In much of Southeast Asia, China and India, the fight against HIV/AIDS is being led by UCLA alumni — trainees sent here to learn from the best
by Dan Gordon '85 (Reprinted from UCLA Magazine, Winter 2004, pp. 32-37)
FROM HIS VANTAGE POINT as a team leader overseeing the UNAIDS effort in the Asia-Pacific region, Swarup Sarkar M.S. '94 is sometimes able to step back from the trenches of the battle against HIV— which has infected 7.4 million of the continent's people — and allow himself to view the big picture.
When the graduate of the UCLA/Fogarty AIDS International Training and Research Program (AITRP) takes stock of the ground war against HIV/AIDS in this part of the world far from Westwood, he sees the enormous influence of his alma mater. “Most of the people working on these issues in the region have been trained at UCLA,” he says. “Dealing with issues that are difficult and controversial, such as hidden populations and gay sex, needed a vision, particularly in countries where you have to convince governments to allocate money for a problem that isn't apparent to them yet. I see the work my colleagues are doing, and I am inspired.”
Survey the leaders of HIV/AIDS-prevention-and-control programs in Southeast Asia, India, China and other regions, and you're likely to be struck by their familiarity with the UCLA campus. Since 1988, the UCLA/Fogarty AITRP has provided master's- and doctoral-level training to more than 130 health professionals from China, India, Brazil, Thailand, Vietnam, Cambodia, Myanmar, Indonesia, the Philippines, Laos and Hungary. They learn basic epidemiology and other public-health fundamentals that help prepare them to return to leadership positions at home, where they now form an influential UCLA alumni association on the other side of the globe.
"The UCLA program has had an amazing impact in the Far East," says Kenneth Bridbord, director of the Division of International Training and Research at the John E. Fogarty International Center, the international agency within the National Institutes of Health that funds scientific research to reduce global health disparities. "If you had to use one word to describe it, it would be ‘leadership' — leadership in science and in public health for that part of the world where the UCLA/Fogarty AITRP has focused."
That ‘leadership', spearheaded by founder and director Roger Detels, extends well beyond the tutelage the trainees receive while under the AITRP's auspices. Through the contacts he's made over the program's 16 years — and on the basis of his groundbreaking work in the United States as head of the long-running UCLA Multicenter AIDS Cohort Study — Detels, a professor of epidemiology in the School of Public Health, is often brought into HIV/AIDS-policy discussions and scientific investigations in Southeast Asia and beyond, having been invited to consult with numerous government and public-health officials.
"Dr. Detels has a lot of experience, and at the same time he also has a lot of vision about the future," says Warunee Punpanich, a pediatrician at a large hospital in Bangkok, Thailand, that serves underprivileged children, 600 of whom are currently being treated after being born to HIV-infected mothers. She was sent to UCLA to become the facility's first physician fully trained in epidemiology. "[Detels] has seen why some countries' programs are successful and some are not," she says.
HIV INITIALLY SPREADS THROUGH HIGH-RISK GROUPS — in Asia, it has most commonly started in sex workers and injection-drug users — before moving into the general population. The most effective way to prevent the spread of the disease is to protect these marginalized, high-risk populations — not always a popular political move.
Yet, there are success stories. In Thailand, more than a million people have been infected with HIV, but because of aggressive campaigns for clean needles, condom distribution and education, that's nearly 400,000 less than had been projected to occur by this point. The Thais responded swiftly to the first sign of a problem, establishing an early-warning system (known in epidemiology as "sentinel surveillance") with assistance from Detels and one of his former trainees; they followed up with bold strategies, including a strict edict requiring brothels to ensure that condoms were used by every client. New cases of HIV infection dropped by 80 percent.
"Because AIDS is such a long-duration disease, in order to identify risk factors and behavior and evaluate whether prevention is effective or not, you have to monitor so many things," says Chuleeporn Jiraphongsa Ph.D. '00, a former trainee who runs the Field Epidemiology Training Program at the Thailand Ministry of Public Health. "But when it comes to surveillance, we are the best in the region. Other countries come to learn from us."
Through much of Asia, cultural norms encourage men to have multiple sex partners, even after marriage, while women are to remain monogamous. The disparity results in a thriving commercial sex industry and a potential hotbed for HIV transmission. Thailand, followed by Cambodia, put economic pressure on brothel owners by threatening to shut them down unless all clients in their establishments used condoms. Most other countries in the region have attempted to suppress commercial sex, driving the trade underground and making it more difficult to track the high-risk population — and more likely that the sex workers, who wield little power in their relationships with clients, will fail to demand the protective method.
