Tip:
Highlight text to annotate it
X
>> Hello. Good afternoon. My name is Amy Lansky, I'm the deputy director for surveillance, epidemiology and laboratory
sciences in CDCs ***/AIDS prevention, which is part of the National Center for ***/AIDS, viral hepatitis, STD and TB
prevention. It's my pleasure to welcome you here today to the first session of ***/AIDS: 30 Years of Leadership and
Lessons, which is sponsored by the Sample Family Foundation and the CDC Foundation. I appreciate that you're here today
and that you hiked up the hill in the heat to join us for this event.
As many of you know, 2011 marks the 30-year anniversary of the first publication in CDC's morbidity/mortality weekly
report, or MMWR, about what came to be known as AIDS, and later *** infection. To commemorate the unwavering commitment
of public health professionals, clinical care providers, and tireless advocates in the years that followed those first
reports, this series will raise awareness about the bold strides we've made with the ***/AIDS epidemic, provide a
platform to examine our successes and our challenges over the past 30 years, and serve as a basis for moving forward.
This lecture is one of eight that CDC will be hosting throughout this summer to closely examine the defining moments
that changed the course of the ***/AIDS epidemic. And if you want a complete list of all eight events in this series,
you can visit the CDC website, which is CDC.gov/***, and there are also copies of the series at the sign-in table out front.
I also was asked to remind you that there will be an evaluation form for this date, for today's session, and that will
actually be very helpful to us in thinking about the future sessions, so if you could please fill those out before you leave today.
Today's conversation will focus on an area of the *** epidemic, which has been celebrated for its successes: The
prevention of mother-to-child transmission of ***, which is also known as PMTCT. Prevention of mother-to-child
transmission of *** is hailed as one of the most successful prevention initiatives in the epidemic's history. In one of
the earliest steps taken to control the epidemic in 1985, CDC recommended against breast feeding by *** infected mothers.
Prior to the implementation of antiretroviral prophylaxis in 1994, nearly 25 percent of infants born to ***-infected
mothers in the United States became infected.
Personally, I was working in the Division of Reproductive Health as a summer intern back in 1994 when the ACTG 076 trial
results came out, and I still remember the energy and the enthusiasm and some of the, wow, what do we do next. And so
it's been dedicated efforts from scientists, from policymakers, that have turned these results into public health practice.
And today, as a result of that science policy and advocacy groups challenging boundaries to explore effective prevention
strategies, the mother-to-child transmission rate is approximately 2.5 percent in the United States.
The estimated number of infants born in the United States with perinatally acquired *** infection has declined from
1,650 cases in 1991 to just 131 in 2009.
There are an estimated 6,000 persons under the age of 13 living with perinatally acquired infection in 2007. We
estimate that the number of *** infected women delivering infants has increased from approximately 6,000 in the year
2000, to 8700 in 2006. And so if we take that number of pregnant women and the reduction in the transmission rate, one
can calculate that we're preventing approximately 2,000 cases of perinatally acquired *** infection in the United States
each year. With an estimated lifetime cost of *** care at $385,000, it's clear that PMTCT can lead to significant
savings in the long term.
PMTCT has to some degree served as a model for other areas of *** prevention, probably most notably as a model for use
of antiretroviral prophylaxis both pre- and post-exposure. Our contemporary ideas about *** testing, the opt-out
approach, and the concept that testing should be a routine part of medical care, were first established in PMTCT and
served as a function for other populations. In this era of prevention through health care, PMTCT is a good example of
health care-based *** prevention.
Perinatal *** infection, however, reflects the disparities of the overall *** epidemic. The most recent data indicate
that 85 percent of perinatally acquired *** diagnoses occurred in African-American or Hispanic infants, but among all
infants only 37 percent were African-American or Hispanic.
The tremendous reductions in mother-to-child transmission in this country have led us to consider it possible that it
could be eliminated, and we've developed a conceptual framework in which that work can be conducted.
We're overseeing the national progress of the framework through our collaborations of the sort that are laid out in
President Obama's national ***/AIDS strategy. As much progress as we've made towards elimination of mother-to-child
transmission, and as much as we can foresee, it's important to remember that elimination is not something that will be
accomplished only once. It will require sustained effort for as long as women are acquiring and living with ***
infection and having babies.
Cases of mother-to-child transmission likely signal that systems are in need of improvement. Not only for pregnant
women, but for a local approach to making diagnoses and initiating and maintaining treatment plans.
PMTCT is to a large degree the provision of appropriate care for ***-infected women. A key challenge in preventing
mother-to-child transmission remains the fact that too many women don't know that they are *** positive, and they're not
being routinely tested when pregnant. People who are infected with *** but not aware of it are not able to take
advantage of therapies that can keep them healthy and extend their lives.
We've assembled this afternoon a distinguished panel of discussants who will take us through more details of this
history and help us see the future through its perspective. Our moderator for today's session is Dr. RJ Simonds, who is
the vice-president for program innovation and policy at the Elizabeth Glaser Pediatrics AIDS Foundation.
Prior to joining the Elizabeth Glaser Foundation he spent 20 years as a medical epidemiologist at CDC in its domestic
and global AIDS programs, with a special focus on *** prevention, care and treatment of children. Most recently Dr.
Simonds served as deputy director for CDC's global AIDS program and as deputy principal for the President's Emergency
Plan for AIDS Relief, or PEPFAR. He also assisted with the early development of the Global Health Initiative in 2009.
Dr. Simonds received a bachelor's degree in geography from the University of California at Berkeley, completed -- earned
a medical degree from the University of Hawaii, completed pediatrics residency at the Children's Hospital at Pittsburgh
and trained in CDC's Epidemic Intelligence Service. In 2010 he was honored as a finalist for a Service to America
medal, an award that celebrates federal employees for public service.
Please join me in welcoming Dr. Simonds and the panel, and he will introduce the rest of the panel. Thank you. (Applause.)
>> Dr. Simonds: Thank you very much, Dr. Lansky. And welcome to all of you, and thank you for coming on such a hot day
to join in this discussion this afternoon.
I'm particularly honored to be asked to moderate this session because it's -- I hope it's going to be both entertaining
and educational and interesting for people to hear the story of, the successful story of preventing mother-to-child transmission.
I'm also honored to have been part of the story in my own way and to be able to know a lot of you out there that have
also been part of the story and have a chance to reflect on what the successes have been and how we've gotten there over
the past 20 to 30 years.
We've got, as Dr. Lansky said, we have a wonderful panel who will not only be able to tell you facts and figures and
details, but also tell you some of the human stories, and be able to answer questions about what things were really like
back then, as the story unfolded.
It is actually a story in rapid progress, not only, as Dr. Lansky mentioned, not only is there an elimination of
mother-to-child transmission effort in the United States, but it's now going worldwide. Just yesterday, world leaders
including the head of the United Nations, the Former President Bill Clinton, ambassador -- AIDS ambassador Eric Goosby,
and many other dignitaries met in New York City and announced the launch of a new coordinated major global efforts to
eliminate mother-to-child transmission and save the lives of their mothers across the world over the next several years.
So this is -- you're hearing part of the story, but I think there will be more of the story to tell when we sit down
here in 10 years and talk about the 40th anniversary.
The panel we have are really three friends of children. And not just children in general, but specifically ***-infected
children and those children who might have been infected with *** had their efforts to prevent those infections not been successful.
I think the sum total of their career is quite long, even though they are not old. They have been working in this area
a long time and have a lot of experience somehow that managed to escape the aging process.
