Dr. Jonathan Mermin



MILLER: This is Dr. Bess Miller. I'm here with Dr. Jonathan Mermin. Today's date is August 22, 2018, and we are in Atlanta, Georgia, at the Centers for Disease Control and Prevention. I'm interviewing Dr. Mermin as part of the oral history project The Early Years of AIDS: CDC's Response to a Historic Epidemic, the PEPFAR Years. We are here to discuss your experience during the early years of CDC's work on PEPFAR, the President's Emergency Plan for AIDS Relief. Dr. Mermin, do I have your permission to interview you and to record this interview?

MERMIN: Yes.

MILLER: Jono, you have worked passionately on the HIV-AIDS [human immunodeficiency virus, acquired immunodeficiency syndrome] epidemic since the early days in college at Harvard [University], as a medical student at Stanford [University], and as an internal medicine resident at San Francisco [General Hospital]. At CDC, you served as Director of CDC Uganda during the critical years between 1999 and 2006, including the early PEPFAR years when 00:01:00antiretroviral therapy became a reality for Africa. You then served as CDC Director in Kenya, overseeing a broad range of infectious diseases. You came back stateside in 2009 and served as Director of the Division of HIV-AIDS Prevention until 2013, when you assumed your current position as Director of the National Center for HIV-AIDS Viral Hepatitis, STD [Sexually Transmitted Diseases] and TB [Tuberculosis] Prevention. You have done so much, and yet it always seems as if you are just getting started. Let's begin with your background. Would you tell me about where you grew up, and your early family life?

MERMIN: I grew up in the Bronx, in New York City. My father died when I was four. I have a twin sister and an older brother. When we went to school, I think one of the important ethos for our family was that you had to pay a lot of 00:02:00attention to academics and you had to care about the people around you. My mother made sure that we thought about that, both (with) our individual lives and the context for how we were living within the broader community and nation.

MILLER: You went to college at Harvard. This was 1983, and there were already 3,000 AIDS cases reported in the United States. The cause of AIDS had been identified at the Institut Pasteur in France. You were already very interested in HIV/AIDS at this time. Can you tell us a little bit about that?

MERMIN: To some extent it was happenstance. I was studying in school, and I had the opportunity to take an independent study. There was a prominent professor, 00:03:00[Dr.] Ruth Hubbard, who had written a lot on bioethics, and the most important thing for me at that time was (that) I'd really like to spend some time and learn from Professor Hubbard. I went to meet with her, and I said, "I want to study anything." She said, what are the areas of interest to you? I mentioned a few, and I said, "-- and then there's AIDS." She said, "You know, I don't know a lot about AIDS. Let's work on AIDS." So, I spent that semester writing a paper about what was going on with AIDS. I was also at that time a work-study student with a professor in a circadian rhythm laboratory at Brigham and Women's Hospital. That professor was also interested in AIDS. His name was [Dr. Charles] Chuck Czeisler, and he ended up establishing a study group on AIDS and public 00:04:00policy that brought together the Kennedy School of Government, the School of Public Health and the Harvard Medical School, to look (at) and examine some very specific topics related to policy. Should there be premarital screening for HIV and other issues that were going on at the time. He had representatives on that group from the city health department, the state health department, all the academia, and folks who were actually running clinics in Boston. Many of the people like [Dr. Jerome E.] Jerry Groopman and [Dr. Kenneth H.] Ken Mayor, and [Dr. Martin S.] Marty Hirsch were already prominent in the field. He said to me, "I just heard you did this independent study on AIDS. Why don't you take a year off from school and come work for me and help me establish this thing?" I said that would be fantastic. So, I dropped out of school for a year and ended up helping to establish that study group and learned a lot at the time. This was a 00:05:00time when there was a letter in the Boston Globe that recommended that all people with AIDS be quarantined on an island off the coast of Massachusetts. There was a lot of fear. People were concerned about their own health. They were concerned that this disease might spread. There was discrimination and a tremendous amount of stigma. I think I started in the field within that context of the social and economic environment that had led to some of this. Also, the fight for gay rights at that time was inextricably combined with AIDS. That really started my interest, and I continued to do HIV work really for the rest of my life.

MILLER: Who influenced you to go to medical school then?

