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This post is by the Global Center’s Rabita Aziz.

Dr. Thomas Frieden discussed the Centers for Disease Control’s global health agenda today at an event sponsored by the Washington-based Center for Strategic and International Studies. Frieden, who became director of the CDC in June 2009, spoke about the CDC’s work in reducing the prevalence of global HIV/AIDS and about his commitment to tuberculosis control. Frieden led New York City’s efforts to control and reduce multidrug-resistant tuberculosis cases in the 1990s. He then went on to work with the Indian government to assist with national tuberculosis control efforts, which resulted in more than 10 million patients being treated and 2 million lives saved.

Frieden outlined the themes and goals of the CDC’s new Center for Global Health, led by Dr. Kevin DeCock. The new Center aims to strengthen the use of data to manage health programs and bolster governmental public health systems. Other goals include developing country capacity, ensuring global health security, and ultimately helping people live longer and healthier lives. Working to achieve these goals will generate trustworthy data that can be relied on to make good decisions, and it will also help create good public health sectors.

Frieden went on to say that it is essential to develop disease-specific programs as a means to achieving their goal of helping people live longer and healthier lives. He said it’s imperative to establish effective HIV/AIDS and TB programs, and implement methods that we know work, while also learning more about things we don’t yet understand. It is also imperative to garner political leadership and commitment, as many decisions made in the field of global health are political decisions.

He cited PEPFAR as an excellent example of what can be achieved with proper political commitment and leadership. Frieden explained that before PEPFAR, there were countries in Africa in which two-thirds of all adult deaths were attributed to HIV/AIDS. The scale-up of ARV treatment has drastically reduced these numbers and has extended the lives of millions. He went on to say that PEPFAR-funded ARV treatment has helped in reducing the spread of HIV as well. He also cited big successes in reducing the number of vertical transmissions, with over 300,000 children of HIV-positive mothers being born free of HIV in recent years. In addition, programs like PEPFAR help support ministries of health and strengthen health systems, which has a positive impact on other areas.

Frieden also spoke of the success of TB programs, which have cured 36 million patients and have saved 5 million lives in the past 15 years. Despite these achievements, Frieden emphasized that TB programs need to be strengthened further, as there are too many countries facing drug stock-outs and dealing with poor laboratory capacities.

One audience member asked Frieden to comment on the recent reports of of HIV-infected persons being turned away from clinics in PEPFAR countries such as Uganda, in part because of flatlining of funding for global AIDS programs. Frieden responded to this concern by saying, “We’re not at a situation in any country where we’re limiting expansion.” He went on to say that an effort is being made to encourage other nations to step up their own treatment programs.

Watch a portion of Dr. Frieden’s discussion here:

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At the start of a forum today on the Obama Administration’s Global Health Initiative, Jen Kates, the Kaiser Family Foundation’s director of global health policy and HIV, laid out eight major questions about the proposal—queries that will go a long way toward determining whether the initiative is a success or not.

After a 90-minute discussion, most of those key questions—such as how much funding the GHI will get, how the money will be divvied up, and how its goals will be measured—remained unanswered. But we did learn a few things from the U.S. government panelists who are developing and overseeing the implementation of the GHI, the White House’s controversial initiative calling for a more integrated, comprehensive approach to funding global health.

Amie Batson, the deputy assistant administrator for global health at USAID, had the most news to share. On governance of the GHI, she said a “strategic council” had been established, and it would serve as a forum for pulling together all the government agencies that have expertise in achieving the GHI’s goals. The group has partners from a gamut of federal agencies—from the departments of the Treasury and Defense to NIH and CDC.

At the more operational level, she said, there was a “trifecta” of leaders– USAID Administrator Rajiv Shah, CDC director Thomas Frieden, and Global AIDS Coordinator Eric Goosby—charged with developing and executing the GHI. “They are tasked with defining a shared or joint operational plan,” she said, and each of them has a deputy charged with delivering on that plan.

Batson also said the Administration would release a final GHI plan by early summer. And by the end of this month, officials would announce the first ten “GHI Plus” countries; those countries will then get additional technical, management, and financial resources to implement integrated programs and make investments across health conditions. (The list of GHI Plus countries will be expanded to 20 in later years.)

“We’re now engaging very actively with the countries,” she said. The GHI Plus countries will offer a sort of field test “where we have an intensified learning effort.”

