For the second time in less than a month, HIV advocates have been generally elated by news that one of their own has taken a senior job at the Centers for Disease Control and Prevention (CDC).
On Nov. 17, we learned that New York City’s “HIV czar” Demetre Daskalakis, M.D., M.P.H., was going to head up the CDC’s HIV prevention efforts. Then, on Dec. 6, news broke that President-Elect Joe Biden will appoint Rochelle Walensky, M.D., M.P.H.—the chief of infectious diseases at Massachusetts General Hospital and a professor of medicine at Harvard Medical School—to helm the entire CDC.
“It’s an inspired choice,” said Matthew Rose, domestic policy and advocacy head at Health GAP. “Dr. Walensky is an amazing doctor and educator, but also does a lot of primary research thinking about how health care works and gets implemented, and whether it has efficacy. ... I think she will make CDC [excel at] putting guidance into practice.”
In addition to being the leading infectious-disease clinician at Mass Gen, Walensky is also a well-known and heavily published expert on the cost-effectiveness of HIV testing, treatment, and prevention, both domestically and globally.
As we entered the modern era of highly effective antiretroviral therapy earlier this century, Walensky was among the first to confirm that HIV medications offered huge, long-term medical savings—both in terms of treatment (preventing severe illness and death) and prevention (thanks to viral suppression leading to sexual untransmissibility, a.k.a. U=U).
Rose and others also lauded Walensky for her recent work on COVID-19, especially her research looking at the most cost-effective ways to roll out vaccines and deploy other therapies. “Having her at the helm on COVID will be amazing,” Rose said.
Walensky Will Need to Repair Damage and Meet High Expectations
“The Trump-era CDC has been kneecapped the past year on COVID, denigrated and destroyed under [outgoing CDC director Robert] Redfield,” said longtime HIV activist Gregg Gonsalves, a public health professor at Yale University. “She needs to rebuild it back to its premiere status, even as she gets us out of the COVID crisis.”
Gonsalves was referring to Trump-era incidents at CDC that have shocked the public health community during the coronavirus pandemic, such as its failure to roll out testing properly, its extremely muddled [and Trump-muzzled] guidance on risk in places like churches and schools, and—perhaps most disturbingly—revelations that Trump political appointees meddled with the CDC’s COVID-19 public messaging, despite the CDC’s longstanding reputation as among the most effective and scientifically independent public health agencies in the world.
Repairing that reputational damage is a tall order. “She’s got to figure out how to start rehabbing CDC’s public image so people will trust them again,” said Rose. “She has to start by holding some very large roundtables about how states can respond to COVID, because states have been left on their own.”
In addition, aside from the immediate public health emergency of COVID-19, Walensky will be expected by the HIV advocacy community to bring her years of HIV experience to bear for the task of moving forward with the federal Ending the HIV Epidemic (EHE) plan, which has rolled out unevenly.
“We’re going to need a really strong hand from the CDC in getting these [state and county] health departments who’ve been slower to respond to be more accountable,” said Rose. “Having Demetre [Daskalakis] is going to help with some of that,” he added, but Walensky’s role will be to “have CDC determine how we can take EHE best practices [from certain localities] and have them expanded elsewhere.”
Among the specific EHE-related needs that await Walensky’s attention, according to advocates, is figuring out how to bring HIV pre-exposure prophylaxis (PrEP) up to much higher levels of uptake and adherence—especially among vulnerable groups such as gay Black men and Black transgender women, who have not had the same level of access or openness to PrEP that has been available to, for instance, middle-class gay white men in urban areas.
“PrEP’s been a failure as a public health intervention for reasons that have nothing to do with its [proven] efficacy,” said Kenyon Farrow, the co-executive director of Partners for Dignity & Rights, who is a part of several nationwide coalitions that focus on Black gay men and sexual health. “It’s been because of terrible implementation nationwide. People still don’t even know what it is, how it works, or how to access it, even though we now have generic Truvada and injectable versions of PrEP coming down the line.”
Farrow said he hoped the CDC, under Walensky, would roll out “a real national public education campaign on PrEP,” noting that the agency could accomplish a great deal with a more savvy approach to social media. He also expressed hope that the CDC would talk more widely about health issues in Black communities, where people “are tired of feeling ghettoized, and like the only time [health officials] talk to them is about HIV.”