I think the demonstrated tenacity and commitment and passion I'm sure will come out in their remarks, but I would like
to vouch for that, that these are amongst, you know, the people who have stuck with it, have -- no one really knew how
this story was going to go when it started, and being able to have the faith and commitment that we can make a
difference is really the hallmark of all three of the speakers that we have today.
They're all leaders in their organization and leaders globally. You could go -- you know, in this field you can go
anywhere in the world and talk about Martha or Elaine or Chewe, and just their first name indicates who you're talking
about. You've got a set of world leaders here today to tell the stories.
So what I'd like to do for this session is I'm going to introduce each of the speakers briefly, but not too briefly, and
then we're going to hear from each of them, their piece of the story. Dr. Rogers will talk about the beginning years of
discovery of AIDS in children, and the events happened in the early years of the AIDS epidemic. Dr. Abrams will discuss
the response and what happens in the United States, in particular, following much of the successful research. And Dr.
Luo will speak to the global scene and what's happened globally in response to some of the research successes.
So -- and then following the three speakers, we will have an open question and answer period where you can all save up
your questions that you have and have a chance to quiz the experts on anything that you would like to ask them related
to this topic. I promised them that we would only allow easy questions and questions that they could answer without
revealing either their age or their -- or any private details about how they really uncovered some of the secrets of the epidemic.
Our first speaker is Dr. Martha Rogers, who started her career in CDC as the AIDS epidemic was starting at CDC, so was
amongst the early epidemiologists who investigate the first cases of whatever it was before it was -- before even the
word AIDS was defined. And being there in the beginning and being a trained pediatrician, she was the natural go-to
person as cases of AIDS began to be reported in children in the early 1980s.
And she rode that role for the rest of her career at CDC, and afterwards. She was -- she led major research efforts out
of CDC to define the transmission rate to children, to identify risk factors for transmission to children, to identify
ways of testing *** in young babies, as well as led the policy-making efforts to take the research findings and the
things that we were discovering through epidemiologic work, and make -- and listen to both the research, but also the
community that was being affected by the AIDS epidemic in children, and coming up with scientifically excellent,
practical, and community sensitive guidelines on how to deal with such difficult issues as testing back when -- back
when it was not so easy to get an *** test, and when stigma was much more of an outcome that one might expect from an
*** test than treatment and care.
She also led the effort at CDC following the 076 trial that we'll hear a little bit about, helping to set up the early
surveillance systems for pediatric AIDS in the United States, and really was CDC's face of pediatric AIDS. She's now
retired from CDC and is now at the Taskforce for Child Survival as their ***/AIDS lead and also is a clinical professor
at Emory and directing the Lillian Carter Center for International Nursing.
She also continues to help the CDC ***/AIDS efforts' scientific excellence by being a reviewer of manuscripts, the
untold quality control system of CDC.
Our second speaker is Elaine Abrams. Elaine is a longstanding leader both in the United States and globally as a -- the
wonderful combination of clinician, researcher, and developer of cutting edge programs. She's as comfortable I think in
clinics in Harlem as she is in Swaziland and is comfortable leading the scientific groups of the NIH's research
consortium as she is at the WHO in Geneva advising on policy. She's taken her experience from the front lines and from
the research, and really made a huge difference in the lives of children.
She began her career in Harlem starting a family care center there that helped children and families with *** infection,
and grew an academic career at the Columbia College of Physicians and Surgeons at the Mailman School of Public Health,
where she's now a professor of pediatrics and epidemiology there.
She was the original brain child behind the MTCT plus program which moved -- began early on, moving the agenda from just
preventing transmission of *** to children to making it a care and treatment issue of mothers, of children, and of
families. And we're seeing that clearly as the way the response is going ever since.
She continues to be a scientific leader, being the head of some of the research committees and the impact network, and I
think her official title is the senior director for research in the MTCT plus initiative at the National Center for AIDS
Treatment and Care program at Columbia, known as ICAP --
Our third and final speaker is Dr. Chewe Luo who, like Dr. Abrams, has combined a frontline clinical career with a
research career and then more recently being more heavily into the policy and coordination and global scene. She's a
native Zambian, and did practice pediatrics in both Zambia and in the UK before starting to work with UNICEF, where
she's been for the past -- well, I can't say how many years, because that might start to give away people's age. I
promised not to use years anymore.
She -- maybe I'm worried about my own age, I don't know. Anyway, she started -- she's worked in a number of positions
in UNICEF as the country advisor in Botswana for ***/AIDS when Botswana was scaling up their PMTCT program; was the
regional advisor for the eastern central Africa -- eastern southern Africa based in Nairobi, and more recently she's
been in UNICEF headquarters in New York City, where she's the senior advisor for ***/AIDS, and in that role is
responsible for overseeing the technical aspects of the mother-to-child prevention programs, but also the pediatric care
and treatment, adolescent prevention, and treatment and care of orphans and vulnerable children.
So I'm going to stop talking and allow our panelists to talk, but I did want to provide you with some of their
backgrounds so that you know that these are not just talking heads but these are real people who love children and have
devoted their career to the issue that we're going to be discussing today.
So without any further ado, I'll ask Dr. Rogers to take the podium and tell us about the early years.
>> Dr. Rogers: I'm not sure why he's making such a big deal of age, but maybe I'll tell you mine pretty soon.
Could I have the first slide. Let me start by thanking the organizers for inviting me to share with you the history of
the public health efforts to understand and control the *** epidemic in children.
Thinking about how it was 20 to 30 years ago is a challenge, and I have to say really stretched my memory. So let me
apologize at the outset if I fail to remember some things correctly or omit things that some of you may think are
important. For the epidemiologists in the audience, this is a case of severe recall bias.
Let me start my presentation with this single slide. This one depicting the epidemic curve of pediatric AIDS in the
United States. This slide shows the rapid rise in the number of cases,
followed by the rapid fall with the epidemic coming under control.
As you can see from the slide, pediatric *** disease has nearly been eliminated in the U.S. The pediatric epidemic
still ranks as one of the most important battles won in the struggle against ***/AIDS.
And you'll hear that story told here today.
But let me pose a premise. That although children represent only a small fraction of the worldwide epidemic, the study
of pediatric *** has provided some of the most important research and undergirds our prevention efforts not only in
children, but also in adults. I'll return to this premise later in my talk, but let me begin at the beginning.
In 1981, the year that the first cases of what would later be known as AIDS were reported, I was a newly minted 30 year
old pediatrician -- do the math, and you can figure my age -- beginning work at CDC.
I was sure that I had the coolest job on earth, that is, an epidemics intelligence officer. I was sent to New York City
for three weeks along with two other EIS officer to interview all the known living AIDS cases at the time for the first
major case control study.
I met Polly Thomas, the EIS officer who was assigned to the New York City Department of Health, who would later become
my partner in the investigation of the pediatric component of the epidemic. But that was later to come. The first
cases in children had yet to be reported at this time.
That early classic case control study went on to show that the most likely cause of this mysterious new disease was an
infectious agent passed by *** contact, and was passing rapidly through the *** networks of young gay men.
We would later learn of the possible bloodborne route of transmission when intravenous drug users began to also show
similar signs of the illness. Still, at this point no cases in children had been reported. And since I was a
pediatrician, I was sent off to do work in other pediatric epidemics.
I was later called back to the AIDS scene in 1982 by my soon to become mentors, Jim Curran and Harold Jaffe, when the
first cases in children began to be reported. I quickly reconnected with Polly Thomas, and we established the
surveillance system for children and began canvassing the New York City hospitals for cases of pediatric *** disease.
