with the number of care providers. For example, we developed a Field Epidemiology and Training Program, run by the MOH with our support, aimed at building the capacity of public sector health workers to understand how to manage outbreak responses. That program launched in 2008 and has been active ever since, and 75 percent of the training is fellows going out and doing active work in the public health sector. When H1N1 happened, those fellows were part of the government’s initial response and were sent out to document the spread.

In addition we had a relationship with the school of public health – giving physicians and others opportunities to gain experience in the public health area. We worked very closely with the national laboratory – which was on same site as our office – to build their capacity to roll out their national training lab to improve the quality of the lab work being done by health workers.

We also formed an active relationship with the Fogarty Institute (run by the National Institutes of Health) to link the capacity to train different cadres of workers for specific aspects of HIV disease – one of which was TB/HIV activities because it is a fairly specialized area. There was a very vibrant relationship there to expand the availability of qualified health workers. USAID was active in this area too.

We did a lot of work around strengthening the knowledge base and skill base of those already in the public health sector and expanding the work force in terms of building precise capacities of specialized areas. I agree it was a big problem; it was a problem that we really did try to respond to via a variety of training programs.

Now you are the head of the CDC in Haiti. I know there is a campaign underway – in addition to improving sanitation and clean water – to vaccinate the people against cholera. How effective is that vaccine and is it safe for people with HIV? Are they being prioritized?
The cholera vaccine pilot is not a CDC activity we are just providing technical advice to ensure the methodologies are sound to Partners in Health and the local organization that are looking at piloting the vaccine. “Shanchol” is an oral vaccine produced and licensed in India. In the clinical trials it showed 67 percent efficacy with full dosage at two years follow up, and two doses are required. It’s safe for people greater than one year of age.

I am not aware of specific studies for that vaccine that look at HIV populations in particular. I’m also not aware of any specific focus on people with or without HIV. After the outbreak of cholera last year the disease did spread pretty quickly to all parts of the country. My understanding is these groups involved in the pilot have identified some communities well-known to them where they will be initiating the pilot.

I’m excited with our partnership with MOH in Haiti and I think we’ll be doing some important work in areas of HIV, immunization, maternal health issues (including a new emergency obstetrics program that should really impact maternal survival in delivery),  and a new vaccination strategy working with MOH, GAVI and others. I think there is a huge bolus of activity resulting from the generosity of the American people post-earthquake that is going to have a big impact on the life of Haitians.

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