Dr. Eugene McCray

EUGENE MCCRAY

MILLER: This is Dr. Bess Miller, and I'm here with Dr. Eugene McCray. Today's date is June 24, 2016, and we are in Atlanta, Georgia, at the Centers for Disease Control and Prevention [CDC]. I am interviewing Dr. McCray as part of the oral history project, The Early Years of AIDS: CDC's Response to a Historic Epidemic. We are here to discuss your experience during the early years of CDC's work on what would become known as AIDS [acquired immune deficiency syndrome]. I must ask, Dr. McCray, do I have your permission to interview you and to record the interview?

MCCRAY: Yes.

MILLER: I've worked with you and for you since the very beginning of this epidemic, Eugene, and it's a privilege to be able to reflect on this with you today. You have had a leadership role for many different aspects of this disease for your entire career. For this oral history of AIDS at CDC, we will initially be focusing on the early years, which began in June 1981 with the publication of 00:01:00the first Morbidity and Mortality Weekly Report on the five cases of Pneumocystis carinii pneumonia among homosexual men. But in view of your extensive experience with developing and implementing CDC's programs on AIDS in Africa and Asia, I'd like to take some time later in the interview to discuss this with you.

Let's begin with your background. Can you tell me about where you grew up and your early family life, and then where you went to college?

MCCRAY: Sure. I grew up in a rural area in South Carolina called Bishopville, South Carolina. My parents were farmers, and I grew up with five sisters and three brothers--a big family. So I learned to work with a large group. But anyway, I left home at about age 15 to start college and went to Morehouse College here in Atlanta. Then after graduating from Morehouse, I went on to 00:02:00medical school at Wake Forest University, did my internal medicine training at the University of North Carolina in Chapel Hill, and then came to CDC in 1983 after finishing my medicine residency.

MILLER: If you don't mind, I'd be interested--you left [home] pretty early at [age] 15. Were you the only one in your family that went to college, or how did that work?

MCCRAY: Actually, no. My mother is a very strong person, and one of the things she always told us is that "you graduate from high school, you either go into the military (if you're a boy) or you go to college (if you're a girl)." So all five of my sisters actually went to college. Four have college degrees or higher degrees. I went to college, but my other brothers all went into the military. So I have two brothers with a 30-plus military year career, and my younger brother has about a ten-year military career. So we all did exactly what she said.

MILLER: Wow. Great mom.

MCCRAY: But I left home at age 15 mostly because during those days if you were academically gifted, you skipped grades. So I skipped a couple of grades and started college a bit early.

MILLER: Where were you in the birth order in your family?

MCCRAY: I'm number three. During the family cohort that I was in, I was sort of the middle child, so I was always compromising and keeping peace at home.

MILLER: A good training for your future career. Who or what influenced you to go to medical school?

MCCRAY: That's a question that has been asked many times. Actually growing up, I didn't know anybody who was a doctor or even a nurse. When I was in college, I was initially a math major but took a lot of science courses. One of my mentors thought that I had an aptitude for medicine and my personality sort of fit, and 00:04:00I was encouraged by my mentor to apply to medical school. So I did it sort of as an afterthought. I took the medical college admission exams, did very well on them, and then applied to medical school. Of course, coming from a large family, a single mother because my father died when I was 12 or 13 years old, I knew that I could only go to medical school if I went someplace that gave me everything, and Wake Forest did that. They offered me a full ride, and of course I went. I enjoyed every minute of it and have never regretted going into this area.

MILLER: How and when did you get interested in public health?

MCCRAY: During my residency is when I actually got interested in public health. The medicine program at Chapel Hill provides you an opportunity to spend a fair 00:05:00amount of time doing community medicine. When I was thinking about my career after finishing my residency, I knew I didn't want to start private practice right away. I wanted to do an infectious disease fellowship. What happened is I was interested in hospital-acquired infections and had looked at a fellowship at the University of Virginia with [Dr. Richard P.] Dick Wenzel at the time. I learned about six months or so after applying that he was going to be leaving, and I decided to look elsewhere. I was encouraged to look at CDC, and so I did. I was also encouraged to look at the EIS [Epidemic Intelligence Service] program, because I was told that CDC had a great hospital infection control program. So that's how I ended up starting in public health. How I ended up at CDC is basically on the advice of one of my advisors at Chapel Hill who knew that I was interested in community medicine, population health, etc.

MILLER: Let's shift our focus to your work at CDC. So you came to CDC in July of 1983 as an EIS officer. By this time the syndrome was called AIDS. It was thought to be caused by an infectious agent, and [it was] known that male homosexuals, IV drug users, persons that had received blood or blood products, and possibly persons from Haiti were at increased risk of acquiring the disease. As of June 20, 1983, 1,641 cases had been reported. Can you tell us about your initial EIS assignment? Did you start working on AIDS issues right away?

MCCRAY: Actually, no. As I mentioned earlier, when I came as [an] EIS [officer], I came to CDC to do EIS, I got assigned to the hospital infection control 00:07:00program. My first year was really outbreaks. I did at least four outbreaks my first year. But during the second year, I wanted to get involved with a more long-term project, and I actually had the opportunity to take on a project that had been started by one of the former EIS officers. The project was looking at risk for occupational acquisition of HIV [human immunodeficiency virus], mainly looking at healthcare workers in hospitals and other settings who may have been exposed to HIV, either having blood or other body fluid exposures. That was my initial work that I did in HIV, and it actually was very, very informative.