Today’s forum, hosted by the Kaiser Family Foundation and available online here, was the most extensive public discussion yet of the GHI, a $63 billion six-year plan announced by President Obama nearly one year ago.  It has been the subject of much debate because, while the plan includes many lofty and significant goals, some advocates fear it will not be adequately funded and that it may shift focus away from critical programs, such as PEPFAR. Key officials crafting the plan say the U.S. needs to turn its attention to other health problems, such as child and maternal health, but they do not seem to fully grasp or acknowledge the links between specific diseases, such as HIV and TB, and women’s health.

The shift could have serious repercussions on the ground in the developing world. For example, the GHI’s goals on TB represent a significant step back from more aggressive targets laid out in the Lantos-Hyde Act that reauthorized PEPFAR, even though TB claims 1.8 million lives a year.

At today’s forum, Ann Gavaghan, chief of staff in the Office of the U.S. Global AIDS Coordinator, said the GHI should be viewed as an opportunity to build on the stunning successes achieved in fighting global AIDS and other diseases over the last decade, not as a step back from those efforts. “The GHI is not designed to take away from any of those successes but to say let’s recognize what’s been done … and let’s figure out a way to really build those best practices,” she said.

But wide-ranging questions from the audience signaled there is still deep concern about the initiative and how it will be implemented and funded. Several attendees asked about why TB, for example, appeared to be getting short shrift in funding and focus. Gavaghan and Deborah Birx, director of CDC’s Global AIDS Program, both tried to assure advocates that the Administration was committed to combating TB and understood how much of a threat it presents, but neither one specifically addressed the underfunding or weak targets.

Another advocate asked about the apparent contradiction between the Administration’s rhetoric about wanting more international collaboration and its proposed cut to the U.S. contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria. Gavaghan said the White House had made a robust request for the Global Fund and remained fully committed to its success, including active U.S. participation on the organization’s board and in country-level coordination.

Several attendees asked about how the GHI would deal with the severe health care workforce shortage in the developing world, noting that the GHI blueprint issued in February did not offer very many details about that critical piece of health system strengthening.

Batson said that’s because the solution to that problem is country-specific and will have to be dealt with in a focused way in each place. “Many of the governments have put this as No. 1 on their lists, so I think you will see a lot of innovation,” she said.

To learn more about the GHI, read our earlier blog posts here and here analyzing the GHI’s consultation document. In addition, Kaiser has this nice analysis/overview—including the 8 outstanding questions—of the GHI.

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Kevin M. De Cock, MD, has been tapped to lead a new center focused on global health at the U.S. Centers for Disease Control and Prevention. A longtime leader in international health, Dr. De Cock has been at the forefront of the battle against the HIV/AIDS epidemic for more than a decade. As director of the World Health Organization’s Department of HIV/AIDS from 2006-2009, he oversaw all of WHO’s work assisting low- and middle-income countries to scale up treatment, prevention, and support programs. He is now finishing up a stint as Director of CDC’s Kenya office before he moves to Atlanta to launch the CDC’s new Center for Global Health. In this Q&A, he talks about the vision for this new center and the challenges ahead.

 Q: You are about to take the helm of a new center within CDC that will amplify the agency’s work on global health. Why did CDC leaders feel this new center was needed and what are the objectives?

A: When the CDC’s director, Dr. Tom Frieden, took up his functions in the middle of last year, he did two things. Firstly, he defined global health as one of CDC’s core priorities. And I think the significance, the symbolism, of that is considerable. Although CDC has done international work since its inception, it’s really the first time a CDC director has so explicitly named global health as one of his priorities. And to match that rhetoric, he also decided CDC’s work in global health should be consolidated and therefore created a new center.

The creation of the new center does mean that CDC has to think more ambitiously and more strategically about its role in the world, in the hugely changed international diplomatic environment that is so different from just ten years ago. We will be thinking about science and public health priorities and how best to do our work in the 40 or 50 countries where we are engaged. We will work to get a better impact, a more measurable impact, and one that can be communicated more clearly. 

Kevin DeCock who lead a new Center for Global Health at the CDC

Q: You have a long history of working on the global HIV response both in Kenya with CDC and with the WHO.  Many of us are concerned that the Administration’s Global Health Initiative, with its welcome expanded reach, will in fact come at the expense of the robust response envisioned for HIV and TB through the Lantos-Hyde Act.  Already we see evidence of this in less than ambitious treatment targets for HIV and TB.  What is your own assessment of this? Are you concerned about a loss in momentum toward HIV treatment targets that you helped craft, such as Universal Access by 2010? 

A: I think that’s a very relevant question. I have no doubts about the commitment of the Administration to building up the impact of PEPFAR I. And as far as PEPFAR II is concerned, the funding remains huge and the targets remain ambitious and the work is very extensive.

