BY ERIC LEVY
JUST A FEW YEARS AGO, THE HIV/AIDS EPIDEMIC IN SUB-SAHARAN Africa seemed hopeless. About 28.5 million people there are infected with HIV, and life expectancy is anticipated to drop from 70 to 30 years over the next decade. The region has approximately 13 million orphans, many of whom are also infected with AIDS and dying alone. Some communities are facing extinction from the epidemic.
“It’s absolutely devastating what’s happening to children in Africa. It’s beyond belief,” says Dr. Elaine Abrams, associate professor of clinical pediatrics at P&S, associate professor of clinical epidemiology at Columbia’s Mailman School of Public Health, and director of the Family Care Center in the Department of Pediatrics at Harlem Hospital Center. “There are more orphans than can be imagined.”
Dr. Abrams’ work with the MTCT-Plus Initiative has allowed her to see firsthand what this devastating epidemic has done to families. The program (MTCT stands for mother-to-child transmission and “Plus” refers to the addition of family-centered care and treatment to prevention programs) is coordinated by the Mailman School. She is part of a core group of physicians, a majority with joint appointments at P&S and Mailman, who are working to provide HIV/AIDS treatment in resource-poor settings where, until recently, such a thing was thought to be impossible.
Political will combined with a dramatic decrease in the cost of antiretroviral medication and patient monitoring are making it feasible to care for and treat a greater number of patients. As a result, foundations, the U.S. government, and other organizations are increasing their efforts to support treatment programs in regions most severely impacted by the HIV pandemic. The MTCT-Plus initiative, which began enrolling patients in February 2003, is being closely watched as a model for comprehensive, family-centered care and treatment for families with HIV/AIDS.
“This is an excellent example of the close collaborative efforts of Mailman and P&S dealing with a major global crisis,” says Dr. Allan Rosenfield, dean of the Mailman School and principal investigator of MTCT-Plus. He cites the critical role that faculty members from P&S and Harlem Hospital pediatrics and medicine departments and the infectious disease divisions have played in the initiative.
The mission of MTCT-Plus is not simply to provide antiretroviral therapy. Instead, the program offers long-term comprehensive care and treatment for HIV/AIDS. The model of care is characterized by its focus on family-centered care, counseling, preventive care, patient education, psychosocial support, and outreach. The program is also unique because of its multidisciplinary approach to care; a concentration on adherence and continuity care, which is critical to the success of antiretroviral therapy; its efforts at overcoming social isolation; and its emphasis on the importance of tuberculosis, the most common and fatal infection among HIV-infected patients in sub-Saharan Africa. The initiative is expected to decrease morbidity and mortality associated with HIV infection, further reduce mother-to-child transmission, and reduce the number of orphans.
MTCT-Plus builds upon a foundation of pMTCT programs, which focus on prevention of mother-to-child transmission of HIV. Such pMTCT programs expanded throughout the resource-poor world after the discovery of an effective and simple intervention for the prevention of mother-to-child transmission. While pMTCT programs have made great progress in protecting infants from HIV infection, they provide no treatment to their parents or other siblings with HIV. This tragedy was highlighted at the International AIDS Conference in South Africa in 2000, when Dr. Rosenfield presented a lecture titled “Where’s the M in MTCT Programs?” calling for treatment of both the HIV-infected mother and child, not just prevention of HIV transmission from mother to child.