The other thing that happened is during my EIS, I also volunteered at what was called the Atlanta Gay Center. During that time there wasn't much available to treat HIV, but I was involved in just counseling and educating people about AIDS 00:08:00and things they could possibly do to prevent transmission of AIDS. Most of the things were behavioral at that time.

MILLER: So before that time, two guidelines, recommendations, had been published in the MMWR regarding protection of healthcare workers, clinical and lab staff, and this is all prior to the identification of the virus. Then in March of '83, prevention of Acquired Immune Deficiency and interagency recommendations [were published]. So this was before you arrived, but can you describe a little bit about the thinking behind the development of these guidelines? What was the atmosphere among clinicians caring for patients at that time and the laboratory workers?

MCCRAY: Sure. As you mentioned, we did not know what the etiology was for this Acquired Immune Deficiency Syndrome, but we did know that the disease was being 00:09:00transmitted primarily by blood and/or sex. At least that's what the epidemiology was telling us, so we drew on our knowledge of hepatitis B and hepatitis B transmission in healthcare and other settings. The guidelines that were developed were really based on what we knew about hepatitis B and how it is transmitted. So we didn't know at the time that this HIV [human immunodeficiency virus]--which is what it would later be called--was probably less transmissible than hepatitis. But I think it was very insightful at the time to really do that, because I think it really offered a level of protection and a level of security for healthcare workers who were working in the area at the time.

MILLER: Tell us a little bit more about the atmosphere among healthcare workers 00:10:00at that--I mean it was a very emotional time. There's this new disease, surgeons don't want to operate, [there was] a certain level of panic. Had you seen AIDS patients yourself clinically before you came?

MCCRAY: I did my residency in Chapel Hill, and during my second year, as a second-year resident, I took care of several people who were dying from this disease. Of course, we didn't know what it was, and there was a lot of fear in Chapel Hill at the time. Nurses were actually refusing to take care of patients who were living with HIV, so as a resident and intern, we did a lot of the nursing care even because of that. When I came to CDC and got more involved, I spent a huge amount of time traveling and giving educational seminars to nurses, to prison guards, to a number of different folks in healthcare settings about 00:11:00risk related to transmission of this disease and the fact that if you use appropriate precautions, you can be protected. But we were basing it, again, on evidence that we had from hepatitis B transmission, because we didn't have much data on HIV transmission. The study that I mentioned earlier, the study that we were doing looking at trying to assess occupational transmission of HIV, actually helped to shed some light on risk, and I assume that we'll talk about that a little later.

MILLER: Yes, and I'm happy to talk about it now. So this was the so-called needle-stick study. Can you describe a bit about the study, who were the colleagues at CDC and collaborators, and what was the thinking in terms of the design of that study.

MCCRAY: Sure. So the study was designed as a prospective study, meaning that we 00:12:00were identifying people who had needle-stick exposure, exposure to either saliva or other body fluids in healthcare settings, primarily hospitals.

MILLER: Can you explain a little bit for the viewer: what does a needle-stick injury mean? What's the definition of that?

MCCRAY: A needle-stick injury primarily means an act where a needle actually punctures the skin. In some instances it's just a simple puncture of the skin, but in other instances it can be a puncture with actual injection of whatever the fluid or liquid is in the needle. This happens oftentimes in hospitals accidentally, when needles are not being discarded properly. It can also happen during emergency situations where a patient is being resuscitated, and in that 00:13:00process a bloody needle could accidentally puncture a healthcare worker and they can get small injections of blood. So those are the kinds of incidents we were talking about. Other incidents that we thought were important were incidents where people had open wounds or had I guess breaks in their skin, and then did not use gloves and actually had direct contact with body fluids: blood, saliva, other body fluids. We thought that those could potentially be high-risk exposures, so we also were following healthcare workers that had those types of exposures.

MILLER: So how did it work? Was there surveillance going on, active surveillance among healthcare workers, or was it just passive reporting, so to speak?

MCCRAY: So this was an active project, but the surveillance was actually [of] healthcare workers [who] volunteered to participate in the study. We had a national registry where healthcare workers, if there was an exposure, the hospital--and if the worker agreed--the hospital could enroll them in the study, and we would follow them prospectively. Every six months we would collect blood, and that blood was being stored, because if you recall in 1983 or '84 when the study was started, we did not yet know how to test to detect HIV. We knew that it was caused--I think we learned in '83 that HIV was the agent responsible for AIDS, but we didn't have a test, an approved test, until 1985. So we stored those bloods, and then when the test became available, we began testing them.

MILLER: Can you tell us a little bit about that national registry? Did that 00:15:00cover only major metropolitan areas, or how did you decide on the scope of that registry?

MCCRAY: It didn't just cover major metropolitan hospitals. Actually, any hospital that was interested could enroll healthcare workers, and there was basically a number of, I guess, options for them to contact us and get them enrolled. So, for example, there were hospitals as small as Albany Medical Center in Albany [New York] that were involved, and some community hospitals were involved. So it wasn't just large hospitals.

MILLER: Was it major metropolitan areas where you had already seen that there was an issue, or did it focus on New York and San Francisco and LA [Los Angeles]?

MCCRAY: So there were other areas. There were several areas where we had concerns or had seen some issues, but there was no clear documentation. There 00:16:00was anecdotal information, but we didn't have clear documentation that the AIDS that was seen in healthcare workers was directly related to a needle-stick exposure. It was important for us to try to document that as clearly as possible. So we did target large hospitals in San Francisco and New York, even here in Atlanta, Georgia, but it wasn't just limited to the large hospitals.