Now at the same time, there’s no doubt that we have to look to the longer term future and begin to think more deeply about how does the long-term global response get funded? It’s unrealistic for one country to fund the whole response to the pandemic, which is likely to stretch into decades to come.

Actually, it’s a coincidence that you asked this, because we’ve been discussing these sorts of questions for Kenya yesterday and today. And I think we’re okay for the time being. But obviously with 33 million people infected with HIV, and with around 4 or 4.5 million on therapy right now and others waiting to become treatment eligible, the costs of HIV/AIDS are going to increase and we do need to think about innovative methods of financing—sharing the burden more broadly; getting other donors involved, such as emerging economies; getting affected countries themselves to take up some of the costs, which some of them could; and making the response more efficient and effective. I’m not so worried about the immediate short term, but I certainly think some deep thinking is required about the longer term.

Q: Similarly, the tuberculosis treatment targets detailed in the Administration’s GHI consultation document was considerably lower—roughly half—of the goals laid out in Lantos-Hyde. Do you have concerns about a pullback on fighting TB, particularly with the rising threat of multidrug-resistant TB (MDR) and extensively drug-resistant TB (XDR-TB)?

A: I think tuberculosis is always at risk of getting forgotten. The history of TB funding has always been cyclical. It rises when TB seems to get out of control, then the response is funded, the cases come down, and then people’s attention gets drawn elsewhere. That’s been a phenomenon, including in the US, over many years. So I do think there’s a need to continually remind people about tuberculosis. And although I think we’ve done reasonably well addressing TB within the context of the AIDS epidemic, there’s still enormous work to do.

As far as MDR and XDR, these are very important issues. We need better surveillance data, but XDR has been most severe in a limited number of places and MDR also is not a huge problem everywhere. The real answer to drug-resistant TB is prevention and better functioning programs, since it is poorly functioning programs that are at the root of MDR and XDR TB.  I think the response under the GHI is fairly robust, but tuberculosis does need continuous advocacy to ensure it’s kept on the front burner and policymakers continue to pay attention to it.

Q: What role will the CDC play in the Global Health Initiative?  We noted last week the appointment of Amie Batson as the point person for the GHI at USAID, but certainly our physician members see CDC as a critical player in global health.  Will there be a similar liaison from the CDC? And if not, how will the agency ensure that its voice is heard in this new approach to global health?

A: The discussions are ongoing about the governance of the GHI–those discussions are unfinished. But let me reassure you that the director of CDC, Dr. Frieden, is paying the utmost attention to this issue and has been intimately involved … And as this new center is stood up, he’s been paying extraordinary  attention himself to global health issues and these Washington discussions. The CDC will be represented at the highest levels.

Q: Some advocates have argued that CDC has suffered as an agency because it is far from Washington’s reach in Atlanta.  What plans do you have to engage with the Washington community of policy makers, program implementers and advocates on global health?

A: That question has some validity, but there are some advantages also to being in Atlanta. One of the original reasons CDC was put in Atlanta was to deal with malaria in the southern United States in the early 1940s. Two advantages of not being in Washington are 1) it has allowed the agency to develop a very strong technical focus and identity, because being away from the political spotlight, I think an emphasis has been put on its technical work and 2) it’s allowed the agency to grow and occupy more physical space, which in D.C. frankly might have been quite difficult.

On the other hand, meetings in Washington get called, sometimes on short notice, and there isn’t always someone to fly up from Atlanta and so we miss out on discussions. We do have an office in Washington, with a Washington-based director. There’s a deputy for the agency for policy in Washington, who has just been appointed. And for global health, we also have a deputy director for policy and communications position that will be Washington based. We are recruiting as we speak.

Q: There was new evidence presented at CROI last month about the benefits of HIV treatment as prevention. How do we educate policymakers about the broader community benefits of HIV treatment, including the reduced transmission of HIV and TB?

A: Policymakers pay attention to data if they are explained to them in the right way, and we are beginning to see pretty persuasive data on HIV treatment as prevention, especially with discordant couples, where one person is infected and HIV treatment prevents the second person in the couple from becoming infected. To my mind, there’s only one direction this debate is  going—it’s towards early treatment and more widespread treatment. It is giving a biological and biomedical justification for the aphorism that treatment and prevention are inseparable. It’s a very important and emerging theme in HIV/AIDS work.

The role of HIV treatment as prevention, the impact at the community level of widespread treatment on HIV transmission, and the question of when to start treatment for the individual, and the impact that would have on individual health and on TB at the community level–these allied questions are, to my mind, the most important research priorities in HIV medicine today.