Advocates also said they hoped Walensky would reboot CDC leadership against the opioid-overdose crisis and other longstanding infectious-disease epidemics. Longtime HIV activist Peter Staley said, “For the first time in my life, we have a real shot of finally using the CDC to its full effect—not only to fight HIV, but hepatitis C and the ever-ignored stepchild, sexually transmitted infections, where our national record is disgraceful. Assuming they can loosen some additional money from the CDC budget, I think amazing things are about to happen on those fronts.”
Staley called Walensky “one of the great science warriors, a combination of impeccable credentials with an activist’s backbone.”
In Walensky, a Doctor Who’s Unusually Outspoken on Drug Pricing
Walensky may have gained much of her popularity among HIV advocates due to how bluntly she has spoken out against exorbitant drug pricing, particularly for the HIV drug Truvada (emtricitabine/tenofovir disoproxil fumarate) and the COVID drug remdesivir, both made by pharma giant Gilead Sciences.
Walensky said last year that the current sticker cost of HIV meds would seriously challenge the Trump administration’s stated goal of ending the U.S. HIV epidemic by 2030. (Biden has said he would like to do it by 2025.) In May 2019, she testified before Congress that the cost of Truvada—which grew from $7,800 per year in 2004 to $20,000 per year in 2019—was a major impediment to rolling out PrEP at a level that could play a substantive role in stopping new infections and effectively ending the HIV epidemic.
Walensky’s appointment to CDC head was applauded by James Krellenstein, executive director and cofounder of PrEP4All. Krellenstein has played a large advocacy role in the current U.S. government’s lawsuit against Gilead, filed in November 2019, which asserted that the government, not the company, owns the patents on Truvada. (Advocates say that a settlement might be soon forthcoming, in which Gilead might pay the CDC roughly a billion dollars to utilize in its HIV initiatives.)
“I don’t know if I could think of a better choice” for CDC director, said Krellenstein. “She’s been a leader in HIV care and research. But she’s also been a firm but fair critic of pharma—uniquely principled in the infectious-disease field in this regard.” Generally, clinicians and researchers tend not to speak out publicly against drug pricing.
“Even in peer-reviewed publications,” he continued, “she’s repeatedly referenced PrEP4All’s work, which you often don’t see from a researcher of her standing. And she’s just a fantastically energetic, brilliant person. She’s a solutions-focused scientist, really dedicated to making sure everyone can get the care they need.”
Like many, Krellenstein said he hoped that Walensky will yank the CDC back on track when it comes to leadership against COVID-19. “She should do daily press briefings, giving the American people the CDC’s scientific viewpoint about what needs to be done,” he said. “She was a CNN medical contributor, and she’s used to being on national television and making things understandable for all audiences.”
A Lack of Black Talent in Top Federal HIV Jobs
At a time when HIV continues to hit Black Americans hardest, Walensky is the second white person (after Daskalakis) to be appointed to a high-ranking HIV-related job under Biden. (COVID-19, of course, has also disproportionately affected Black and Latinx Americans.)
Prior to Walensky’s appointment, it was widely believed in the public health world that the job might go to Mary Bassett, M.D., M.P.H., a Black woman who helmed New York City’s health department from 2014 to 2018.
Some Black HIV community advocates acknowledged the racial realities of these recent health hires, but said it was not concerning to them because Walensky had proven her accountability to Black and Brown communities. “It’s always nice to have [racial] representation, especially where you haven’t seen it before,” said Rose, “but if they were going to pick a white woman, she’s the best they could’ve picked.”
Rose added, however, that Walensky would have to prioritize responding to an open letter signed by roughly 1,200 CDC employees in July alleging a longtime “toxic culture of racial aggressions” at the agency, such as a lack of Black leadership in uppermost positions and a sidelining of Black employees trying to speak up about racial disparities in health care. (Although no public response was issued at the time, a CDC representative said that Redfield had responded internally to the letter.)
“She needs to say that the agency is building in some accountability measures, and it needs those employees’ feedback,” said Rose. “CDC has a history of not listening to Black employees and their lived experience with health disparities, and she needs to get close to the people who’ve been feeling the most pain from this.”
Farrow, as well, said he wasn’t troubled that Walensky was white. “When I heard the news [that Walensky got the job], it brightened my entire day,” he said. “Concerns [about racial representation] are real and important, but I’m also interested in people who share my political vision about what the barriers [to ending the HIV epidemic] are, about holding pharma accountable to its role in those barriers—and Rochelle is open to those conversations.
“She has guts and is an honest dealer,” Farrow added. “That fact that she chose to say something [about drug pricing], when it probably would’ve been more lucrative for her not to, says something to me about her ethics and values.”