This led us to Harlem Hospital, where Elaine Abrams was also a newly-minted pediatrician. So you can do the math on her
age, too, probably. Unlike Polly and I, Elaine was on the front lines, seeing case after case of babies being admitted
with pneumocystis carinii pneumonia, and often dying within the first few hours of their hospital admission.
Scientists began to speculate on how children were getting infected, since they were obviously not sexually active. The
mothers of children were generally not sick, but usually came from households where someone else was sick, often the father.
So the first hypothesis was the children were getting the disease from having close contact with sick household
relatives. This concern led to much of the hysteria within the public that the deadly disease could be transmitted by
close contact. And so began the discrimination and stigma that remains a hallmark of *** epidemic, even today.
Fortunately, by 1984, clever laboratorians had discovered the causative agent of this new syndrome, what would later
become called human immunodeficiency virus, or ***. We also had lab tests for antibodies to the virus, and could
identify those infected before they came down with the disease.
So Polly and I began to partner with clinicians like Elaine to establish the first cohort study of pregnant women
infected with ***. This study clearly indicated that the main mode of transmission to children was vertical
transmission from their mothers.
We also realized that not all children born to these women, however, became infected. Some remaining well and losing
their maternal antibody after about one year of age. However, since all infants were born with *** antibodies passively
transferred from their mothers, we couldn't tell which infants were going to be infected until they actually came down
with the disease. We needed a better test.
Turns out the labs working on *** at CDC were housed right next door to the epidemiologists just down the hallway,
meaning that epidemiologists like me often came into contact with our fellow virologists meeting in the hallways. Just
such an occurrence happened to me as I met then head of labs, Dr. Gerry Shochetman.
Gerry mentioned to me that a new guy in his lab, Chin-Yeh Ou, was puttering with a new test method called polymerase
chain reaction, or PCR. As he explained the methodology to me, I immediately thought of the problem we were having with
identifying infected infants and arranged for Chin-Yeh to test some of the specimens that Elaine and others had been collecting.
Well, the tests worked, and now the method of amplifying viral DNA known as PCR is the mainstay of infant diagnosis,
allowing pediatricians to identify infants before they become sick and treating them with life-saving antiretroviral
drugs, allowing them to lead a relatively normal life.
But at this point in the late 1980s, ARVs had yet to be discovered. And we still could do very little for the infants
and children, or their mothers. Meanwhile, hysteria ran rampant in the United States. Children with *** were being
denied entry into school. The most famous case being young Ryan White, who was expelled from his middle school because
of fear of contagion. Something had to be done.
I was assigned to work with Jerry Fried on his team at Montefiore Hospital in the Bronx to investigate whether or not
*** could be transmitted through so-called casual contact, that is, living in the same household as another individual with AIDS.
Our study clearly showed that the virus was not transmitted by casual contact. Despite this find, people with AIDS were
still suffering from stigma and discrimination. We needed more evidence.
We got the idea to further this work on casual transmission by looking at households in which the only infected person
was a young child. So we investigated these families, showing again that even young children, with all of their
drooling and diapers and vomiting, did not transmit the virus to their caretakers or other siblings.
These studies served as the evidence behind later legal action to end discrimination through laws such as the Americans
with Disabilities Act, and served as the basis for CDC guidelines for school attendance by children with ***, and for
adults in workplace. We could finally say yes, it was safe for these children to attend school, and yes, it was safe
for adults to be in the workplace.
Now, let me return to my story of the epidemic in mothers and children. Having established that children were mainly
getting infected through vertical transmission, we began to mull over the possible prevention methods.
This turned out -- this turned out to lead us down a very controversial road. Our first thought was to test all
pregnant women to find out which ones were infected, letting them know about their status so they could take measures to
prevent spreading the virus to their *** partners, and so they could make more informed choices about having
children. Seems like a rational approach. This brought us squarely into the sights of AIDS activist groups who were
advocating against the widespread use of the *** test. At this time there were no ARVs, so little could be done for
people who were detected as having the virus.
AIDS activists were concerned, rightly so, about the tests being used for discriminatory actions. So after a lot of
perseverance, and seemingly endless meetings, we published the first guidelines on the perinatal prevention of *** in
1995, recommending voluntary counseling and testing of pregnant women who were at high risk for the disease.
These guidelines were also the first to recommend against breastfeeding. By this time the evidence for breastfeeding as
a mode of perinatal transmission was limited to the recent isolation of *** from breast milk in one laboratory, and a
case report of a woman who acquired *** from a postpartum blood transfusion and later went on to breast feed her child.
That woman was Elizabeth Glaser, who later went on to found one of the most influential nonprofit organizations to
advocate for pediatric *** disease. And RJ now works for them.
Although undoubtedly some children's lives were saved with the breastfeeding recommendation you can see by the epidemic
curve that these guidelines did little to stem the tide of pediatric ***. It was not until the discovery of the first
ARV, zidovudine or AZT, that things began to look up. With the publication of the results in 1994 of a remarkable
clinical trial of AZT used during pregnancy, the tide of AIDS in children finally began to turn.
CDC now had a highly effective prevention tool, and overwhelming evidence now to be able to recommend routine voluntary
*** counseling and testing for all pregnant women, followed by AZT prophylaxis or treatment for those who were found to
be infected. The end of that chapter in that story is evident in the rapidly falling incidence of pediatric AIDS, as
you can see on the slide. But I will leave the details of that story to the next speaker.
I would like to close my remarks with a bit of pride not so much for myself, but for the pediatric *** community.
Researchers, clinicians, public health practitioners, patients, and their families.
Let me return to the premise I started with. Research with and by this community provided the basis for almost all of
our most effective biomedical prevention tools that we have today. The concept that *** infection could be prevented by
ARV prophylaxis is the basis of many of our infected -- our effective interventions today.
Studies in children also provide an indisputable evidence that *** could not be transmitted casually, allowing people
living with *** to lead everyday lives without the possibility of discrimination.
Even in American society, which at that time was highly homophobic, with disdain for other *** high-risk groups such as
gay men and IV drug users, could not turn their hearts and minds against the children who were suffering with this
terrible disease. And this gave us a foot in the door to be able to fight against the stigma and discrimination that
rained down upon all of those who were affected. I was very proud to have been part of that good fight. (Applause.)
>> Dr. Simonds: Thank you very much, Martha, and thank you for that segue into Dr. Abrams' talk on what happened next in the U.S.
>> Dr. Abrams: That was hard to follow Martha. But I'm also delighted to be here, and very proud to be able to say
that as part of this enormous public health success in seeing the curve that Martha had up in her slide, I also think I
have the distinction of having been in the field for so many years that I actually know all of the CDC project officers
who were in charge of the mother-child transmission study. And many of them are in various places in the world today,
and I feel as though I trained them from my spot in Harlem.
Last week, as I was driving to work every day or maybe driving home, Public Radio Station had a lot of aging *** experts
telling their stories of where they were 30 years ago, and what it was like. And it certainly made me think back, as
well, to those very bleak days, which we were caring for many dying children, and dying women, as well. And how
wonderful it is to now have a clinic filled with adolescents. It's not so wonderful to have adolescents all the time,
but it certainly is a tribute to the successes.
So how did we get to where we are from those 1994, even a little earlier, when AZT was introduced? The achievements are
really profound, and I think it's worthy of reflection of ongoing reflection of how this happened.