MILLER: And if anyone had a healthcare worker with AIDS that they suspected was transmitted in the healthcare setting, could they just call you, even though they weren't in the longitudinal--

MCCRAY: Yes. We were tracking healthcare workers with AIDS, and they were also being reported to our surveillance system at the time. So they were being captured in our surveillance system as well.

MILLER: Who were some of the colleagues at CDC that worked with you on this? Was this a big operation?

MCCRAY: Yes, this was a big operation, and it involved a number of different entities within CDC. For example, our HIV laboratory at the time was very 00:17:00engaged in this work. Guys named [Dr.] Martin [S.] Favero and Charles [A.] Schable were actively involved in this work. I was sitting in the Division of Hospital Infections, but I worked very closely with colleagues in, at that time, I guess it was called the HIV AIDS Program. So I worked very closely with colleagues in the HIV AIDS program, but also because this work involved hospitals, there were other colleagues within the hospital infection program that I worked with. Of course, state and local health departments were very much a part of this work. We wanted to make sure colleagues working in the HIV programs or AIDS program in health departments were engaged, because they served as an important source for identifying these kinds of exposures and getting them enrolled in the study.

MILLER: Did you personally get involved with meetings with clinicians? Are there some clinicians that stand out in your mind that were very vocal and involved in this study?

MCCRAY: Yes. Actually, our former director, Dr. Julie [L.] Gerberding, was quite vocal and engaged in this project, but there were also--you're stretching my memory here---but there were also colleagues in New York, in San Francisco, which is where Dr. Gerberding was. Then of course, in New York State a nurse--why am I blanking on her name--there was a nurse that was very much involved. Rachel Strikof was a nurse in New York State who also worked part-time with the department of health and was very engaged and actually was a part of 00:19:00the investigation of the first documented case of HIV transmission related to a needle-stick exposure. But Rachel definitely sticks out in my mind because that was a very seminal event, and I made several trips to New York State to meet with the clinician. Actually, I met with the affected healthcare worker also.

MILLER: So did the study change at all once the antibody test became available?

MCCRAY: Yes. The study was actually enhanced. Once the antibody test became available, we began to test the specimens almost immediately. Then, of course, when a person got an exposure, you tested them initially, and then, as I mentioned, we tested them every six months. Once the antibody test became available, the testing was more frequent. We were getting blood draws at three months, at six months, at nine months and at 12 months, and then continuously. 00:20:00If, after 12 months, there was no evidence of a seroconversion (going from negative to positive status), then we didn't continue to do routine surveillance on that individual.

MILLER: So what were the big findings of this study?

MCCRAY: The big finding from the initial study was that almost all of the documented seroconversions were in patients that had documented exposure to blood, and typically they were injured by a large-bore needle, something that's either 18 gauge or larger. That was critically important, because it really emphasized or really provided good evidence to justify that casual exposure to 00:21:00blood to other body fluids was not really a risk. We later learned that a lot of the risk was related to the concentration of virus in that fluid. So we learned that exposure to blood, almost an injection of blood, was really what was the primary cause of transmissions.

MILLER: And could you estimate how many cases like that there were? Are we talking a fairly small--

MCCRAY: It was less than 1%. In the study that I was involved in, we only had--in the initial report we only had one seroconversion in almost a thousand healthcare workers. It was pretty low, and that percentage was even lower as the number of healthcare workers expanded. I couldn't estimate what it is today, but when you look at surveillance data, healthcare workers with AIDS or HIV that 00:22:00doesn't have any other risk are very low, well under 1%.

MILLER: So the results came out. Did recommendations and clinical practice change then? How did that follow through?

MCCRAY: What happened as a result of the studies [was that] the recommendations that had been published previously were enhanced. We specifically could provide good evidence to basically say that when you're working or taking care of AIDS patients, universal precautions are critically important, and especially paying good attention to exposure to blood and other body fluids. In addition, there was a lot of work done to develop tools that would prevent needle-stick 00:23:00exposure, because we knew that needle-stick exposures were the highest risk. So there was a lot of effort working with manufacturers, etc., to produce needle-stick--resistant equipment so that healthcare workers, even in the best of situations or the worst of situations, would not get needle-stick exposure. Then there was a lot of education about recapping needles, because one of the things we saw and learned as part of the study was there was a long history where people were recapping needles. Our recommendations changed regarding that, and we had specific recommendations regarding non-recapping of needles and using needle disposable equipment and disposing of the needle in that equipment in a safe and effective way.

MILLER: So a big profound--

MCCRAY: Yes, a big profound change, yes.

MILLER: You mentioned universal precautions and hepatitis precautions. Can you 00:24:00briefly state what that is?

MCCRAY: When we talk about universal precautions, we basically are saying to healthcare workers, when people come in to the hospital, you may not know that they are infected with HIV. So we were recommending that for all patients you apply basically what we call universal precautions, meaning that you apply blood and body fluid precautions [to] everybody--and if you have somebody with a known infection, you still should do that. One of the challenges which I want to highlight is that what was happening in many hospitals was, if somebody came in and had a diagnosis of AIDS, there were these signs that they were putting on folks' doors that basically suggested you shouldn't enter the room unless you wore gloves, masks, etc. That was creating a lot of stigma, and there was a lot 00:25:00of misinformation about that. It was really important for us to implement this idea of universal precautions, so that you don't further stigmatize individuals when they are admitted to the hospital with HIV. You should be basically practicing good precautions on everyone, including blood and body fluid precautions.