Dázon Dixon Diallo, founder of the Atlanta-based Black women’s HIV and reproductive justice group SisterLove, said that though she thought highly of Walensky, she was deeply disappointed to see not one, but two, top HIV-related jobs thus far go to white people.
“I love Rochelle, but this is the wrong direction,” she said. “I’ve also noticed that there’s nobody on Biden’s health team so far that represents the South, and I find that problematic. Right now, for me, the signal from the new administration isn’t strong enough. I would love to hear directly from [Walensky] that a commitment to ensuring racial and gender justice will be a part of the framework through all of CDC.”
In New Orleans, Gina Brown, who heads community engagement for the Southern AIDS Coalition, generally reacted positively to Walensky’s selection. “I’m ecstatic that [the head of CDC] will be someone who not only understands the public health landscape but what’s going on around HIV and other health disparities,” she said. “It’s going to be really good for us in the South to have her at CDC, because she’ll bring expertise, compassion, and community understanding.”
But Brown also added that she wanted to see Black and Hispanic women chosen for the next top HIV-relevant positions the incoming administration must fill, including the head of the Office of National AIDS Policy (ONAP) and seats on the Presidential Advisory Council on HIV/AIDS (PACHA). She floated names including Dixon Diallo, as well as Adaora Adimora, M.D, M.P.H., of the University of North Carolina Medical School, and Christine Campbell, an independent consultant with a long history at top HIV and LGBTQ health agencies, including Housing Works and Whitman-Walker Health.
Brown was echoed by Naina Khanna, who heads the Positive Women’s Network-USA, a national coalition of women living with HIV. “It’s great to have a leader and a champion who will restore trust in the CDC,” she said of Walensky. “Her track record shows a commitment to addressing not only epidemics and pandemics, but the social and structural issues that contribute to inequities and disparities.”
But, she added, “We need a commitment that the ONAP office will be led by a Black person, and to make sure that [the other people within ONAP] and PACHA appointments are fully reflective of the epidemic.”
Exciting—and Tense—Times Ahead
Walensky did not reply to a request asking for her thoughts on her imminent role and top priorities. But on Twitter, she wrote, “I began my medical career at the height of the HIV/AIDS crisis, and I’ve spent my life ever since working to research, treat, and combat infectious diseases. I’m honored to be called to lead the brilliant team at the CDC. We are ready to combat this virus with science and facts.”
Twenty-four hours later, the tweet had been liked nearly 100,000 times and retweeted nearly 8,000 times—numbers approaching rock-star status for the relatively insular world of public health.
Walensky’s appointment is also consistent with a pattern among Biden-Harris picks so far: deeply experienced and respected names from the public health establishment, such as Vivek Murthy, M.D., (who will be nominated to return to his Obama-era role as surgeon general) and Xavier Becerra (who will be the nominee to head the Department of Health and Human Services). Becerra, in his role as California’s attorney general since 2017, has sued the Trump administration over immigration, health, and environmental rollbacks.
Unlike Walensky, Murthy and Becerra—who is the second Latinx person chosen by Team Biden for a high-ranking job—will have to be confirmed by the Senate, the control over which hinges on two runoff races in Georgia on Jan. 5.
Though she won’t need to navigate Senate confirmation, Walensky will be one busy bureaucrat when she begins the job: She faces the multiple tasks of taming COVID-19, keeping HIV efforts on track, and restoring public trust in the CDC—not to mention overseeing CDC’s myriad other sub-departments, which handle everything from statistics and implementation to minority health, global health, and lab safety.
But HIV advocates are hopeful that the same community health activist instincts that have guided Walensky’s career so far will remain at the center of her leadership.
“She’s been one of the most influential leaders when it comes to optimizing and delivering HIV treatment, not just in the U.S., but globally,” said Krellenstein. “Up until COVID, HIV has been this country’s largest modern epidemic, and her experience as both a researcher and a clinician, plus her relationships with activists and with organizations like HIVMA [the HIV Medicine Association] really demonstrate her unique resume. And she’s been an outspoken critic of pharma price gouging, which is an issue we’re all going to need to face as we try to bring universal treatment to the U.S.”
Krellenstein noted that a significant proportion of people living with HIV in the U.S. are still not even accessing therapy. Walensky “has as good ideas as anybody on how to rapidly address that and bring the U.S. HIV response up to where it should be for a modern, high-income country,” he said.