So I'd start by saying that first and foremost it's all about the drugs. Drug discovery, finding medications that
effectively stop viral replication, and block viral entry, is really the axis on which all of this hangs. And I think
as Martha pointed out, before drugs we really didn't have much that we could do. We could identify, we could
understand, but we couldn't do.
And the discovery of AZT in particular as a drug that could improve health and reduce viral -- reduce the risk of ***
infection to the baby was truly transformative. And then over time, we learned that AZT was good, but more was better.
As drug regimens for PMTCT became more potent, we saw a concomitant drop in transmission rates among women receiving
these treatments. And this is a frequently shown figure from the women-infant-child transmission -- no, it's the
women-infant transmission study, it should be WITS which was the actual competing NIH study of mother-to-child
transmission that we were always sort of battling with for fame and fortune. But together, those two studies really
painted the picture of mother-to-child transmission in the U.S.
So the slide depicts data from this study demonstrating that MTCT rates by year of enrollment, starting in 1990 through
2003, and by maternal ARV regimen. And you can see starting in the early 1900s, pregnant women weren't receiving any
ART. AZT was introduced, that quickly went to dual therapy, often AZT and 3-TC, and clearly by 2001, 2002, most women
in the study were receiving combination therapy with HART.
The orange line depicts transmission rates, you can see a dramatic drop with the introduction of monotherapy in 93-94,
and then a slow drop over time, as the regimens became more potent and more complex.
Well, it's not really just about the drugs. There's a long list of critical scientific discoveries and technological
advances that propelled efforts to successfully reduce MTCT rates.
This is a short list of just some of the ones that came to mind as I was thinking about this, and I have to confess that
I have a little date memory problem, as well, and you'll see TCR here, which is clearly before my time of discussion.
So new drugs were identified. Efficacy, safety in dosing were determined, including for pregnant women and for infants.
By 1999 there was good evidence that elective cesarean section prior to the onset of active labor could be protective to
the baby and safe for the mother. And there were fantastic advances in laboratory science, which brought us more
accurate, faster ways to diagnose *** infection and monitor *** disease progression efficacy.
And ironically, I also remember quite well collecting bloods and spinning them in this little teeny lab in the pediatric
floor of Harlem for those first studies of DNA PCR. And Dr. Rogers authored one of the first papers demonstrating that
DNA PCR could be used to diagnose infant infection. And it was really a major breakthrough. There are also the studies
that I just talked about that define rates, risks, timing of MTCT, as well as the natural history of *** in pregnancy
and during childhood. And these were really quite important in helping us figure out what needed to be done.
But if it was only about drugs and lab tests, we wouldn't be here today celebrating the accomplishments in this arena.
It was anything but. There were, and have been, an extraordinary set of circumstances that have ensured that these
clinical trial and laboratory discoveries were successfully transformed into achievements in the field.
First, scientists, clinicians, public health officials, community and government, successfully collaborated to address
this public health threat, working together to achieve a common goal. And in the case PMTCT, a collectively embracing
and addressing the complex health as well as psychosocial needs of very disenfranchised poor women of color and their
families living with a highly stigmatized disease.
We were fortunate to have the development, publication and frequent updating of national guidelines for PMTCT that were
often echoed through state and local agencies, bringing together world experts in these areas, and incorporating new
findings in science as well as field experience.
Guidelines were supported by regulation, legislation, and funding initiatives. For example, in New York State, ***
counseling during pregnancy became mandatory, as well as *** testing of newborns of women of undocumented status. There
was a clearly recognition that knowing *** status was the critical piece of health information that a woman needed to
know to make decisions about her own health and the health of her baby.
It should also be emphasized that there's an extraordinary component of the synergy with the unprecedented funding for
health services for poor people living with ***. Through the Ryan White Care Act and other federal and local
government-sponsored programs, PMTCT services for *** infected pregnant women and children were provided generally free
of charge in most parts of the country. And in New York where I work, *** services were almost entirely free, and
women, pregnant women, were never -- were always able to obtain PMTCT services.
Finally, surveillance systems were put in place, including enhanced perinatal surveillance that served to evaluate
perinatal prevention efforts and monitor implementation of the guidelines.
Many states instituted programs to assess service delivery, and to use data to inform program improvement.
And finally, we have to take into account the courage and the willingness of all pregnant women living with *** who
engaged in PMTCT services.
And our attention to PMTCT is somewhat similar. We've put in place a very effective, comprehensive safety net of
different interventions, services, policies and funding which have been highly effective in reducing mother-to-child
transmission and engaging women and families in *** services.
And the second we take our eye off the ball, or stop paying attention to one component, we're likely to get a rebound
effect similar to what happens when you stop your drugs.
There are new challenges ahead, particularly around pregnancy and youth, among youth living with ***. And until we can
effectively prevent new infections in women, we'll need to remain vigilant and committed to our efforts to continue
PMTCT services for every woman living with ***.
Each new infection at this point in a child, each new *** infection, is a PMTCT failure, and it may be fair soon to say
that each new infection in a woman is a prevention failure. So I look forward to the discussion ahead, and thanks. (Applause.)
>> Dr. Simonds: Thank you very much, Dr. Abrams, for your review of the United States post-076 story, and now we'll
have our third and final speaker, Dr. Chewe Luo, to talk about the global scene.
>> Dr. Luo: Thank you, RJ. It's been a long road, Elaine, but coming from Zambia, I just want to say it's been a
wonderful partnership of what a north and south collaboration could be on a very important issue that affects children worldwide.
I just wanted to highlight in this slide, which is very crowded, the body of evidence that we have around
mother-to-child transmission. But just to say that if you look at this slide, and there are many more studies, no
doubt, a lot of what I've highlighted here are studies that have happened in low and middle income countries. And what
I want to emphasize probably the untold story is the amount of capacity development that has underpinned a lot of the
evidence and generation that we have today.
I just want to give my own personal story. When the PATCG076 results were actually released, I was working in our
largest pediatric unit in Zambia. We had already started seeing a lot of babies coming to us and dying of pneumonia,
diarrheal disease, failing to thrive. It was horrific, and for me, maybe I stand here today working in policy and
strategy formulation with governments because it was very difficult as a pediatrician being at the receiving end of
these babies, not being able to actually make the noises that we needed for us to be part of the response.
But the issue was -- and at the time when all this was happening, actually my sister was the minister of health in
Zambia. And I went to her and said, look, we have to do something. And she said to me, look, if I can't give folate
micronutrients to pregnant women, how are we ever going to test women, how are we ever going to give these drugs. And
you're saying that you have to also give them during labor intravenously? How are we ever going to do that?
The other issue that was raised at the time, $1,000 per woman treatment. How are we ever going to get that type of
money, when Zambia doesn't even give $12 for health for anybody in Zambia. It was depressing, and we were all very
desperate. But I just want to highlight the game changers for us was moving on from PACTG, we heard results of the
Bangkok study, Thai, Nathan Shaffer released the results, 50 percent reduction in transmission, $50 per woman treated.
We were starting to see some hope and some light, and we followed the science very carefully. There was myself in
Zambia, Ruth Nduati in Kenya, Phillip Musoke in Uganda. I can talk to my friends who were talking about this.
And it was not until we had the HIVNET 012 study results that all of us actually said we can shift this, we can move
this. And it was at the global strategies meeting in Montreal, I think it was, where we came up with a call to action
to say we have to go back and push for this to happen in our countries.
This slide illustrates some of the results. But again, I just want to talk about, again, the collaborative effort that
has happened between the scientists in the north, scientists in the south. We have a family more or less around this.
Led by WHO, we've been able to quickly translate some of these results into guidance for global action, and Elaine
sitting here is a member of that group.