Cambodia — which, like Thailand, undertook a massive health-education campaign — has the highest national rate of HIV infection in Asia but is beginning to see a downturn in new cases among high-risk groups, an extraordinary feat for a small country ravaged by civil war and genocide. Detels has assisted with Cambodia's sentinel-surveillance program and continues to be called on to evaluate the program, which is staffed by many former UCLA/Fogarty trainees and a current one, Chhorvann Chhea, who notes that despite making headway in the sex-worker population, Cambodia has begun to see an ominous increase in HIV prevalence among pregnant women. "That tells us it's moving from the high-risk group into the general population," he says.
In other countries, culture and politics pose barriers to an effective response. Talking about sex is largely taboo in India, where an estimated 4.5 million people are infected with HIV (second only to South Africa). Condoms are forbidden from being discussed in schools, despite the fact that a large percentage of girls are married by age 16; infection rates among women and newborns are increasing. Poor and rural communities tend to be among the most conservative, with women unlikely to be in a position to insist on safe sex.
THEN THE OPPORTUNITY TO STUDY AT UCLA was originally presented to Sarkar in 1992, he told his supervisor he didn't want to go. He felt he had important work to do at home. Employed by the Indian Council of Medical Research and stationed in the Indian province of Manipur, near the border with Myanmar, Sarkar was battling a rapidly spreading epidemic that few in the mountainous region had seen before.
Though remote, Manipur was a hot spot in more ways than one. Its porous border was a smuggler's route for timber, gems and drugs — mainly heroin — spilling out of Myanmar. Closed off to the world by a brutal military regime, Myanmar's ruling generals were still denying that HIV/AIDS existed within its borders. Sarkar knew otherwise. The flow of people and drugs all but guaranteed that the disease was spreading to neighboring nations. The first evidence was the rate of infections among injection-drug users in Manipur. "When we started looking for it, it really wasn't there," Sarkar recalls. "But then it went from almost zero to 54 percent in a matter of months."
Sarkar was tasked with investigating the outbreak. Among other things, he needed to determine who was affected and estimate the size of "hidden populations" of injection-drug users, sex workers and other high-risk groups lurking in society's shadows. He developed rapid-assessment methods that would eventually become standard procedure and lead to new ways of testing: voluntary instead of mandatory, anonymous instead of identity-based. But those methods had yet to be adopted in larger settings, and Sarkar felt part of his mission was to see that they were.
That's what he believed his supervisor wanted to discuss when he was summoned in 1992. Instead, Sarkar was told he had been chosen to be the first Indian to go through the UCLA/Fogarty AITRP. "I didn't want to leave my field work," he says. "I wouldn't have gone unless I was ordered to. So he ordered me."
Sarkar is thankful for that. “I wouldn't be where I am today had I not attended the program and studied under Roger [Detels]," he says. “He brings many people from different disciplines and nations together to ensure the highest standards of scientific epidemiology. He was so dedicated, committed and caring to students from developing countries. I found it very touching."
Five years earlier, when Detels had responded to the Fogarty International Center's request for applications for HIV/AIDS-training programs to assist developing countries, the situation in Asia was quiescent. But having had enough experience in Asia to anticipate that an epidemic was near, Detels decided that was where he would focus.
An unassuming yet highly respected physician who began his career at the U.S. Naval Medical Research Unit in Taipei, Taiwan, in 1966, Detels was already established as a leading HIV/AIDS epidemiologist. In 1984, before HIV was even known as the culprit, the Multicenter AIDS Cohort Study (MACS) was launched under Detels' leadership at UCLA (one of four initial sites) as the first and largest study to examine the natural history of AIDS, focusing on gay men. In the two decades since, during which more than 5,000 volunteer subjects have participated, MACS has contributed key findings on multiple aspects of the disease.
Beginning in 1988, just after the UCLA/Fogarty AITRP was funded (one of the original eight nationwide; there are now 25), an explosive epidemic of injection-drug use occurred in the countries bordering the infamous Golden Triangle, where Sarkar would be stationed three years later. By the following year, high proportions of injection-drug users in Thailand, Myanmar, China's Yunnan Province and northeast India were found to be infected. The Thais' sentinel-surveillance program, implemented in 1989, documented the spread of HIV/AIDS from that population to commercial sex workers, and from there it moved outside the highest-risk groups and into the majority heterosexual population.
