Interview With Allan Rosenfield, M.D., Dean, Columbia University's Mailman School of Public Health
XV International AIDS Conference
July 14, 2004
This interview is also available in RealPlayer video and Windows Media video formats.
Jackie Judd: Dr. Allan Rosenfield, thank you for joining us. You gave a presentation here on Mother-to-Child Transmission Plus. What did you have to say?
Dr. Allan Rosenfield: First, I sort of presented the history, as the last speaker in a group of six. About 20 years ago a colleague of mine and I wrote a paper, the subtitle of which, in Lancet, was "Where's the M in MCH?" MCH being Maternal and Child Health Programs. There's been great attention to children, and children deserve it. Millions of children suffer high morbidity, high mortality rates, but women were not given any attention. Between five and six hundred thousand women die each year of complications of pregnancy, and millions are damaged. This led to the Safe Motherhood Initiative and a whole focus on maternal mortality, which is now one of the MDG's, [inaudible] Development Goal Programs of the UN, or initiatives of the UN. Four years ago in Durban I was invited by one of the organizers to give a plenary session. They gave me my title. My title was, "Where's the M in MTCT Programs? Where's the M in the Prevention of Maternal to Child Transmissions?" I had not thought much about it until that point in time, but when I did, I realized that we were giving a drug to the mother to protect the child, which is great, and we're giving the child a drug after birth to help decrease transmission, but then we did nothing for the women. She was simply a vessel to pass the drug to the baby. She was written off; she would proceed to get sick at some point and to die, and the baby would be an orphan. But the orphanage is terrible; the idea that we didn't care about the woman is even, in many ways worse. So that led to what we were calling at the time of that meeting, the MCTC Plus Initiative.
Jackie Judd: What's happened since then?
Dr. Allan Rosenfield: Since then, some foundations decided to support the development of this initiative, and we're now working in eight countries -- here in Thailand and seven sub-Saharan Africa. There are some 20 sites. What we're finding is great enthusiasm for the program. We enter a program where a PMTC program is in place, where women have been counseled and tested, and if they're positive, offered nevirapine or some other drug therapy to prevent transmission, and we then follow them, offer them care and treatment. We offer prevention of opportunistic infection management, management of opportunistic infections, and when indicated by CD4 count, offer antiretroviral therapy.
Jackie Judd: So how many women has this program been involved with now, and? --
Dr. Allan Rosenfield: We're about a year and a half in to the active program. At the 12 sites there are more than 4,000 women registered, about 500 women on care and treatment, on antiretroviral therapy at the present time. We had a meeting in November in Zambia, where we brought all the teams together, and our concept has been that this is sort of a holistic care program, not simply offering drugs, but offering care to the woman. We provide it through teams. We're not Columbia workers. This is all local groups, but there will be a doctor and a nurse, a social worker, peer counselors, community workers, all working together as a team to go on and support those who do go on care and treatment. Initially, and it's early, the adherence rates are good, as good as any you've seen in the States.
Jackie Judd: This is in Zambia specifically, or across the board?
Dr. Allan Rosenfield: No, no. Zambia is where we had the meeting. This is in the 12 sites. The adherence rates have been good. This has been the experience of the other programs, Mèdecins sans Frontiéres, MSF, and the Haiti group, Partners in Health. All of these have seen that even though women may be illiterate, they do indeed understand the importance of therapy and they do understand what can be done as they begin to see these programs roll out. We also offer -- we test children, and we offer care and treatment of the HIV-positive children as well as to the partner of the woman who has entered. What we like about the program is that it starts with women. And since in Africa now, 12 to 13 women are infected to every ten men, and if you take young women, as you know from some of the data from Kaiser, that the rates are disturbingly high in younger women compared to younger boys. So this program focuses on women, but then takes care of the family.
Jackie Judd: What are the obstacles that you've found in administering these kinds of programs?