We have Lynne Mofenson who very actively gives us all information in a timely manner, and we're able to actually
generate these responses very quickly for countries actually to respond.
And so today we can talk about elimination, because the science is clear, that if we all redouble our efforts we can get
to what the western world has actually achieved.
So what about the response, what actually happened. I just want to talk to three phases, and for me, what I saw sitting
in Zambia is that the first phase was really the pilot phase. There was a big question around is it even possible,
should we be testing out feasibility of integrating these interventions in our maternal child health units? That was
quickly followed up by scaling up around 2004, and now we have a call to elimination of mother-to-child transmission globally.
I just want to talk a little bit about what happened with the pilot projects. I think following the release of the
HIVNET 012, the UN, UN SPA, UN AIDS, WHO, actually came together and formed the interagency task team to actually
oversee implementation, and 11 pilot projects were actually initiated across the regions globally.
I was sitting in Zambia and working through my Ph.D., which was actually on PMTCT, trying to answer the question of the
determinants for transmission, but also looking at what would be some of the cost-effective interventions that we could
already start looking at. Richard Semba had actually released a study that looked at the association of vitamin A
deficiency and mother-to-child transmission, and for us we are saying maybe this is the magic bullet, we should try out
vitamin A. And as we all know, that didn't prove to be effective in the end.
But UNICEF at the time I was working at the teaching hospital asked me whether I could lead the effort in Zambia to
start thinking about feasibility, they had resources for us to set up the pilot project in Zambia. So I became the
coordinator of our own effort in Zambia, started looking at rural hospitals, clinics, to try and test the hypothesis
that it could be done.
Just to say that in 2003 there was an evaluation that was conducted by Population Council, and the conclusions of that
evaluation was that it is feasible to do this in the developing world.
So following that, there was an active momentum. We did expand our interagency task team from being a UN body to a much
broader body of partners that were all rallying behind the effort in developing countries. And I just want to say a lot
of this was also driven by the push by PEPFA to actually put resources behind this. And you can see a lot of the
partners now on the interagency tasks, they were actually PEPFA funded.
The high level global partners forum in 2005 looking at what was happening, in countries some of the results we were
starting to see. At that point in Abuja we came together as implementers and actually said we have to move more towards
an *** and AIDS free generation of children. And there was the ministries of health actually endorsed this, and that
gave us the momentum to actually move forward with rapid scaleup of some of these programs.
And the interagency task team was behind a lot of the training, developing, monitoring and evaluation instruments, we
were going into the countries to support governments to think through what they needed to do. CDC was instrumental in
coming up with generic training materials that really transformed support to countries in terms of developing capacity
of the frontline workers that deliver on these interventions.
Just to say -- and I'll close shortly -- this is a slide from 2009 from our universal access report. We are very
encouraged, and continue to rally behind the fact that it can be done if we all put our effort behind it. It's not easy.
These results in 2009 showing that 53 percent of women in low and middle income countries were receiving at that time
some form of ARV for mother-to-child transmission is encouraging. It's encouraging to note that the most affected
region, eastern and southern Africa, has up to 68 percent of women actually getting some antiretrovirals. And sadly,
though, I think we need to look at what's going on in west and central Africa. A lot of the central African countries
are either fragile states or they're in some type of conflict. Health systems are a lot weaker than what you see in
eastern and southern Africa, Asia, and other places. And it's not surprising that we have such low levels of coverage.
But the commitment there also needs to be much more than it is at the moment.
So the global community now are rallying behind elimination, I think RJ talked about that. But I just want to end by
saying it hasn't been easy. A lot of the people in this room work in Africa, they work in Asia. The systems are not as
strong as they should be. Trying to deliver this intervention on the maternal child health newborn platform is very,
very difficult. And what I have on that slide is just the level of coverage of some of the elements within that.
We know globally that 6 to 7 percent of women access one antenatal clinic, antenatal visit, but when you look at four
visits, it's much lower, it's about 48 percent of women that come to facilities or are assisted during delivery. And we
know that some of the follow-up interventions like breastfeeding are still very, very weak.
So the issue of trying to broaden this and taking *** out of isolation and making sure that we have a much bigger
portfolio that starts to address maternal and child health services, and the refocus on reducing maternal mortality is
where this debate has to go in the developing world.
Human capital is a problem, and we have to find innovative ways of making sure that women are assisted and that services
are delivered. In Malawi, for instance, most of their rural health clinics are not manned by any health -- trained
health professional, so how on earth do we hope to get to that last mile in a country like Malawi to deliver this? But
what is Malawi doing is that they are investing in community health workers.
So are we ready as a global community to allow those cadres of people to be able to deliver on this intervention? The
policy dialogue on this is not always easy.
The low coverage of antenatal services and access means that the loss to follow-up is a major issue. So as we talk
about 53 percent coverage, do we know what that means in terms of the follow-through of those interventions.
Financing is going to remain a challenge. Funding has flatlined, and we are aware of that, how do we buy more for the
dollars that we're putting out there. So part of what we have to do as part of this debate is allocative efficiencies
and questioning ourselves over and over with are we putting our investments in the right interventions. Thanks. (Applause.)
>> Dr. Simonds: Thank you very much very, Dr. Luo, for your observations on the global scene, and to all the speakers
for sharing your experiences and your vision for the future with us.
We're starting into the question and answer period, so I hope you've been thinking about your questions, and will come
-- and will not hesitate to come to the microphone and ask them.
I think we have our first volunteer, but that should not --
>> I won't take that many. I'm (inaudible), I have the privilege of old age, I think I'm the oldest one here who has
been with AIDS even before Martha. Because of the fact that one of my fellows, Jim Oleski, invited me in New Jersey
where I saw the first case, and then we found our first case in 83, with a brother having died of AIDS earlier, and our
clinics in 83, 84, that's Steve Meshman. So other privileges, we are in Atlanta, Georgia. You know, we're not at CDC.
And I just want to say I'm an EIS officer since 58, okay? So I love CDC.
But I would want to share with you what we have done here with the many people here from Emory and Grady, Mike and
Jackie and Steve and so forth, what we tried to do here, and what we've achieved or not achieved.
So in 83, first clinic, 84. We find the first *** in the world year in Zaire in 1959, so this is 52 years. And if you
want to say 30, you should leave out the ***. Because AIDS was only 81.
Then we went on to be on the -- start the AIDS taskforce in Georgia, the second one in the country. We went to the
pediatric redbook, tried to stimulate them, they were all involved with Haemophilus vaccine, not AIDS, at the time.
In 85 we went to the first AIDS meeting. And I bet, Dr. Chewe, you don't know where the first AIDS in Africa meeting.
I was at yours in Zambia in 2000.
>> Dr. Luo: Right.
>> Do you know where the first one was? In Brussels in 1985.
>> Dr. Luo: Right.
>> In 87, we had -- sorry, in 85 we developed the first international disciplinary AIDS foundation in Geneva, the Prague
WHO was doing nothing. In 87 we had the first International Conference on AIDS in children, adolescents, and
heterosexual adults that some of the people here have been to, and about 700 people, and it was published and so on.
In 87 -- in 86, we had gotten the first AIDS drug, among the first four or so, AIDS drug trials, where the thing they
did not fund was combination therapy. We funded the other projects. And that goes to show how stupid people can be on
the review boards. But that led eventually, one of my fellows and now professor in pediatrics, Ray Schinazi, to develop
two of the drugs, 3TC, and the last one, which is part of trivor, whatever it's called. He claims that 80 percent of
the world are using it, it may be 50 percent, but that is a big plus for the drugs.