MILLER: So that was the 'universal.' It's not every kind of precaution, it's that it's universal in that it's [applied to] everyone.

MCCRAY: That's right. It's universal regardless of knowledge of patient status.

MILLER: Okay, interesting. And the blood and fluid [precautions] might involve gowns and gloves.

MCCRAY: That's right. If you're involved in a procedure where you know there might be opportunities for blood or body fluids to be aerosolized or splattered, that's when you need to make sure you are taking on blood and body fluid precautions, wearing gloves, wearing gowns, [and] in some cases wearing a mask 00:26:00with protective shields.

MILLER: That sounds like it was a very worthwhile study.

MCCRAY: Yes.

MILLER: I'm sure there were some anxious times in the public. Did it take that finding to get the surgeons to begin to be willing to operate again, or was it before the results were known?

MCCRAY: No, I think this study really helped influence a lot of that, because we now had data to show that if you do the right thing, you could prevent transmission. So I think it helped with surgeons, it helped with the dentists, because it helped us in terms of providing better information to dentists about the things they should do to protect themselves and to protect patients. It wasn't just one-way, it wasn't just the patient that we were concerned about, it wasn't just a patient transmitting to a healthcare worker. There were also 00:27:00concerns about healthcare workers transmitting to patients, because, as I mentioned, there were some healthcare workers who were living with the disease but healthy and able to continue practice. So we had to think about both sides of the coin.

MILLER: Thank you. Well, several years later, around 1988, you began working on the so-called Family of HIV surveys, which began in 1987. By then, over 30,000 cases of AIDS had been reported in the United States. This was another enormous undertaking. Can you describe this activity a bit? What were the settings, what was the impetus to do this study?

MCCRAY: At that time we had what we called AIDS case surveillance, and we knew that once people were diagnosed with AIDS, it only represented what we called the tip of the iceberg. There were many more people living with HIV who had not 00:28:00gotten to the point of reaching symptomatic AIDS. So it was really important for us to get a sense of how many people in the U.S. might be infected with this disease, with HIV. So the surveys that we did, the "Family of Surveys," was really a series of surveys that targeted HIV testing in certain specific population, ones that we considered to be high-risk populations. We focused on sexually transmitted disease clinics [and] tuberculosis clinics, because we knew that patients who were diagnosed with tuberculosis were--we knew that HIV patients were at high risk of acquiring tuberculosis. We also focused on family planning clinics, because it was important for us to have some sense of information on childbearing women and their infection risk. We looked at drug 00:29:00treatment centers, so one of the surveys focused on drug treatment facilities. Then there was a neonatal survey, where we actually did surveys to look at HIV status of mothers who were having children in the U.S. Then we did some sentinel surveillance in hospitals in the U.S., especially high-risk hospitals. This was, as you say, indeed a huge undertaking. We didn't do it in every single place in the U.S. We did what we called sentinel surveillance, so there were sites that we identified in states and cities where we knew there were significant problems. But we also wanted to go to areas where there wasn't a lot of HIV being reported, so that we could have some sense of what it looked like across the U.S. And these data were critical in forming our later transition to HIV reporting as a national strategy.

MILLER: So this one was done in many, many metropolitan areas. How was this funded, and where was the support for something that was this big?

MCCRAY: Almost all of the funding was federal funds, and the support in terms of funding came from the federal government. There was a huge staff at CDC that was responsible for developing the protocols, working with state and local health departments and implementing the protocols. But it was actually the folks in the cities, in the STD [sexually transmitted disease] clinics, in the drug treatment centers, the staff in the health departments and those clinics that really did a lot of the data collection and specimen collection that allowed us to be able to 00:31:00test people for HIV. Then, of course, our lab did a lot of the testing, so it was a huge, huge effort.

But the sentinel surveys also allowed us to develop some innovative approaches to testing. Dried blood spots, for example. This is where we used filter paper. You can get a small sample of blood, put it on a filter paper, and it dries. You can bring it back to the lab and they can then test it for HIV. That was a technology that was developed during this period and has been very helpful even today, in terms of helping us be able to test more in areas where there may not be the ability to draw blood and do serum testing and so forth. So this involved a huge amount of work by a lot of folks, both at CDC and in the field, and of course our colleagues at NIH [National Institutes of Health] were collaborating 00:32:00with us on much of this work.

MILLER: Are there some names that stand out in your mind of colleagues at CDC?

MCCRAY: Wow, there are lots. Dr. Tim Dondero was actually the chief of the HIV Sero Epidemiology branch, and not my direct boss but the director for the branch. Then of course my supervisor, Dr. Ida Onorato, actually led the surveys that were based in clinics. She was my direct supervisor and really was very influential in helping convince state and local health departments to participate in the survey. There was not a requirement that they do, but we had to really show them how this was important to them and important to the nation. She was very influential in doing that. Of course the leadership at the time, Dr. [James W.] Curran, was tremendous. I mean, he was the vision for all of this 00:33:00work. Of course there were many states that played an important role. New York State at the time played a very important role, and I don't recall the specific names there, but at NIH there was Dr. [Harry W.] Haverkos. I don't know if you remember him, but Dr. Harry Haverkos was a very important collaborator, and he actually worked with us on the surveys as well.

MILLER: What were the big findings? What were the impacts of those surveys?

