‘Training the trainers’ to fight AIDS battle:

Taped on the side of a gray filing cabinet in Eric Krakauer’s Harvard Medical School office is a black-and-white photograph of a 4-year-old Vietnamese girl holding a bowl of food and wearing a sour expression.

When Krakauer met her in Vietnam in 2001, she had lost both parents to AIDS and been cast out by her remaining family. She was at a hospice for AIDS patients and infected with the disease. She, too, was to die in April 2002.

“She just looked at me. She didn’t speak. She didn’t smile or laugh. In terms of vulnerability and in terms of stigmatization, she is the face of AIDS in Vietnam,” said Krakauer. “Whenever I don’t know what to do, I look at her and she tells me.”

Krakauer, an instructor in social medicine at Harvard Medical School, has made the struggle against AIDS in Vietnam a personal battle. That battle evolved from a casual meeting during a 1998 vacation in the Southeast Asian nation to a full-blown partnership between Harvard Medical School, the U.S. Centers for Disease Control and Prevention, and the Vietnamese government.

Krakauer created and now directs the Vietnam-CDC-Harvard Medical School AIDS Partnership (VCHAP), funded by a $2.9 million cooperative agreement with the CDC, which is part of the U.S. Department of Health and Human Services. Last spring, VCHAP put on its first two nationwide conferences in Vietnam with the aim of better training medical leaders and educators about HIV infection and AIDS. This fall, the partnership will send its first full-time fellow to the country. Lisa Cosimi, a specialist in infectious disease at Brigham and Women’s Hospital, will head to Vietnam Sept. 8 to spend the next year coordinating training projects, attending regional AIDS meetings, and working with Vietnamese medical personnel.

Mary Kamb, director of the CDC’s Vietnam office, said the epidemic is still new enough in Vietnam that information is scarce in the country. The partnership’s strategy of “training the trainers” can greatly multiply its efforts, she said. The partnership provides not just training, but also training materials to those who take part in its workshops. That allows them to take both knowledge and educational materials back to their home hospitals and clinics to help educate staff there.

As part of its efforts, the partnership has also sponsored internships for Harvard medical students to work on AIDS in Vietnam. Ngoc Phan, whose resulting research on peer education programs was published in the Journal of Community Health in February 2003, said the experience opened her eyes to the complexity of fighting a disease such as AIDS.

“Before, to me, medicine was really an interaction between a patient and the doctor,” Phan said. “When I was in Vietnam, I realized so many factors affected the care of the patient, including social, political, [through] government funding, etc. Throughout my stay in Vietnam I kept thinking, ‘Wow, this medical care has reached one person and there are still thousands out there who need help who will never get it.’”

Krakauer’s Vietnamese efforts grew out of a casual meeting in 1998, when he was in Vietnam on vacation and decided to visit a college friend who was working in the country. That friend introduced Krakauer to the head of Vietnam’s National AIDS Standing Bureau, with whom Krakauer wound up touring the country. Krakauer acted as an informal adviser on HIV/AIDS policy until a year later, when the Vietnam-CDC-Harvard AIDS Partnership was formed.

“It’s a physician’s greatest privilege to be able to respond to a great need,” Krakauer said. “I stumbled upon a situation where there was tremendous need and limited local ability to respond to it. It presented an opportunity to help alleviate a lot of suffering that is unnecessary because the means to prevent it exists.”

Kamb, Krakauer, and Cosimi all see the opportunity in Vietnam to avert the tragedy taking place on the African continent and looming in China, Russia, and India.

AIDS in Vietnam is an epidemic still gathering steam, with less than 1 percent of the population infected with HIV. By comparison, in Botswana, with the world’s highest infection rate, 38.8 percent of adults were estimated to be HIV positive at the end of 2002, according to UNAIDS and the World Health Organization.

Vietnam’s first case of HIV infection wasn’t reported until 1990. To date, 69,000 cases have been reported, with 6,000 deaths from AIDS. International health experts estimate that the number of cases is much higher than reported cases, as high as 300,000.

Though infection rates in Vietnam’s general population are still low, they are much higher in high-risk populations, such as sex workers, with 30 percent infected with HIV, and intravenous drug users, where in some parts of the country 90 percent are HIV positive.

With the disease just beginning to cross over to the general population and given Vietnam’s good medical infrastructure, the right programs coupled with access to anti-retroviral medicines could make Vietnam an international example.

A plus for anti-AIDS efforts is the engagement of the Vietnamese government, which has had various programs in place to educate the public and fight the disease since the mid-1990s. Krakauer’s small office is adorned with government-issued anti-AIDS posters featuring a dancing, smiling condom, and an anti-AIDS calendar with cute babies giving AIDS-prevention pitches.

With training programs up and running and another national conference on the drawing board for next March, Krakauer said the group will begin work on the difficult task of getting anti-retroviral drugs to Vietnamese AIDS patients.

One of Krakauer’s frustrations is the scarcity of the anti-retroviral drugs that have proved effective in treating AIDS in other nations. Like many developing countries, Vietnam is stymied by the high cost of these drugs, which can cost $10,000 or more per year to treat a single person with a three-drug brand-name regimen. Those costs are out of reach for both individuals in Vietnam, where the per capita income is just $400 per year, and even for the government, whose per capita health care expenditure was just $4 in 1999, Krakauer said.

“That doesn’t buy a lot of anti-retrovirals,” he added.

High-quality generic versions of the drugs are much cheaper, in the $300 to $350 range for a year’s supply of a three-drug regimen now available on the international market. But Vietnam is concerned that purchasing those drugs may spark an economic backlash from industrialized nations where the original drugs were developed, Krakauer said.

Developed nations and major international organizations need to make clear there would be no repercussions if countries like Vietnam allowed generic drugs approved by the World Health Organization into the country. Further, Krakauer said, they need to help pay the cost of those drugs, since even $300 is beyond the means of most Vietnamese families.

Krakauer said that effective treatment would go far to dispel the stigma that afflicts people with the disease. As long as an AIDS diagnosis is a death sentence and a cause of ostracism, people will be reluctant to get tested and hesitant to inform sex partners. Krakauer cited data from colleagues in Haiti and Africa that indicates when treatment becomes available the stigma dissipates and interest in being tested rises.

“In many ways, HIV treatment is itself a highly effective form of HIV prevention,” Krakauer said.

As he sat in his Harvard Medical School office, clicking through images of gaunt patients he met in Vietnam, Krakauer said it’s frustrating for him and his fellow doctors to work while feeling that their hands are tied. They know that lifesaving anti-retroviral medicines are taken for granted in rich countries but remain unavailable in most settings like Vietnam. Krakauer looked at an image of an emaciated man lying in bed, bones clearly defined under his sagging skin.

“If he could still swallow pills, he could still have been saved and he could have gone back and taken care of his family,” Krakauer said. “We’ve got to start treating people.”