Then we went to Sweden to learn the early spot, which was a way to diagnose the babies, because by Liza you couldn't,
but spots you could tell the cells that the baby had.
And then with Chedi, at CDC we compared it, and by three months it was as good, but PCR was better at one month.
So we tried to do that.
Anyway, I will leave, then, to Steve Meshran, because he took over the -- he was a fellow with me in, what, 93 to 95, or
something like that. Anyway, then he came back in 98 or 9. And by that time, remember in our international thing we
already were pushing for adolescence, and we were always concerned. And we have now I believe one of the most -- the
greatest number of adolescents in the adolescent clinic at (indiscernible) where Jackie *** and Steve was, but Jackie
is still here. So we have a big clinic, still very active, and now we're seeing the children have grown and the
adolescents coming in fresh. And we are actively trying to work with that group, which is now at least in developed
countries the most important one, as we have done yet.
And finally -- as you can see, I'm pretty passionate in my old days -- finally, my passion went to a play that was made
in -- play cantatas, some of you have heard it, called about children of AIDS. The grief and the promise.
There's no question all of us here grieved when there were kids and we couldn't do anything about. Except stick needles
and kept the developed kids -- countries, you know, suffering from all the drugs we're using, and eventually they would
die. While the others would die earlier. But still.
So the grief was there, and is still there. And it's very important to of course go with a global program, and make
sure, make sure, that when we treat -- prevent a mother from passing on the agent, that we treat the mother and whoever
the male partner is, who is economically the one.
Otherwise, we're going to continue to have AIDS orphans. And I haven't heard a word about AIDS orphans, so could you
fill us in as to where we stand with that, RJ? And Steve might fill you in, from 89 on.
>> Dr. Simonds: Thank you very much Dr. Namis, for your frank and hard-hitting comments as usual, we wouldn't expect
anything else but that from you. And also for bringing the story back home to Atlanta and to the important role that
Atlanta has played even outside of CDC's role in fighting the epidemic. Maybe I'll ask -- you specifically wanted some
comments on orphans and where we are with that, and I thing I'll ask Luo --
>> -- preventing more orphans.
>> Dr. Simonds: Maybe ask Dr. Luo to address that.
>>Dr. Luo: Thank you, I think that's an important question. UNICEF does work on this issue. And as we do well in
treatment, we hope that the burden of orphaning -- this is the unspoken problem, because all of us for some reason are
pushing *** making sure that people get on to treatment. And there's a very narrow constituency of people trying to
work on orphans and vulnerable children, and many times it's nongovernment organizations, international and national,
that are trying to respond.
But in terms of numbers, we do on a regular basis model based on the epidemic, and based on what's happening in terms of
the response. We tried to calculate how many orphans out there actually coming out -- I mean occurring as a result of ***.
And the sad thing --
>> (Inaudible)
>> Dr. Luo: Yes, I'm actually coming to that, sorry I'm going around the bush, here. But the recent number is actually
16 million. 16 million.
>> 16?
>> 16, and 80 percent of those are in Africa. 1-6. So it might surprise you, but it doesn't -- it shouldn't, because
as we do better and make children live, even those that are infected, we will continue to have these children whose
parents would have died, who actually feed into that pool of orphaning. We hope that as we do well on treatment, as we
put more mothers on treatment, that we will reduce the burden of orphaning. I think epidemiologists maybe can help me
here, but I don't think we expect this number of children to go away soon.
I think the children will continue to be there for the long term.
>> -- role the most prominent role (inaudible) drugs.
>> Dr. Luo: Exactly.
>> And then becoming vulnerable (inaudible)
>> Dr. Luo: Exactly.
>> Dr. Simonds: Thank you, very important issue to track. Dr. Rogers, would you like to make a ---
>> Dr. Rogers: Yeah. I'd like to, as expert on how it was, I'm glad Andy brought up the effort here in Atlanta.
Because if my memory serves me well, I think Grady Hospital was actually one of the first institutions to begin routine
testing of pregnant women way back in like --
>> (Inaudible) seven.
>> Dr. Rogers: Yeah, really early. It was very, very controversial, and most other hospitals were afraid to go that
route, but they were very brave here and actually took that very important stand. I think very early on, and showed us
that in fact the world wasn't going to come to an end if you tested pregnant women. It was actually the right thing to
do. And so thanks for bringing up the group here. (Applause.)
>> Dr. Simonds: Very good. Thank you.
>> If you wouldn't mind introducing yourself.
>> Oh yeah, sure. My name is Madison, I'm a health writer from CNN. And I was just wondering, I have a two part-er
question for you. Sorry, this is very rudimentary for all the scientists. Basically I wanted to know are all pregnant
women in the United States, are they all screened for *** when they're pregnant? And the second part-er is -- let's
see, are there still cases of babies being born with *** through perinatal infection in the U.S., and if so, even if the
numbers are -- you know, pretty low, why or how does that still occur?
>> Dr. Simonds: Elaine, would you -- that's two questions. One, are all women screened for *** during pregnancy? And
two, are there still cases of *** infection in children born --
>> Yeah.
>> Dr. Simonds: And if, so why.
>> Dr. Abrams: Probably better to answer the second question. It's recommended that all women be tested during
pregnancy as a standard part of care. Do all women get tested? It varies. With where you live, whether you obtain
prenatal care, and the resources, local resources for testing.
And probably somebody from the CDC could talk about -- okay.
>> Yeah, I'm not going to give a history from 89 to the present.
>> Dr. Abrams: Just in terms of the second question, which is -- I could answer easily, that there are new infections
that occur; they're rare. And we would estimate in the hundreds, probably. And again, the experts with numbers would
give you better numbers. And they're considered PMTCT failures, and I think there are -- I can speak specifically to
New York State, where we're seeing women who were infected late in pregnancy, and not necessarily identified. So might
have a negative test early in pregnancy, and not repeat testing. Women who become infected perhaps acutely during breastfeeding.
And women who have not accessed antenatal services for a variety of reasons ranging from costs to perhaps substance use.
So those are the primary reasons, but I was just -- with a colleague from New Hampshire who said they had their first
case -- their first infection in four years in the state last December.
>> I'm Steve Messime from CDC. The last sentence you said, a lot of clinicians will say it's been several years since
their last transmission. There still are transmissions every year. It's been reduced about 90 percent, 90 plus percent
since its peak. There still are transmissions. Probably most of them are traced back to the women not being tested
while pregnant, even though it's been our policy to recommend all women to be tested for a long time now. Their rates
of testing in some of the states are rather uneven; it's very in high in some states where it's required,
or where it's more or less required.
Overall, though it's on the order of maybe three-quarters that are being tested, if you could average the rate of tests.
So that is probably the basic reason why they miss chances for interventions. They also might breastfeed later, that
kind of thing. So testing is the main one.
>> Dr. Simonds: Thank you. Dr. Mermin.
>> Hello, I'm Jonathan Mermin with the division of ***/AIDS at CDC.
First, thank you all for coming and giving such wonderful presentations.
I was really struck by how much you highlighted that knowing what to do doesn't always mean that we get it done. And in
the current age we have some constraints that seem to be different to some extent domestically in the U.S. and overseas.
So for example, we do have strong guidance that indicates that not only all women should be screened for *** during
pregnancy, but also that they should all receive antiretroviral therapy.