MCCRAY: The basic finding for the surveys in clinics [was that] we were able to show there was significant HIV prevalence among STD patients, TB patients and people attending drug treatment centers. That was actually consistent with what 00:34:00we were seeing in our national surveillance systems for AIDS. When we looked at women of childbearing age, we were able to document the level of HIV prevalence among women of childbearing age, and in the U.S. at the time it was well under 1%. Then when we looked at family planning clinics, we were able to identify women who were at high risk, especially women who had history of drug use, who had history of multiple sexual partners, who had history of exchanging sex for drugs or money, things like that. So we were able to identify some key high-risk populations in the U.S. that we needed to target our prevention efforts to.

MILLER: How was that done? Was it so-called anonymous testing, or was it so-called blinded testing? Can you explain the difference between those and what you used for those studies?

MCCRAY: In the STD clinics it was what we called anonymous testing, basically 00:35:00meaning that--sorry, blinded testing, not anonymous testing. Blinded testing. So basically when the client came in, the clinic had the names and so forth, but they completed a form that had no personal identifiers. It only had an ID number that identified the client, and that ID number was linked to all of the specimens that were collected. There were no personal identifiers, so it was considered blinded. There was no way for us to then provide a result back to the client, so it was what we called blinded testing. There were instances where anonymous testing was done as part of an effort to get citizens who were interested in knowing about their status. They could go to an anonymous testing site and get tested, and they got their results, but no one else knew about 00:36:00their results. We did not capture those kinds of information. Our information was only captured in these sites in the clinics where we were doing what we call blinded testing.

MILLER: For the blinded tests, did those patients ever get their results or they never did? And what was the debate? Obviously, as time went on and the world changed and there were more things to offer patients, that was discarded, but for those earlier years, was AZT [azidothymidine] available in 1988 and '89?

MCCRAY: AZT became available in 1987, but it was not widely accessible at the time.

MILLER: So what was the debate about?

MCCRAY: The debate was about the ethical [question]--was it ethical to test people and not give them their results. So as part of the protocol for the 00:37:00surveys, every person that got tested was provided an opportunity to go and get an anonymous test or even get tested with their name, by name, etc., so they could be referred. Even in that same STD clinic, there were provisions for anonymous testing so the person could learn their status. So that was the way we dealt with it when we were doing the surveys.

But as time went on, of course, and when AZT became available, then later when DDI [didanosine, one of the early AIDS drugs] or when NRTIs [Nucleoside Reverse Transcriptase Inhibitors] became available, we then had to rethink and relook at what we were doing. I don't recall the exact year, but at some point it was 00:38:00considered unethical to do blinded testing. When you test a person and they test positive, we felt that it was critically important for them to know their status so that they can then do things to protect themselves and protect their health, as well as prevent transmission to others. We were beginning to get data at that time that showed that just knowledge of status changed people's behavior in terms of decreasing their risky behaviors.

MILLER: So this was, again, probably pretty expensive. In retrospect, do you feel like it was worth the effort? Was that a good initiative?

MCCRAY: Yes, I think it was a very good initiative, and I think it was definitely worth the effort. If you recall, there was really not much available in the mid 80's and up until the beginning of the 90's in terms of preventing 00:39:00risk. So having people aware of their status was critically important to really affect change and behavior. Also just awareness of status sometimes helped people do other things in terms of educating friends and partners and others about things--if the partner is negative--things that they should be doing to prevent transmission. What we could offer people then was only supportive care, and for those who were negative, behavior change, so there was a lot of effort put on that. I think the largest impetus for behavior change was people who were infected who basically talked to their friends and talked to their partners and actually mobilized the community to affect change, because AIDS was a death sentence and you didn't want to get infected with this virus. So there was huge motivation in the community to stay uninfected, and it was really being driven 00:40:00by, I think, the people who were infected. I think the public health response at the time was not where it needed to be. It was the community response that really made the difference before the treatment era.

MILLER: It's 20/20 hindsight. Do you wish that you had given the results earlier in the serosurvey studies, and did Act Up [AIDS Coalition to Unleash Power] and other community representatives want that? There were risks and benefits to doing that.

MCCRAY: Yes, there were risks and benefits. At the time I think it was the right thing to do, because even before we started the survey there were some ethical consultations, but those consultations were primarily within the scientific 00:41:00community. It was later in the epidemic that we began to engage the advocacy community more in this effort, and groups like Act Up played a major role in helping us think through this. And, yes, in 1988 when Act Up became very active and engaged in this process, it did make a huge difference. They were pushing for us to make sure people were aware of their status, although it was interesting, because there was still a large cadre of people who were saying, why should I know my status when there's nothing you can do for me? This was in '88 when AZT was just becoming available, but only a few people, only a limited number of people had access to it. People didn't want to know their status, because it was a death sentence basically that affected their mental health, it affected their relationships with others, etc., etc. So getting people to want to get tested was a challenge. It was really a challenging time, but I do think 00:42:00that at the time when we were doing the surveys, it was the right thing to do not to provide people their results directly. It would have inhibited people from participating in the survey, and we probably would have gotten really biased results. I do think that when treatment became available, it [withholding results] did become unethical. It was the right thing to do, and Act Up pushed us in the right direction; Act Up and others pushed us in the right direction.

MILLER: Thank you. That was a fascinating time.

MCCRAY: Yes, it was.

MILLER: I guess moving toward the last big area I wanted to cover, and that is the Global AIDS Program, the international work. So in 2000, you assumed leadership as the Director of the Global AIDS program at CDC. This was the beginning of a very large presence for CDC internationally. Can you describe the 00:43:00early days of this initiative? I believe it was called the Life Initiative at that time.