In 2001, the M in MTCT started to become a reality. MTCT-Plus began as a response to UN Secretary General Kofi Annan’s “Call to Action” to increase access to HIV/AIDS care and treatment in resource-poor settings. An international group of scientists, clinicians, policy-makers, and patient advocates was sponsored by the Rockefeller Foundation to develop the program. Later that year, the concept was refined and the foundation chose Dr. Rosenfield and Columbia’s Mailman School of Public Health to coordinate the initiative, raising $50 million from an unprecedented coalition of private foundations. This funding was supplemented in July 2003, when the initiative received a $65 million award from the U.S. Agency for International Development to expand care and treatment over a five-year period to approximately 15 additional demonstration sites and to increase the number of patients enrolled at current sites.
The initiative has established 12 MTCT-Plus demonstration sites — 11 in sub-Saharan Africa and one in Thailand — and has successfully enrolled more than 1,300 patients since February 2003. These include mothers as well as children and household members.
“All the sites were able to be up and running in a remarkably short period of time. It is a testament to the site teams and their commitment to this concept and to their devotion to the goals of the initiative,” says Dr. Wafaa El-Sadr, professor of clinical medicine at P&S and of epidemiology at Mailman, chief of infectious diseases at Harlem Hospital Center, and director of MTCT-Plus.

MTCT-Plus

Demonstration Sites
Cote d’Ivoire
Kenya (2)
Mozambique
Rwanda
South Africa (3)
Thailand
Uganda (2)
Zambia
MTCT-Plus

Supporting Organizations
Bill & Melinda Gates Foundation
William and Flora Hewlett Foundation
Robert Wood Johnson Foundation
Henry J. Kaiser Family Foundation
John D. and Catherine T. MacArthur Foundation
David and Lucile Packard Foundation
Rockefeller Foundation
Starr Foundation
United Nations Foundation
U.S. Agency for International Development
Planning grants have been awarded to additional sites:

Kenya
Tanzania
Congo
Cameroon
South Africa
Zambia



Malawi (2)
Mozambique
Nigeria
Zimbabwe
Ethiopia

Dr. El-Sadr assumed leadership of the MTCT-Plus program after 15 years of working with AIDS patients at Harlem Hospital. “My experience at Harlem has taught me that in order for a care program to work it must focus on the needs of the patients. I learned you can’t just take care of a mother without caring for her child or vice versa and that achieving positive health outcomes requires more than just providing medications. You’ve got to build trust, you have to create a welcoming, friendly environment, and one must develop a multidisciplinary group of providers that work together as a team.”
The MTCT-Plus Initiative provides far more than drugs to its sites. Faculty at Mailman, in association with international colleagues, have developed treatment protocols, standardized medical record forms, and training materials. Mailman experts also have worked to create a centralized procurement system, purchasing and supplying medications to sites. A data management team has developed monitoring tools and algorithms. MTCT-Plus funds are used to support staff salaries, renovate clinics, and create linkages with community-based services. On-site multidisciplinary training has been conducted, and follow-up training will occur regularly.
This was a particularly good time to launch MTCT-Plus because of the plummeting cost of triple antiretroviral therapy from $10,000 to $350 just three years ago, when pharmaceutical companies lowered their prices in response to international pressure. “A few years ago, a program such as ours would have been unimaginable,” says Miriam Rabkin, a 1992 P&S graduate and a 2002 MPH graduate of Mailman who is assistant clinical professor of medicine at P&S and of epidemiology at Mailman and medical director of the MTCT-Plus Initiative. “Not only have antiretrovirals become less expensive, but we have learned that they can be given safely and effectively without expensive laboratory monitoring. We also know that patients in resource-poor settings such as Africa can be as adherent to medications — and sometimes more adherent — as their counterparts in the United States and Europe.”
Columbia faculty who have worked with site teams in Africa say the initiative is achieving even more than was anticipated. “It’s been a very uplifting experience,” says Dr. David Hoos, assistant professor of clinical epidemiology at Mailman. “I’ve spoken to patients who say we’re making a difference in their lives.”
While attending a training session at the Zambia site, Dr. Pamela Collins, assistant professor of clinical psychiatry in epidemiology, recalls a patient telling her, “The major problem this program will face is that people will be beating the doors down to get care.” Dr. Lisa-Gaye Robinson, assistant professor of clinical pediatrics, an attending physician at Harlem Hospital, and a trainer at the Kisumu, Kenya, site, adds, “The site team is very encouraged and optimistic that our program will have a positive impact on the community.”

| TOP |