MUSC researcher Michael Sweat, Ph.D., gives a nod at his trendy treadmill desk tucked into the corner of his office, commenting that he actually does use it. He has to – to maximize his time.
Sweat recently was named co-prinicipal investigator of a $15 million HIV study funded through the U.S. Agency for International Development, heralded by some as forthcoming landmark research that could turn the tide of the AIDS epidemic.
It’s an ambitious project he’ll be coordinating with Deanna Kerrigan, Ph.D., Johns Hopkins University as well as four other institutions, including the Department of Defense, the Imperial College of London, the Tanzanian Primary Health Care Institute and The Muhimbili University of Health and Allied Sciences in Tanzania.
Holding appointments as director of MUSC's Family Service Research Center in the Department of Psychiatry and Behavioral Sciences and, more recently, the director of MUSC’s Center for Global Health, Sweat said he decided to take on the additional challenge of being co-principal investigator because it’s such an amazing study.
The study will be conducted in Iringa, Tanzania, with support from the U.S. Agency for International Development and is part of a suite of three large studies examining what is termed "HIV Combination Prevention." These studies will examine the combination of HIV testing and counseling, antiretroviral therapy, male circumcision and targeted behavioral intervention at the community level with a goal to deliver them on a large scale to an area hardest hit by HIV.
“Mathematical modelers have asked what would happen if all these therapies are combined and brought to scale. There have been quite a few papers showing that if you do these evidence-based practices, you can stop an epidemic," Sweat said. "It creates a perspective that this is something that is doable, and we can get actually get ahead of this curve and stop an epidemic, so these are very high profile projects. It’s like we’ve hit a tipping point.”
Scaling up is critical, as mathematical modeling indicates that to achieve a significant reduction in new infections of HIV very large proportions of the population need to be reached.
“It’s hard with this many people to coordinate. The challenge we have are the numbers are so huge with thousands and thousands of people. But if this works, it’ll be the game changer. It’ll be the future of how we approach doing treatment and prevention and care.”
Tanzania is a perfect study area. An estimated 1.2 million people aged 15 and over, or just more than 5 percent of the adult population, are living with HIV. In Iringa, the prevalence is estimated to be as high as 16 percent, illustrating the enormous lessons to be learned overseas, he said. “When you do these studies in places with really large numbers of new infections, you can do things you can’t do here in the US. When new infection rates are rare as they are here in the U.S., to mount a study to show efficacy would require millions of people to mount a trail. It’s unaffordable.”
The global research, though, can benefit those in the United States, such as a recent finding that treatment leads to prevention. In the past four years, there have been promising trials regarding the effectiveness of certain interventions, with a big breakthrough last year that showed the impact of treatment on transmission, Sweat said.
“That was a home run. They found a 96 percent reduction in transmission of people on treatment. That was a really big thing. Suddenly no longer was treatment, which is expensive, competing with prevention. It was prevention. That was big news – international news that gave hope to a lot of us in the field. It energized people and the politicians with the hope that the epidemic could be stopped.”
|Dr. Michael Sweat balances his field work in Africa with his duties at MUSC.|
Much focus hangs on this research, given the state of the nation’s economy and the global economic crisis. Donor fatigue has set in, consuming much of the foreign aid budget for health with questions being raised about the sustainability of this level of effort, he said.
“There is a feeling that if we don’t show a big impact can be done, donors will move on to something else, is my guess. This will become just another background tropical disease that’s considered unsolvable at a huge humanitarian cost. Millions of people will die from this.”
Sweat, of course, doesn’t know how these studies will turn out, but he feels hopeful based on the growing literature about what is working to stem the spread of AIDS. The studies will combine many interventions, including providing male circumcision with a recent study showing it has a strong impact on HIV transmission, cutting the acquisition rate among men by half.
Addressing the vulnerability of young women and female sex workers also will be a focal area. The research is being done in an area crossed by the TanZam highway, the main trade route linking landlocked Zambia to the major Tanzanian port of Dar es Salaam. “What’s driving the epidemic in Iringa is the TanZam highway that runs through there," he said. "There’s a saying that there are three risk factors for HIV – sex, blood and asphalt. It’s so true. You get truckers and men separated from their families, and there’s a lot of sex going on. There’s a cash economy there with a lot of plantations.”
Sweat said they also will be doing community interventions with groups of men and women to address economic vulnerabilities and safe sex issues. “We work intensely to address the gender norms that make adolescent girls vulnerable. One strategy that has shown promise is cooperatives where young females can work together and market goods and generate income.”
Believing in the concept of social capital, Sweat said there’s a huge social component to the study. “There are benefits of social connectedness. The networking helps you to get jobs and helps you have self-assurance. There’s well-developed literature that shows that. A lot of times when you see big health problems here in Charleston, it’s because people are very socially disconnected. The strategy is to build up these networks around the girls and challenge gender norms and build up some income.”
A behavioral change scientist, Sweat’s main theoretical focus is called ecological theory. Most interventions have historically been based on a one-on-one model, such as counseling or education. However, multiple studies are now showing that what really drives behavior is not just the individuals and what they’re thinking cognitively, but it’s the environment that they are in, the social and ecological environment that they live in day to day, he said.
This intervention strategy where you look at the ecology of things and the social structure... That is so compelling to me.
Dr. Michael Sweat
“What drives epidemics is being disconnected from people, having economic vulnerability or being in an environment where things like gender norms are not to your advantage - that’s where you get problems. This intervention strategy where you look at the ecology of things and the social structure – you don’t just focus on the individual – you look what’s going on around the individual and intervene at that level. That is so compelling to me. That is actually where the field is moving more and more. “
Sweat was drawn to MUSC from where he served on the faculty of Johns Hopkins University because of the social-ecological focus of MUSC’s Family Services Research Center (FSRC), which is a world leader in this work. He feels his work at the center and his global research converge in this theoretical approach.
“Tanzania is a great example. Trying to address the problem at multiple levels – the biological, behavioral and community level all at the same time. That’s a link to what goes on at FSRC. That’s what this group is really renowned for.”
To have MUSC become involved with a global research project of this scale is good for the institution, he said. Several faculty now are involved, and it brings in funding and training opportunities as well as opportunities for other projects. “There’s enormous interest in global health work here that’s unmet right now. We can also tap into all sorts of training programs to bring foreign students to campus, which is good for the school and adds to the diversity. All in all, it’s win–win.”
Beyond that, he thinks it’s just the right thing to do.
“We live in a global world. An uncontrolled AIDS epidemic is a humanitarian crisis that has consumed millions of U.S. dollars as we try to step up to that,” he said, adding that it also is an issue studied by the CIA as epidemics can destabilize governments and lead to huge social challenges, such as the alarming growth of orphaned children vulnerable to exploitation.
“There is a cost savings to the U.S. taxpayer. If we can figure out how to do this cost-effectively, we end up saving on our foreign aid budget. And, there’s a humanitarian aspect to this. As a leader in the world, we have some responsibility to use our expertise to help the rest of the world. That’s good for our country.”