And yet overseas, based on both WHO and other normative agency guidance, but also country guidance, there's been a
decision implicitly made by some of the ministries of health to both reduce the CD4 count level, which would indicate
antiretroviral therapy for all adults, but also for pregnant women. And I'm wondering as the resources are leveling
off, what kind of discussions are happening internationally, particularly in Africa, about balancing the availability of
antiretroviral therapy for pregnant women and for all adults with ***.
>> Dr. Simonds: Thank you, I think I'll ask Chewe to.
>> Dr. Luo: I think this is an important question, and I'm happy that Elaine is also here, because she's part of the
group that develops these guidelines for WHO.
First of all WHO guidance is very much driven by evidence. And as I said in my talk, we have been following up the
scientific evidence very clearly. I've had a one-to-one discussion with Lynne Mofenson and myself to say why is it that
in the U.S. have decided to go in this direction of triple ARVs for all pregnant women. Because when we review the
literature, and you've been part of the generation of the literature, CDC has done several studies on this issue, we do
come to the balance of thought that for women with higher CD 4s, actually given the intervention that we now say option
A, which is an AZT backbone with nevirapine at delivery, with a tail for baby -- for mother, and then extended
nevirapine therapy for baby, could achieve as good a result as giving triple therapy to mothers through breastfeeding.
There are operational challenges, of course, for both regimens. CD4 continues to be a barrier.
I go to these facilities, I just came back from Zambia, I was in a rural district court, Chama, and I spent some time
with a laboratory technician at one of the clinics and I asked her one question. What -- if you had to tell me what
your one wish is for PMTCT in this clinic, would be from your perspective as a laboratory person, what would that be.
She told me point of care CD4.
So one of the challenges is that as we develop these guidelines, the operational implications of what we are saying in
those guidelines has to be considered.
So am I saying that we should then give triple therapy? No, I'm saying we have to find ways of supporting programs for
them to be able to deliver on what we're asking them to do.
Equally, in the same locality I went to another clinic that had no lab. So I asked them, so these are the guidelines
and Zambia has done very well in translating, and I said so what do you do when women come in, when do you start the
drugs? We encourage them to go and have a CD4 test. They have no car at the clinic that can transport these mothers to
the nearest place, where they don't have any system in place to actually do a CD4.
So you can imagine then what's happening to those mothers in those -- it means that they're all getting one standard,
which probably is suboptimal for women.
When you look at triple therapy, I think we -- I've come to an understanding that in America you have a patient-centered
care. What we're talking about in a lot of these localities is a public health approach. That you would apply as a standard.
Now, equally, there are challenges in delivering three drugs to a woman. And from what Elaine just said at the end of
her talk, around stopping treatment and restarting and the issues around that, equally, trying to do this for all women
that don't need treatment now would be extremely challenging in developing countries.
But there are activists out there that are pushing us hard to have an equal standard between the north, and I think it's
important for all of us to be part of that conversation.
The latest publication of treatment, the HPTN 56, I think -- 52? I think it's equally pushing us harder to think about
how we use the PMTCT platform as prevention. And so there will be some discussions around this, I'm sure. And I think
the debate is going to move to let's treat all women with three drugs, because there are benefits for that.
But I don't think we're at the stage right now to make any recommendation on this, based on the evidence that we have.
I don't know, Elaine, whether you want to --
>> Dr. Abrams: I want to answer the question a little differently, because I'm not sure -- I think part of what you're
asking was the change from 200 to 350. I'm meaning --
>> Cost implication, yeah.
>> Dr. Abrams: -- more women eligible for therapeutic ART.
And I think the dialogue has varied by country. And many countries have actually expressed their commitment to this
based on how quickly they've moved.
So the new guidelines for PMTCT came out in 2009. Ethiopia has only just met to revise their guidelines.
And I think from the very beginning, at least the beginning of my experience working in Africa in particular, that there
hasn't been the urgency to address maternal health issues, and particularly the issues of pregnant women, that I think
we had here. That really was part of what propelled the success of our -- of PMTCT. And the same for children.
In Zambia, the last time I was there the guidelines group was meeting, and there was a big question about whether to use
a PI as firstline treatment for all children. And there were huge concerns about costs. And for those of you who
aren't familiar with it, Kaletra is a relatively expensive drug for babies.
But this is in a country that's using Tenofovir for adults as its first line therapy, which is quite costly. And when
you put the cost of adult drugs next to -- you're talking about very few babies who are actually getting treatment. You
begin to say, well, what are we talking about.
And I have -- I think that the specific health needs of pregnant women with ***, and children, have not been center
stage in many places I've worked in.
>> Dr. Simonds: Thank you.
>> (inaudible)
>> I think there are a lot of different needs. There's malaria, there are lots of other health needs,
and there's a long history to this.
>> (inaudible) mother, father and the baby all one --- you can't just --- the baby and not treat the mother and father.
>> Well, you're not going to prevent the baby unless you treat the mother.
>> --- okay and notice -- now orphans, and you (inaudible)
>> Dr. Luo: I just wanted to add to what you're saying. The debates and dialogue around this has been hard. I work
for an organization that looks after children which is UNICEF, and we have a huge focus on child survival as a focus.
When you look at attribution, you look at what's killing children globally. People -- I mean, there's no question that
malaria kills more children. Pneumonia kills more children, diarrheal disease kills more children.
Attribution of *** to mortality in Africa for instance is 8 percent, and it's much lower in many countries.
So depending on where the conversations are, if you're looking at child health specialists in the ministries of health,
they're much more focused on trying to address those other things, and not ***.
And then when you look at who is driving the treatment agenda, it's adult physicians and people who are setting up these
adults clinics. They don't fully understand the needs of children.
And it's only in the last few years, thanks to Elaine and others, that we've started setting up facilities that can
adequately treat children, and these people can now start having a conversation with planners and national governments
to make sure that children are now on the agenda.
It's not all that bad. I think the conversation is going on, but we were late in the game to try and put children on the agenda.
>> Are you saying that we had a Congress who would say why all this (inaudible) AIDS we've got all these (inaudible)
priorities. (Inaudible) because of AIDS it's going to take us -- it's going to take us --
>> Dr. Luo: You're right.
>> I'm sure we have a representative from the --- I know the -- I'm African-American, okay? So I don't understand why
this did not become a priority from the very beginning. Don't you look to the future?
>> Thanks. I think we have time for a couple more questions. Not to dismiss that as a critical issue what the
long-term vision for this has to be. When I said I realized I had a question, I didn't get a chance to answer, but
before I ask it I want to think you all, I know three of you travelled a long way to speak today, and we couldn't have
asked for a better discussion, I just want to offer that. It was terrific. (Applause.)
>> My question is as some of the children, a lot of the children who were born infected of AIDS are well into adulthood
now, I didn't know if you all had any combined wisdom about what their their challenges might bas as far as for the
transmissions or their medical issues the years are going by.
>> Dr. Simonds: Maybe lets take all three of the last questions, then we'll answer them.
>> Mine, Jonathan Mermin again, is really just how do you deal with the prevention paradox, that we've done really well
in reducing perinatal transmission in the United States. So well that there's decreasing attention,
and potentially decreasing resources.
And we are now talking about elimination, and I'm just wondering if that's come up in your work over the past three
decades of working at ***, and do you have any recommendations to people who care about this issue.
>> Dr. Simonds: Thank you, and our final question.
>> Okay, that's quite a series of questions. I guess mine is a little bit more specific, and maybe not within the realm
of pediatrics as much, but what -- my name is Margaret Lanthian at CDC, and my observation is that in projects we're
doing throughout the country, that it's not uncommon that the cases of transmission are often to women who didn't intend
to have the children that they are having.
