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Vol. LXV, No. 11
May 24, 2013
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‘Something Amazing Happened’
Response to HIV Alters Health Care Paradigm, Says El-Sadr

On the front page...

Dr. Wafaa El-Sadr

Dr. Wafaa El-Sadr

The myth of the American hero glorifies the rugged individual—the cowboy who rides alone. But there’s a new model: the public health heroes. The plague fighters.

Working in their teams, there is magic.

Some people think that HIV has gone away, but over the last 3 decades, more than 60 million people globally have been infected with the virus and nearly 30 million people have died of AIDS.

This makes the ongoing work of physicians and researchers such as Dr. Wafaa El-Sadr essential. She recently visited NIH to give the annual Dr. James C. Hill Memorial Lecture, “The Global Response to the HIV Epidemic: Lessons Learned and Lasting Legacy.” A full house attended her talk in Lipsett Amphitheater.

Continued...

“We are fortunate to have Wafaa here,” said NIAID director Dr. Anthony Fauci in opening remarks.

A MacArthur fellow and a member of the Institute of Medicine, El-Sadr has “shaped women’s health like Marie Curie and Florence Nightingale,” he added.

A distinguished physician, she is director of Columbia University’s ICAP, a large center engaged in global health programs, and principal investigator for the NIAID-funded HIV Prevention Trials Network.

As an infectious disease specialist in the 1980s, when the first HIV cases were identified in the U.S., El-Sadr created a comprehensive care model at Harlem Hospital Center in New York City, where she was chief of infectious diseases for two decades. HIV makes people vulnerable to TB, and with multidisciplinary teams, she integrated HIV and TB treatment. This may look simple on paper, but it takes long hours, tenacity and grit. It means caring.

Here’s one result: the TB treatment completion rate at the Harlem clinic jumped from 11 percent in 1992 to 95 percent in 1993. At the same time as she was working to establish models of care for individuals and families with HIV and patients with TB, she advanced the concept of community-based research through engaging the populations she served in clinical trials.

She took her local model and went global.

By creating meaningful partnerships with governmental and nongovernmental organizations within countries, said Fauci, El-Sadr’s efforts through ICAP strengthened their own health care systems and shaped the way HIV/AIDS and TB care are delivered to sub-Saharan Africa, Central Asia and other hard-hit areas.

Here’s the background:

  • Of the estimated 34 million people living with HIV around the world, 22 million live in sub-Saharan Africa. Places most affected with HIV/AIDS have the least access to care and treatment.
  • In 1950, life expectancy in select countries with HIV prevalence in Africa was 47 years. With the impact of the HIV epidemic, the gains in life expectancy until the 1990s have been lost.
  • We have an entrenched epidemic in this country, El-Sadr said. The U.S. ranks seventh in terms of the number of people living with HIV globally.
  • In 1996, antiretroviral (ARV) therapy transformed HIV/AIDS from a death sentence to a chronic disease.
Says El-Sadr, “There’s magic working on a team of researchers, implementers and a diversity of disciplines. There are lots of opportunities in HIV, from basic science all the way to public health. Every individual can find their spot in that spectrum.”

Says El-Sadr, “There’s magic working on a team of researchers, implementers and a diversity of disciplines. There are lots of opportunities in HIV, from basic science all the way to public health. Every individual can find their spot in that spectrum.”

Photos: Ernie Branson

“Fortunately there was a great mobilization and many in this room were part of this,” El-Sadr said. In 2003, with the establishment of the Global Fund, and then PEPFAR in 2004, “there was a historic global and U.S. government response.”

Meanwhile, in sub-Saharan Africa, health systems were in crisis, with a care model that was episodic, not continuous.

By strengthening the building blocks of health care, a new model of “continuity care,” based on chronic care systems, was launched in partnership with in-country organizations.

In addition to workforce and infrastructural changes, continuity care required a transformation of other elements: having medical records available, charting tools and a staff dedicated to data collection and data management.

“To utilize the data to enhance the quality of the programs and to inspire the achievement of targets is very important,” El-Sadr said. As for governance, “Patients are now at the table,” informing design and implementation of programs.

ICAP’s goal was to achieve “effective, equitable and efficient HIV programs.” And “something amazing happened,” El-Sadr said. “One of the most remarkable achievements ever in the history of public health.” These same health systems were transformed into ones able to provide high-quality services.

Through ICAP support, more than 1 million people with HIV and related conditions have received care and over 800,000 have been given access to ARV. Overall, the impact has been profound—death rates in PEPFAR-supported countries are down and worker productivity is up.

El-Sadr also addressed “a raging controversy.” Did global HIV response jeopardize the response to other health threats such as TB, malaria and maternal-child health services?

Fortunately, there is little evidence that confirms these fears. El-Sadr’s team has published articles showing that there may in fact be synergies benefiting non-HIV conditions, such as in maternal health as demonstrated by an increase in deliveries by HIV-uninfected women at health facilities.

Lessons learned from the HIV response include:

  • “A huge paradigm shift” beyond episodic care towards life-long care works for both care and prevention.
  • Adaptation of the HIV chronic care model for confronting chronic non-communicable diseases. A pilot study that adapted HIV-related tools and examined their feasibility and effectiveness in a diabetes clinic showed “substantial improvements in some of the measurements.”
  • The HIV prevention and care cascade means you can’t succeed in just one element, but in the whole process. No simple fix.
  • Telescoping the time period from discovery to action, rapidly implementing and scaling up innovations.
  • Research on implementation and scale-up is necessary in order to advance knowledge and public health impact.
  • Then there’s the power of people. “The power of affected communities…generates demand, energy, brings people to our programs and keeps them engaged.”

In the discussion after her presentation, El-Sadr was asked if we’re going to have the same leadership and focus on the HIV epidemic in the next generation.

“I believe that we have to enable new leadership. There’s magic working on a team of researchers, implementers and a diversity of disciplines. There are lots of opportunities in HIV, from contributing in the basic sciences all the way to being engaged in public health. Every individual can find their place in that spectrum.”


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