FROM THE START, the program's objective has been simple: to build the capacity of the overseas institutions to control HIV/AIDS by preparing trainees in the most sophisticated epidemiological techniques and research methods. Given that mission, Detels was adamant on two counts. First, trainees would be required to complete the fieldwork for their master's thesis or doctoral dissertation on their home turf, tackling an urgent HIV-related problem. "It's my feeling that if you're working with developing countries, it's not appropriate to put them through esoteric research," Detels says. "You want them involved in projects that are going to contribute to informed health policy, because that's where the need is." Second, in exchange for their scholarship, trainees would have to promise to return to their home institution at the completion of the program. In a country such as China, applicants had to be carefully screened to ensure that their interest in the program wasn't merely a vehicle for defection.
As the UCLA/Fogarty program was being launched, many of the collaborating nations were grappling with their first reports of rapidly spreading HIV. Not wanting to pull leaders out of their country for a two- to-four-year program at such a time of need, Detels traveled abroad and offered one-to-two-week in-country training courses as an alternative. The short courses had the dual benefit of helping the developing nations get their HIV/AIDS-control programs up and running while also strengthening UCLA's relationships with the collaborating institutions. Detels was often afforded the chance to meet with government officials, urging them to recognize and invest in addressing their epidemic's root causes.
Some were more realistic than others. On one occasion, an official flatly told Detels his country didn't have sex workers. "That's awfully interesting," Detels said in reply, "considering the major reception committee of young ladies when I arrived at my hotel."
In the end, many nations listened. Detels assisted the Myanmar and Indonesian governments, as well as Thailand's and Cambodia's, in establishing sentinel-surveillance systems, and has mentored many trainees in subsequent studies that evaluate and update these early-warning programs as the epidemic evolves. Moreover, the extensive network Detels built across the region has led to numerous collaborations on research and prevention programs, often long after his trainees have returned to assume leadership positions back home.
Among the most fruitful of Detels' pairings has been with one of his first trainees, China's Zunyou Wu M.S. '92, Ph.D. '95, who has become one of that country's best-known HIV/AIDS researchers. In the late 1980s, as escalating injection-drug use among young men in the Golden Triangle was spreading HIV at an alarming rate in the villages of southern China's Yunnan Province, Detels, Zunyou and colleagues created a drug-prevention project in which village leaders organized youths into teams to tackle community-improvement projects as a way of building self-esteem, and provided informal settings where youngsters could socialize. The program resulted in a two-thirds drop in drug-use initiation among young men. Based on that success, Detels was asked to help implement a similar study in a commune in northern Vietnam, where HIV had begun to move from injection-drug users to the larger heterosexual population. One of the infectious-disease-control professionals at Vietnam's Ministry of Health who helped to establish that project, Nhu To Nguyen M.S. '04, is now enrolled in the Fogarty/UCLA program.
Detels and Zunyou also collaborated on the first report of an HIV epidemic among former plasma donors in China — mostly poor rural villagers who would sell their blood to commercial centers as many as two to three times a week. Their revelation in 1995 that former donors were infected — most likely through contaminated equipment used in the collection of plasma and reinjection of blood cells — led to an immediate shutdown of all illegal commercial plasma centers by China's Ministry of Health. Nearly a decade later, the ramifications continue. In her dissertation on high-risk sexual behavior among the infected former plasma donors in Anhui Province, current UCLA/Fogarty trainee Guoping Ji has established that many are visiting commercial sex workers locally and in urban areas, and that their rate of condom use is low.
The UCLA/Fogarty AITRP has produced spin-offs, including a two-year program training AIDS researchers in India led by John Fahey, a professor of microbiology, immunology and molecular genetics, and of medicine. The participants spend three months at UCLA designing research projects in consultation with faculty, and then return to India to carry out their projects while remaining in close contact with their UCLA mentors. Notable achievements include the training of a scientist developing a vaccine against a strain of HIV common in India. The program has also forged a productive relationship with the Tuberculosis Research Center in Chennai (formerly Madras). Given that HIV and TB co-infection is high, complicating treatment, Fahey and colleagues convinced the center's leadership to move into AIDS research and send a scientist to UCLA for training. India's Armed Forces Medical Services has sent several officers, contributing to the knowledge base that enabled it to begin using anti-retroviral therapy to treat AIDS patients a year before the Ministry of Health.
