“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.”
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
- “A huge paradigm shift” beyond episodic care
towards life-long care works for both care and
- 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
- 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
“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.”