MCCRAY: Yes. The Life Initiative, or the Leadership and Investment in Fighting the Epidemic. I think the initial funding was in 1999, and the program started in 2000. It was a very challenging and wonderful opportunity. We had in the late '80s, early '90s begun to document in Africa that there was a heterosexual epidemic, and it was much worse than we could imagine. Uganda was one of the first countries where this had been seen. There were people like [Dr.] Helene Gayle, people like [Dr] Kevin De Cock and others who were spending a lot of time in Africa for other reasons, [and they] were beginning to see this and telling 00:44:00us that this was happening. So it was really wonderful in 1999 when President Clinton provided initial funding to support this initiative. So our initial efforts involved trying to get programs up and running in about 15 countries. Actually, it was 12 in Africa and three outside of Africa, [one in] the Caribbean and two in Asia. So it meant there were a lot of people involved, including you, and it meant working together with the leadership in the country, primarily the ministries of health, primarily the AIDS program, and working collaboratively with other partners to develop a comprehensive program focused on HIV prevention.

Remember at that time, there was treatment available in the U.S., but there was nothing in place to provide and support treatment in Africa. So our initial 00:45:00early years were really focused on primary HIV prevention and not on treatment. It was called the Life Initiative. Then in 2000 with changing leadership in the White House, there was additional funding. When the funding was increased, it became then something called the Global AIDS Activities and then the Global AIDS program. So the funding was increased, and with that funding increase, we were expected to increase our presence in Africa and Asia. Then we began to move into South America, Brazil and Central America. So this increased funding was very useful, because it did allow us to expand, but again, to focus on prevention.

But one of the things that happened early during the second year of the initiative is that there was a big push for us to really provide treatment. The 00:46:00treatment that we were providing at the time was all palliative care. The care was all palliative, basically just supporting people, treating opportunistic infections, etc. But treatment became a big push, and I have to say that Act Up and others were very much a part of this. I think one of the things that happened with support from leadership [was that] we were able to do a number of treatment demonstration projects in Africa to show basically that if you treat folks in Africa, their adherence was just as good. It could be just as good as in the U.S., and we could have basically the same or better outcome, and there were a number of studies that were able to demonstrate that. There were studies done by NIH, there were demonstration projects that we did, and then by the year four, by 2004, we were transitioning to not just prevention in Africa but also 00:47:00treatment. Of course, later the office of the Global AIDS Coordinator was established as part of PEPFAR [President's Emergency Plan for AIDS Relief].

MILLER: So in those early years you were in 15 countries. Can you describe a little bit more about what CDC's presence was? There were field stations; there were personnel. How did that develop?

MCCRAY: Yes, so the 15 countries that we worked in, the strategy was to really work with the country to develop a country plan. But that country plan would be implemented collaboratively by CDC staff that were assigned to work in those countries, as well as the ministry of health and other partners. So we did in 00:48:00all of those countries have specific staff that were assigned. We usually ended up having a country director, who was usually an epidemiologist or a medical officer, and other key support staff. Surveillance was important, prevention was important, so we ended up having key staff that supported some of those core areas. But we also wanted to make sure we had local staff employed and working as part of the response. So in all of these countries we developed country officers. Those country officers worked very closely with the ministry of health and primarily the AIDS program, and we also worked with partners that helped with the implementation of our programs on the ground.

MILLER: So surveillance and prevention. Can we start with surveillance? Let's take some of the countries in Africa. They're all different, and they had very different systems. Let's take Uganda or Kenya, some with maybe better 00:49:00surveillance potential. How was that developed in some of the countries? What were some of the challenges there?

MCCRAY: Sure. So when we hit the ground in many of these countries, there was no real surveillance happening. So we didn't really have a sense of what was really going on. One of the things we did was work collaboratively with partners, including at the time UNAIDS [The Joint United Nations Program on HIV/AIDS]. We conducted national surveys to try to understand what was going on with HIV infection, because it was clear that trying to do routine AIDS surveillance as we had done in the U.S. was not going to be an effective strategy. So we initially embarked on national surveys to try to better understand what was going on.

MILLER: And how might that work? An example of a country--

MCCRAY: Yes, it's basically you go in using a population-based approach. You 00:50:00identify a sample of areas where you want to do testing. You basically do something similar to what we had done in the U.S., where you go in, you do an interview, and you collect blood samples and you test those samples. But you do it basically based on a population-based approach, and then you come up with estimates of infection for the country.

MILLER: And the lab was--were the specimens sent to CDC in Atlanta?

MCCRAY: It depended. The goal was not to have specimens sent to CDC. There were regional labs that were established that we worked with, but in some instances specimens were sent to CDC. I need to back up, because even before we started doing the national surveys, we started implementing surveys focusing primarily on childbearing women, and those were the early data. The first data we were 00:51:00able to get were looking at women of childbearing age and having a sense of what that rate was. Then looking at population information, we extrapolated the data we got from childbearing women to the entire population. So that was the first step, and then later we started doing a more population-based survey, where we sampled both men and women. Most of the laboratory support for that was done by WHO and CDC and then regional labs that CDC helped to establish. The goal was, and I think we're there now, was to establish laboratory support in every country that could actually do this work. We are there now, and we've been there now for a number of years, but, of course, the quality varies in some countries. It varies country by country.

MILLER: So with the early sentinel surveillance, what were the findings? Were 00:52:00they shocking, and what were you finding?