INES DOURADO GRADUATED WITH a degree in medicine from the Catholic University of Salvador, Brazil, in 1981, two years before AIDS was first reported in her country. Brazil would become the epicenter of the epidemic in South America, accounting for 57 percent of all AIDS cases in Latin America and the Caribbean. By the end of 2001, approximately 610,000 Brazilians were living with HIV/AIDS; among populations at greatest risk, an estimated 42 percent were infected.
Dourado was on the faculty at the Federal University of Bahia in 1989 when she took leave to study at UCLA, earning her doctorate through the AITRP.
"AIDS was becoming a major public-health problem in Brazil. My intention was always to come back after my Ph.D. and be involved in AIDS prevention, to contribute to the scientific advancement here in Brazil," she says, sitting in her office on the fourth floor of the university's Instituto de Saúde Coletiva (Collective Health Institute), where she lectures on epidemiology. As she speaks on this hot, humid afternoon in October, the thumping of drums mixed with the sounds of people performing capoeira — a cross between a martial art and dance created 400 years ago by slaves — filters up from the streets of Salvador da Bahia. The air of this city at the hub of Afro-Brazilian culture is thick with the smell of acarajé, a local delicacy of bean mixture and dende oil cooked on street corners by Baianas — dark-skinned local women dressed in heavy, white lace.
Brazil has managed to cut its AIDS mortality rate in half over the last 10 years, in part by ensuring that all those infected with HIV have access to free anti-retroviral medicines. The strategy was made possible by a controversial law that allows the government to produce generic copies of imported drugs in case of a national emergency. Today, the government produces eight of the 15 drugs in the cocktail and has negotiated discounts of up to 70 percent for the others by putting pressure on international drug companies. The innovative strategy has turned Brazil into a leading example in the fight against AIDS.
Other countries, including the Asian nations that collaborate with the UCLA/Fogarty program, have struggled. So-called highly active anti-retroviral therapy (HAART), while potentially lifesaving, requires a complicated medication-taking regimen and financial wherewithal, both of which continue to serve as significant barriers in much of the developing world. Even as the cost of HAART comes down and countries begin to produce the drugs themselves, the infrastructure for identifying people in need of treatment and effectively managing patients through the complex therapy is often severely lacking.
"Treatment is becoming increasingly available in these countries, but if you don't know who is infected, you can't provide it," says Detels. He notes that the majority of HIV-infected individuals in Asia are unaware that they're infected, which makes them less likely to reduce their risky behavior. "Unfortunately, the stigma attached to being identified as HIV-positive — or merely getting tested — continues to be so terrible that a lot of people must decide whether doing so is worth the risk of losing their job and being alienated from their family and community," Detels explains. With that in mind, several UCLA/Fogarty trainees are undertaking projects to identify factors associated with stigmatization among health-care workers and villagers.
EVERY SPRING QUARTER, Detels offers an international HIV seminar course in which UCLA/Fogarty trainees give presentations to their fellow students on the state of the epidemic in their home country. "It's an eye-opening experience to hear the issues of concern and lessons learned from other places," says Warunee. It also contributes to a strong bond that develops among the trainees — one that continues long after they return home. "Besides the knowledge that we obtain, we're able to build networks of important contacts, people who bring passion to their subjects and can be valuable resources in the future," Warunee says.
Dourado agrees that at least as valuable as the specifics of the science she learned at UCLA have been the friendships and professional connections she made with colleagues. "I see some of them at international meetings. If I have a major question about something, I write to them. We exchange papers. If there's something major I have to deal with, I can always count on them to discuss things with me. We have kept that going," she says.
When Detels isn't circuit-riding through the collaborating countries, he's in regular e-mail contact with his former protégés, whose intense loyalty to UCLA has also paid off for several of Detels' campus colleagues. Mary Jane Rotheram-Borus, director of the Center for HIV Identification, Prevention, and Treatment Services at UCLA, has worked with ex-trainees to implement a study in which migrant workers are taught to deliver HIV-prevention messages to their peers in outdoor markets in China; she has also worked with former trainees who head HIV programs in India, Vietnam and Thailand. "The infrastructure that exists has allowed a lot of us, in a short period of time, to do important work that would not have been possible without the pipeline established by the UCLA/Fogarty program," she says.
"This is like having a large family," Detels says, beaming with the pride of a parent. "You develop a lot of very close relationships. I've met a lot of amazing, highly committed individuals. To help them develop as trainees and then to see them walk into leadership positions in their home countries and make a difference has been fantastically rewarding."
Dan Gordon is a contributing editor to UCLA Magazine. With additional reporting by Robert Horn from Bangkok, Thailand, and Andrew Downie from Salvador da Bahia, Brazil.