Q: On drug-resistant TB, there’s a lot of excitement about new diagnostics in the pipeline that could lead to faster, better tests for drug-resistant strains of TB. If such a vital tool comes to market soon, will the US have the resources to help get it out widely to the field?

A: If new tools become available, such as diagnostics, that are shown through research to improve outcomes or to make interventions more effective, more efficient, then they do get adopted and sometimes remarkably quickly. We’ve certainly see that within HIV medicine. You have to be impressed with the scale of up therapy and rapid HIV testing. There is also a movement in programs in lower and middle-income settings towards laboratory strengthening and an interest and emphasis on point-of-care tests, be they for malaria , TB or HIV. But the technology has to be developed first, has to be refined, and has to be evaluated.

Q: You haven’t officially transitioned into your new job yet and are wrapping up things in Kenya as we speak. What kinds of successes has the CDC seen in Kenya and what challenges remain for your successor there?

A: CDC has had a very interesting history in Kenya. It was in 1979 that the first D.C. assignee arrived here and he was sent to initiate collaborative malaria research.  And up to and until the early 2000s, the agenda was almost exclusively research, which CDC always tries to link to policy development and programs.

But with the advent of PEPFAR, and subsequently our work in emerging infectious and global disease detection, we’ve become much broader. Our research has had direct impact on health policy. For example, malaria research on the efficacy of insecticide-treated bed nets was extremely important. In HIV, the clinical trial of HIV treatment to prevent mother-to-child transmission through breastfeeding contributed to a change in international guidelines.

As for what comes next, we have been very infectious-disease oriented. It is time that we begin to extend our work—and this is mandated actually through the GHI—to non-communicable disease priorities, including tobacco use, salt intake, hypertension, diabetes and injuries. And we have to address maternal and child health and extend our work to neglected tropical diseases. These will be the challenges moving forward.

Q: When you get to Atlanta, what will the new center’s structure look like and what will its portfolio include?

A: It will be structured like other centers within the CDC, with an office of the director that has central functions like policy and communications. Currently there are 4 operational divisions in the new center. The first one is the division of global HIV/AIDS, the operational arm of the CDC for PEPFAR implementation. A second division is focused on parasitic diseases and malaria. Third, there’s a division called global disease detection and emergency response, which does international work on emerging infectious diseases, response to outbreaks, international surveillance and response to humanitarian emergencies. And fourth, a division that deals with health system strengthening and is well known for its work in field epidemiology training. We will have to work towards better integration of all CDC’s work in global health.

There is of course a great deal of work in other aspects of public health with global implications done in other parts of the agency, for example our work on immunizations. Whether those will move into the new center is under discussion, but the important point is that the new center will  do all it can to support all of CDC’s international work.  And perhaps that summarizes the identity we seek – a global public good for public health.

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Although some details are still murky, a first-blush analysis of  Obama Administration’s fiscal year 2011 budget doesn’t look good for US efforts to combat the HIV and tuberculosis epidemics. From treatment to prevention, these global health threats could get short-changed under the White House plan.

Let’s start with PEPFAR, the President’s Emergency Plan for AIDS Relief. For the second year in a row, the Administration has called for a single-digit increase for this program, about 2.6 percent, or $141 million. That small increase comes despite lofty campaign promises, congressional mandates, plus a pledge that PEPFAR would serve as the “cornerstone” of the Administration’s new Global Health Initiative (more on the GHI later).

The White House’s PEPFAR budget is not adequate to preserve vital momentum in HIV treatment scale-up, nor is it enough to fund important new HIV prevention innovations in the developing world.

The numbers for TB are even more disheartening. The Administration only requested a $5 million increase over 2010 funding, a paltry amount for a disease that last year killed more than 1.8 million people, including 500,000 women. Moreover, the Centers for Disease Control’s TB program, with its critical clinical trials network, would be cut by more than $1 million, further undermining US capacity to evaluate new diagnostic, treatment and prevention tools for TB. This comes in the face of evidence that drug-resistant TB is a growing threat and if left unchecked, could spiral into a broader global health catastrophe.

Here’s a more detailed analysis of all global health funding from the Global Health Council:  GHC FY11 CBJ GH Funding Chart (Draft). The Kaiser Family Foundation also has this helpful breakdown. The Global Center, the GHC, and other groups will continue to analyze the budget as more details come out.

One bright spot in the Administration’s request was in biomedical research at the National Institutes of Health, which would see a $1 billion boost under today’s plan, including $98 million for HIV/AIDS research at NIH, a significant increase at a time of constrained resources.