MCCRAY: Yes, some of the data were quite shocking. For example, in some countries like Botswana we were finding data, the early data were showing that one in four women living in Botswana of childbearing age was infected with HIV. In Uganda that percentage was lower, but it was well in the teens, between 10% to 15%. That's what we were seeing in a lot of the countries in eastern Africa, where we had women of childbearing age having infection rates that were much, much higher than what we were seeing in the developing world. Similarly, when we went to places like Asia, the rates were a lot lower, except in certain special populations. So when you looked at women of childbearing age, the rates were much lower, but when you looked at drug users and looked at commercial sex workers, etc., those rates were much higher. It was a much more focused epidemic 00:53:00involving specific populations in Asia, but in Africa it was a much more generalized epidemic involving general population, heterosexuals, etc.

MILLER: So I know that you made many, many visits to countries. Can you describe a bit about what AIDS clinics or hospitals caring for AIDS patients were like at that time?

MCCRAY: Wow. It was very challenging and somewhat depressing. Because AIDS was such a problem in Africa, hospitals were completely overwhelmed. You would go to a ward that should be housing 20 people, and you'd sometimes see 60 people. There were instances where you'd go into the ward, and you'd have one bed and you'd have a patient in the bed and a patient underneath the bed, because the hospitals were completely overwhelmed by HIV and there wasn't much that could be 00:54:00done. Even palliative care involved just making sure they had food and water and so forth. Drugs were not available to treat their Pneumocystis carinii pneumonia, to treat their Kaposi's sarcoma, to treat the other opportunistic infections that they had. So patients went to the hospital to die, partly because some of the communities didn't want them in the community. There was so much stigma associated with being diagnosed with AIDS.

MILLER: So you've mentioned this a bit, but prevention was the basic tool. Can you describe a little bit about what the prevention strategy was at that time and the political climate around that?

MCCRAY: The prevention strategy included what we called the ABC's: abstinence, 00:55:00be faithful, use condoms with every sexual encounter. This really became the mantra during the PEPFAR era, partly because of the political environment at the time. There was a strong push by the conservative element to really push abstinence, even though we didn't have a lot of data to support the effectiveness of abstinence. So countries had an opportunity to adopt a combination approach. Many countries had abstinence as a base for their response, but we knew that in many places that was not going to work.

Being faithful: let me explain a little bit what that was all about. One of the things we knew was that in many of the African countries, having multiple sexual 00:56:00partners was a common occurrence. Especially men had many sexual partners, and for women who were not married, it was not unusual for them to have multiple sexual partners. So the idea of being faithful was really to try to encourage the males and females to be faithful to one partner. Then, of course, condoms were really the only tool that we had in terms of a structural intervention to help prevent transmission of HIV. Of course, there were lots of behavioral interventions where people were getting counseling support. When one would get tested, if they were negative, you usually would say, that's wonderful, but these are the things that you can do to protect yourself: use a condom every time, know your partner, etc., etc. For people who were positive, in addition to 00:57:00encouraging them, really instructing them to use a condom with every sexual encounter, you talked about other things that they could do to reduce their risk of transmitting the disease to their partner.

MILLER: So this was a strategy, but the funding was also tied to this approach, isn't that right?

MCCRAY: Yes. I don't remember the specific details, but there was a certain percentage of the funding that had to be used to support an abstinence-only program. That was actually measured and assessed on an annual basis in each of the countries. But during this time some of the countries were very--they understood what their epidemic was about, and they understood better than we did what worked and what didn't work. There were some countries that did not accept this idea of having abstinence be a major pillar of their program. They did 00:58:00implement abstinence-only programs, but in those programs they also talked about if you are not able to abstain, these are other things you can do to protect yourself: you can use a condom, you can limit your number of sexual partners, etc. So rather than just saying abstinence only, it was abstain, but if you're not able to abstain, be faithful and use a condom.

MILLER: And then you moved into the drug era, and that was towards the end of your leadership.

MCCRAY: Right.

MILLER: What would you say were some of your major challenges in directing this program, and of course, there were many.

MCCRAY: Yes. There were a number of challenges administratively. Administratively, CDC had a history of working internationally, but mostly to do research. We did not have the experience establishing programs where we had a physical presence on the ground working with a country. So having the authorities to do the work we needed to do, the federal authorities, to do the work that we needed to do internationally didn't exist at the time this program was being developed. So we met many challenges just trying to get our presence established in countries. Thanks to some support we got from the State Department and from the U.S. Agency for International Development, we were able to get some things done, and that has improved over time.

I think a second challenge was the level of capacity that existed in-country to do this work. The ministries of health, especially the AIDS programs, had 01:00:00limited capacity and technical capacity, as well as human capacity. So we had to address that at least temporarily, during the first three years or so, by bringing in partners to assist the ministry of health in doing their work. We brought in partners like the National Alliance of State and Territorial AIDS Directors to help these programs establish strategies and so forth. We brought in the Association of Public Health Laboratories to help countries establish public health laboratories, because public health laboratories didn't exist in many of these countries. When they existed, they weren't really serving a public health function, they were basically serving a diagnostic or clinical function. Then we brought in universities and other partners, international NGOs [non-governmental organizations] to come in and work with partners in the community, to work with hospitals to help establish treatment programs, etc.

So there was a lot of capacity that needed to be built in these countries, and then, of course, the financial--the ability to manage money. There was a lot of money coming in, both from the U.S. government and from other partners, and many of these ministries of finance and ministries of health didn't really have the capacity to manage the funds. So inappropriate use of funds and loss of funds were challenges we had to deal with. There were many challenges, but I think the challenges were worth it. When you see what's happening with the epidemic today, I feel it's definitely been well worth it, because we're seeing decreases across the continent and I think it's been very effective.