And in the early days of the epidemic it was a really touchy issue to talk about whether women should or should not be
having children, but I don't see a real concerted effort here to make sure that women can have good solid access to
contraception or family planning or maximizing their family health before getting pregnant. And we have a long ways to
go in working with the infectious diseases physicians here who are working -- who are caring for *** infected women.
I'm just curious if there are actually models from other countries to help integrate that. Because we're very
Balkanized here in this country, in terms of clinical specialties. I'd like your thoughts on that.
>> Dr. Simonds: Okay, so here are some tough ones. Adolescence, family planning.
>> Dr. Abrams: I'll do the adolescents, that's the easy one.
>> Dr. Simonds: The rest of you please chip in, you can chip in your comments on any of these as we wrap up.
>> Dr. Abrams: As I mentioned earlier, clinics are filled with adolescents. A lot of children perinatal disease as
well as youths acquiring *** infection behaviorally. And I think that particularly the children with perinatal
infection have huge challenges. Many of these children have been trying to take medications for their entire lives, and
we're seeing at least in our clinic, and I think everybody is, lots of the youth either beginning to get pregnant,
carrying pregnancies to term, many not. But facing the similar issues around disclosure, around use of contraception.
And I think they're the next great challenge.
There surprisingly haven't been many transmissions among perinatal youth, I actually don't know any that have been in
the literature. But I think everybody is very vigilant about multi-drug resistance, because many of these kids are
living with multi-drug resistance virus.
So that's last piece of this story. Some of them are transitioning into adulthood beautifully, but many of these children aren't,
having lived with this disease and many of the associated issues. Not just about the disease, but impoverished families,
drug use, and such. And I think seeing them all finally transition into successful adulthoods is the last piece.
>> Dr. Luo: I'll start with the prevention paradox, and just I think what's going on in the U.S. is equally going on in
the developing world. And the main reason for that is that a lot of the money that's going into these programs is
actually coming from countries like the U.S., and the conversation that's going on in Congress here has a real bearing
on what happens to PEPFA and the future of that, and the fact that money -- moneys are flatlined in a lot of the countries.
The conversation from where I read it is that the global effort is moving much more towards global health. The
conversations are moving much more towards maternal child health.
And the way things are being discussed at the moment is the whole issue of trying to have better integration alignment
with these other programs, and the idea is that those programs will probably be drawing much more -- much more money
than what we have for ***.
The reality right now, though, is that there's no new money. A lot of people are talking about how do we use the ***
platform to deliver for other things. There have been pledges that have been made, they stock to 40 billion, except
when you actually dissect it, that 40 billion is not money on the table.
So the conversation at least in the global efforts is to have better alignment integration of these programs, so that
you can actually sustain them that way. Hopefully we can also still keep the lens on the results that we've achieved.
On the family planning, we issued a paper at the end of the last year, Mary Mayhe is the lead-off on this, just trying
to unpack elimination, and what to take globally to actually achieve it.
60 percent of the reduction we're talking about, and the global goal is 90 percent reduction, is going to have to do
with providing these drugs efficiently to women. Treatment plus preventive drugs.
Another 16 percent is actually going to have to come from prevention of infection in women as well as family planning.
Now, the response to date has not been to the level that would have wanted it, because the global strategy for PMTCT has
always included family planning. The support for a much more accelerated effort behind this has not always been matched
by the resources that we need. And so hopefully with this new agenda, new platform for elimination, and the new
platform also for focusing much more on strengthening maternal health programs, we can see a real effort behind making
sure that women actually do receive these interventions.
The conversation is around what are we talking about. We're talking about integrating it in all *** programs like VCT,
Era T programs, as well as PMTCT programs. Whether that's going to achieve the results that we need, we have to wait and see.
Family planning is a difficult one, I think. Whether we talk about *** or no ***, it's a very difficult agenda, I think.
I won't try and answer the adolescent issue, because for us we're very scared, especially in Africa, because we don't
have systems to carry through these children. I used to work in a sickle cell clinic in Zambia, and children were
scared to be transitioned to adult clinics, because there was no adolescent care at all. And so we ended up keeping our
children with us until they were ready to go themselves.
So I don't know how we're going to deal with this adolescent issue, but it's something that's coming up and is being
discussed, because I think it's a question of time, we'll have to set up the systems that we need to be able to care
through the children that we'll be saving.
>> Dr. Simonds: Thank you. I hate to leave anybody standing. We do need to wrap up, but I think if we have a quick question.
>> I won't talk as long as that other old person.
>> Dr. Simonds: Thank you.
>> I'm Jackie Nuther from the Grady IDP and I just -- I've been hearing the terminology around adolescence for the last
year as two categories, perinatally infected and behaviorally infected. Well, let's remember that we have kids that are
in neither group. You know who they are? They are those who have been sexually abused by mama's boyfriend or whatever
else. So behaviorally infected I think is kind of a judgmental term that shouldn't be applied, really to anybody,
frankly, because it could be anybody's behavior, and especially with young gay youth or MSMs, they often are taken
advantage of, too.
So I just want to throw that out there, that I think that terminology needs to be revisited a little bit. So we don't judge.
>> Dr. Simonds: Thank you very much. I think the issue of terminology is not a trivial -- is never a trivial issue,
because it really frames how we talk about and look at issues, and I think that's one of the other lessons as we, you
know, roll out an important public health program in the context of a very -- in sensitive and politically charged
issues that we do need to pay attention to language and how we're speaking about them.
Well we've gone over time, which I apologize for. I presume anybody who really wanted to leave earlier, would have. So
I think you're all here as volunteers at this point. But we do need to wrap up. And I think we've heard a couple of
major themes. One, we've had some people who have the ability to reflect on several decades' worth of history to share
those with us, and allow us to think about and revisit some of the issues that are still relevant today, and how they
played out. And then I think we've been challenged by our success to do more, to do things in a better way, and to take
the successes and not only extend them geographically, but programmatically to see how we can build on the successful
approach to preventing children from becoming infected to, as Dr. Nami is reminding us, to keeping their families
healthy and preventing children from becoming orphans.
We have these -- we can build on the programs that we have to do more in these ways.
We've also got challenges, as Dr. Mermin mentioned, about keeping the eye on the ball, and I think needing to be smart,
and figure out how to -- how to keep the engagement with those who make policy decisions, those who make budget
decisions, and keep ahead of them. And I think part of that will be on what we can build and what more things we can
gain on this success and not just keep it walled off as, okay, we've been there, done that, and move on, but to see what
more can we do to build on what we've done already.
So I want to thank everyone for their attention, for coming, and for your questions and engagement. I -- you may have
questions that you didn't want to stand up and ask, and I think if you can catch the audience before -- or the speakers
before they go, they probably would be willing to answer those for you.
So and I want to end by reminding you of two things. One, there are evaluation forms somewhere. They may be -- may
have been on your seats or they may be outside, and maybe someone can tell me where they are.
They're out front. And I know at least some of you are epidemiologists and know the value of data and providing
feedback to programs on how they could do better. So this is the first session of a series of sessions, and your
feedback can help continue to have excellent sessions going forward.
We have I think the next one is next week, Thursday, where we have a Nobel prize winning speaker whose name I can never
pronounce, but I think if you come here she will be able to pronounce it for you.
And I believe that's -- Francois Barre-Sinoussi, they've told me. And she will be speaking on Thursday evening, I
believe, at Emory. And if you need any further information about that, I think the website and that stuff is all outside.
So thank you, everybody, and have a safe drive, and don't get too hot out there.