There’s no question the U.S. faces tough choices amid spiraling deficits and a difficult economy, but underfunding much needed global health programs, which account for a fraction of the federal budget, is not the answer to America’s fiscal woes. Investment in these programs will reap immense dividends down the line–in financial, diplomatic, and public health arenas alike.

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Amid the continuing effort to provide desperately needed medical care to earthquake victims in Haiti, the CDC today released guidelines for clinicians traveling to Haiti and for those treating patients returning from the country.

This link lists some of the infectious diseases, such as tuberculosis, that providers may encounter while treating refugees or returning relief workers. And this link includes guidance and resources for clinicians who want to help with the US response, including what vaccines are needed and other advice.

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Please note: the HIV Implementers Liveblog has concluded.  Please visit the main page of the Science Speaks blog at https://sciencespeaks.wordpress.com for further articles and coverage of other events.

Caroline Ryan is the author of this post. Ryan is Director of Program Services and Chief Technical Officer in the Office of the U.S. Global AIDS Coordinator, or the PEPFAR program.

Here is some information from the rapporteur session at the end of 2009 HIV/AIDS Implementers’ Meeting. It covered 59 sessions and 255 presentations in addition to selected posters.

Here are some highlights from each of the sessions:

1. Women and Children – (more…)

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Well, we may not like President Obama’s budget too much. And we’re more than a little worried about his global health proposal. But at least Obama is putting good policy folks in place to combat infectious diseases, here and abroad.

Today, the president picked Dr. Thomas Frieden as director of the Centers for Disease Control and Prevention, a fantastic move and one that bodes well for HIV and TB prevention and treatment. Here’s the press release the Center for Global Health Policy, along with IDSA and HIVMA, put out today after the news became official:

 Right-click here to download pictures. To help protect your privacy, Outlook prevented automatic download of this picture from the Internet. Right-click here to download pictures. To help protect your privacy, Outlook prevented automatic download of this picture from the Internet. Right-click here to download pictures. To help protect your privacy, Outlook prevented automatic download of this picture from the Internet.

Deirdre Shesgreen
Senior Communications Officer
Center for Global Health Policy
703-740-4954
dshesgreen@idsociety.org

Physicians and Scientists Hail Choice of Thomas Frieden to Head the CDC

May 15, 2009

The Infectious Diseases Society of America (IDSA), HIV Medicine Association (HIVMA), and the IDSA/HIVMA Center for Global Health Policy applaud President Barack Obama for his appointment of Thomas Frieden, MD, as director of the Centers for Disease Control and Prevention. (CDC)

Dr. Frieden’s experience—as an epidemiologist, an administrator, a researcher and a clinician—make him an outstanding choice to lead the CDC at this critical moment in protecting America’s public health. Dr. Frieden will bring to the CDC unwavering dedication, immense talents, and a strong track record of battling deadly epidemics, such as tuberculosis, HIV/AIDS, and most recently the 2009 Influenza A: H1N1 virus that threatens to spark the next influenza pandemic.
 
“Thomas Frieden demonstrated extraordinary vision, leadership and organizational ability in containing the multidrug resistant TB epidemic in New York in the early 1990s,” said Richard Chaisson, MD, a member of the Global Center’s advisory committee and director of the Johns Hopkins Center for Tuberculosis Research. “He then took that expertise to India, where he transformed that nation’s TB program, creating a model for the world and saving hundreds of thousands of lives as a consequence.  His commitment to using scientific approaches to disease control will serve the nation well.  He is an outstanding choice to lead the CDC.”
 
Roy Gulick, MD, chief of the infectious diseases division at Weill Medical College of Cornell University and a member of HIVMA, said Dr. Frieden will be a forceful advocate for putting evidenced-based science into practice in the battle against HIV/AIDS. 
 
“As health commissioner of New York City, Tom Frieden increased community services for the infected community.  He emphasized prevention by promoting needle exchange and condom use.  He worked hard to promote routine HIV testing so that more New Yorkers would know their status.  He worked closely with HIV providers to monitor the HIV epidemic in New York and reached out to communities of color,” Dr. Gulick said. “With his training in infectious diseases and public health and his track record as New York City health commissioner, he is an outstanding choice for director of the CDC—he certainly will make a difference for those infected and affected by HIV in the U.S.”
 
“As an infectious disease physician and a New Yorker, I have been incredibly impressed with Dr. Freiden’s response to the recent Influenza A H1N1 outbreak and previous outbreaks of other diseases. Given the potential for an influenza pandemic, all of us should take comfort in having him at the helm at CDC,” said Anne Gershon, MD, president of IDSA and a pediatric infectious disease specialist at Columbia University College of Physicians in New York. “He will be a standout at CDC, but we will miss him in New York.”
 

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