MILLER: Thank you. I'd like to close with just a few questions about the personal aspects or impact of your work on AIDS. You were a part of something that changed the history and course of public health. How has that affected you personally?

MCCRAY: Well, for me it's been very rewarding, but it has had a personal impact on me. I'd like to just acknowledge I am a gay man, and when I got involved in this epidemic in the 80's as a physician, it was an easy thing for me to do because I had friends who were dying from this disease and who died from this disease. I have a whole cohort of friends that died in the '80s and early '90s from this infection. Personally, I was also involved in caring for people living with HIV/AIDS, because in my 4th year at CDC, when I became full-time staff and I finished my training, I was allowed to work one day a half day each week in a primary care HIV clinic. I actually took care of people who were being diagnosed 01:03:00with and living with HIV, even before drugs were available and then later when drugs became available. So at a personal level, it's been very rewarding for me to be a part of a big effort, both in the U.S. and globally, that is really providing care and support to so many people.

For me, seeing the transition that happened, from the 80's where we had nothing, to 1995 when HAART, which is Highly Active Antiretroviral Therapy, became available, and now having friends who have been living for 30 years with HIV who are healthy, who are virally suppressed, who are living basically normal lives, is so rewarding. I think the challenge we have now is the younger generation who are in their 20's, mid 20's and younger, who've never seen a person die from 01:04:00this disease, waste away and die from this disease. That had an impact on me and my generation, because we saw that and we know how important remaining uninfected is. But the younger generation hasn't seen that. Also the people they know that are living with HIV are living and they're healthy, they look well, they are well. So that has had an impact on the younger generation. I'm concerned about what we're seeing in terms of trends in young people, not just in the U.S. It's also beginning to happen in Africa, where we're seeing increasing trends in HIV incidence and diagnosis in young people. Personally I would not have done it any differently. I've had 30-plus wonderful years working in public health, both at CDC and working as a clinician, and also I've been 01:05:00engaged in the community a lot and will continue to be engaged even after I leave CDC.

MILLER: What impact did it have on your subsequent professional work? Are you still working on AIDS?

MCCRAY: Yes, I am. Approximately I guess 19 months ago, I accepted a position to serve as the director for the Division of HIV/AIDS Prevention, which is our domestic HIV program. So I'm very engaged still, and that work is also very rewarding because for 15 years I was away from the domestic HIV work. It's been a huge learning curve for me, but it's also been a very rewarding experience. There are many things that I learned from my experience working in the international environment that I find transferable to what we're doing here in the U.S. and vice versa. So I think that it's really important as we move 01:06:00forward that we learn from each other. In Africa they have a hundred times more people on treatment than we do in the U.S., so we can learn from some of the successes that they're having with treatment in Africa. We're having great successes in the U.S., but we still need to learn from each other.

In the U.S. also the number of people being diagnosed with HIV has been decreasing, so we don't have a huge pool of new infections, which limits our ability to do important research. But there is important research we can do in Africa and Asia and other parts of the world, where there's a lot more HIV infection, that really has direct application to what we're doing in the U.S. I think that one of the things I'd like to end by saying is that I believe that today--I know, not believe, I know that we have the tools to really end AIDS 01:07:00globally and in the U.S. Well, the U.S. is part of the globe, and the biggest challenge we have is making sure those tools get to the right people in the right places and in the right combinations. I'm talking about things like treatment. We know that getting people on antiretroviral therapy and supporting them so that they stay on those drugs, [they can] remain sustainably virally suppressed. Having their virus stay at a low level, they are healthier and they will limit their transmission of virus to their loved ones. So treatment as prevention is something that we know works.

The other thing is that for people who are negative, we now have the ability to put them on what we call pre-exposure prophylaxis [PREP] as a preventive. You take a pill one time a day, and you can prevent transmission. It's very 01:08:00effective. Everybody is not going to be eligible for PREP, but it can be very effective in preventing transmission from folks who are in discordant relationships, meaning where one person is positive and the other is negative, and in a number of other high-risk situations. Finally I would say that there's a large pool of folks who are not at high risk but may be sexually active periodically. There are other effective interventions like condoms, like counseling, risk-reduction counseling and things like that, that can help individuals. So we have the tools. We just need to make sure they're getting to the right people. For us in the U.S., access is really critical, and young people, I mentioned before, is the group that I'm most concerned about.

MILLER: In retrospect, is there anything that you wish CDC had done differently? 01:09:00You've described many, many wonderful initiatives that CDC did.

MCCRAY: I think that early in the epidemic if we had engaged the community more, I think we would have seen quicker and better outcomes. Because I think we were a little slow and because we didn't really know what to do, the community taught us a lot, and they continue to teach us a lot. In my new role I don't really embark on anything without getting input from the community, because it's the people who are living with the disease and who are affected by the disease that can tell us what's going to work for them. So I think the community engagement was the one area where I think we fell short early in the epidemic. Part of it--it's not a fault, we just didn't have the talent or the right individuals 01:10:00around at the time that really knew how to engage the community. But it's something that we've learned, and I think we do it much better now, not just domestically, but I even think we do it much better internationally. I have to give my kudos to organizations like Act Up that were in our face, throwing blood on us and doing many things to really get our attention, and we had to respond and we did. So I'm really proud of what we did, but I do think that we could have been more effective if the community were more engaged earlier.

MILLER: Thanks very much. Excellent.

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