Dr. Allan Rosenfield: At the present time, because we were working with groups that were already doing the PMTCT and were interested in the training -- we developed a training program and a clinical guidelines manual and a process for monitoring and evaluation -- there's been an enthusiastic reception by the people running the program and by the teams they put together. It has been a very positive experience. Admittedly, a very small program, but I think everywhere these clinical programs have been introduced which marry prevention and public health and care and treatment -- and one of the nice things about the PMTCT to MTCT Plus is we're going from a preventive program to prevent transmission to a program that offers care and treatment. We think that offering care and treatment offers people more hope, and should increase the number of women being willing to come for voluntary testing and counseling. So it so far has been a plus, and a model upon which we are now moving with our President's Emergency Initiatives. We're one of the first recipients to work in five African countries.
Jackie Judd: Five additional African countries?
Dr. Allan Rosenfield: No, some of them are the same. But it's not for MTCT Plus specifically, it's for a broad-based roll of antiretroviral therapy across the board, but the same philosophy, and the same approach that we've done with our initial program will be what we embark on as we're now just starting the PEPFAR, as it's now being called.
Jackie Judd: With the PEPFAR money, how many more women will be involved?
Dr. Allan Rosenfield: Well, the expectation is that a very large number, by the end of five years, well over 100 thousand at the end of five years. Just starting now, so I can't give you numbers at the present time. Obviously the issue that everyone is discussing at this meeting relates to, can we buy fixed-dose combination drugs made abroad. At the present time, we cannot. With out MTCT Plus grant, because it's private foundations, purchasing through UNICEF moves up the procurer of drugs for us. We purchase whatever WHO has pre-qualified.
Jackie Judd: The other issue that's being talked about a lot today at the conference is South Africa's decision regarding nevirapine. Fill us in on that decision is and what impact do you think it will have?
Dr. Allan Rosenfield: I think it's a bad decision, number one. Single-dose nevirapine is not the best therapy that we have, but it's the therapy that we can put in place the fastest.
Jackie Judd: And this is what's given to a woman during labor --
Dr. Allan Rosenfield: During labor --
Jackie Judd: To prevent the transmission to the child.
Dr. Allan Rosenfield: To prevent transmission. This regimen, one dose goes to the woman and one dose goes to the baby. It reduces transmission by about 50 percent. Using two drugs, or even triple therapy, you can decrease the transmission to two percent. Eventually that's where we want to go, but that requires a great deal more resources and training to get those rolled out, if you will. The single dose nevirapine, on the other hand is something that we can do now. And that's what's happening. In South Africa they were beginning to really move with a nevirapine only program and coming in with better programs behind that, but they just can do it more rapidly. This is a major setback, and I'm very supportive --
Jackie Judd: What do you think the consequences will be?
Dr. Allan Rosenfield: Hopefully the protests will get it turned back to where they were heading. But if not, it means far, far fewer women will be given a drug to decrease transmission.
Jackie Judd: Final question for you, one that I've asked other people we've interviewed this week, and that is, what is your definition of this being a successful conference?
Dr. Allan Rosenfield: Well, these kinds of conferences have two purposes. One, it brings together lots of different people from lots of different perspectives for discussions, in the corridors as well as what goes on in the formal sessions. In Durban there was a formal call for action, and let's begin treatment, and that was landmark meeting because of the call that led to the western world being willing to consider large sums of money, in the billions, for the first time for care and treatment -- that we couldn't write everybody off. There's not going to be a comparable call from this meeting. There's been a lot of debate about the US position in regards to the drugs that can be used and other related issues, and the contribution of the US to the Global Fund, and so those kind of issues are going to come out of the meeting, but we've heard some wonderful sessions on a whole range of issues, and programs and initiatives. I think from my own perspective, the fact that there's been a heavy focus on women, the rights of women, the needs of women, the issues of orphans, that maybe we're going to move those agendas forward in ways that we haven't in the past, and that's my hope coming out of the meeting.
Jackie Judd: Thank you very much, Dr. Allan Rosenfield.
Dr. Allan Rosenfield: Thank you, my pleasure.
Jackie Judd: I appreciate it.
Dr. Allan Rosenfield: Good.
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