MERMIN: I became interested, I think, because I was interested in AIDS. I wanted to make a difference. It might be considered trite, but it was really (that) I felt (I was provided a) gift that I had opportunity. The hard part was, how do you pick--how do you pick (from) all these options? To some extent you have to pick because you have to graduate from college. I really enjoyed the idea that being a doctor would give you tools, that if times were rough, you still could feel like you were helping people. I also really liked individual care. I had been an emergency medical technician [EMT] briefly, and I had been a Candy Striper at the local hospital. I tried to get a feel for what it would be like to actually care for people in their time of need. I was both intimidated by it, realizing there's a lot to learn and it's scary to make a mistake, but also realizing, wow, if I could get those skills that would make me useful. I think 00:07:00there was an underlying desire that somehow, I wanted to have utility, and medical school was an option.

MILLER: Where did you go to medical school?

MERMIN: I went to Stanford [University].

MILLER: This was 1987 to 1992, I think. Did you see AIDS patients during your medical school?

MERMIN: I did. This is essentially the beginning of the peak of HIV in the United States. By the time I went to medical school, the Bay Area was experiencing thousands of people with HIV. I chose Stanford partially because it was warmer, and I found Boston really cold. If you took five years instead of four years for medical school, you could actually pay for most of your tuition. So, I ended up with very little debt when I graduated from medical school. It 00:08:00also provided the opportunity to save money by working, so you would actually do research either domestically or globally as a medical student, to be paid by the university enough to essentially cover tuition. I worked in a laboratory on HIV with [Dr.] David [A.] Katzenstein and his colleagues. I ended up doing a study where we looked at the semen of men with HIV to see if the spermatozoa themselves had any HIV RNA [ribonucleic acid] inside the sperm and also whether the white cells in semen had any HIV incorporated into its DNA [deoxyribonucleic acid], and the answer was no. We were able to essentially clean the sperm enough and then lyse them, and we found no RNA actually within the sperm. That really 00:09:00was important at the time because people wanted to reproduce, and there were questions about whether you'd also have risk of transmitting HIV. I also had a chance to go to Cameroon with a colleague of mine, Dr. Reuben [M.] Granich, who also later did EIS [Epidemic Intelligence Service] and global HIV work here at CDC. When we went to Cameroon again, it was 1988. There was a professor at Stanford who was working with Peter [M.] Ndumbe, who was a professor at the University of Yaoundé, trying to develop a simple HIV antibody test that could be used in the field in Africa. So, we had an opportunity to stay within the HIV world. Even locally we were involved in a program that was going out to East Palo Alto [California] and trying to provide prevention services to people who injected drugs. There was a lot of support for HIV work from the student body.

MILLER: At this time, you were just at the beginning of AZT [zidovudine] in '89. For the most part, what types of diseases were you seeing in AIDS patients, in medical school and internship?

MERMIN: I tend to see my time in medical school and then my residency in internal medicine at San Francisco General Hospital together. I chose to go to San Francisco partially because San Francisco General Hospital was the place you went if you wanted to really learn HIV, and it served underserved populations, which made a big difference. In this very small primary care internal medicine program, it was almost like getting a fellowship in HIV care. We had patients who were intubated with Pneumocystis carinii pneumonia [PCP], people who had Kaposi's sarcoma, people who had non-Hodgkin's lymphoma, and all of the 00:11:00opportunistic infections, including tuberculosis, that were very common for people with HIV. There was something else going on, and that was that the world of HIV had already looked at prophylaxis. How do you prevent these infections from occurring, even though we couldn't restore someone's immune system just with AZT? That was the time that AZT had to be taken every four hours and (you had to) wake up to make sure you're taking your medication. Even with dual therapy with Zalcitabine [ddC] or even Didanosine [ddI], it ended up being inadequate to really help people live the kind of lives they can live today. But with prophylaxis, if you took Bactrim, you were able to prevent PCP. People had been in the hallways outside the ICU [intensive care unit], and suddenly we emptied our ICU of people with PCP. You still had people coming in occasionally, but those were people who were diagnosed with HIV infection at the time that 00:12:00they had their opportunistic infection. For people who had been already diagnosed, you could prevent it (opportunistic infections). I still remember people who developed Steven's Johnson's syndrome from taking cotrimoxazole (generic name for Bactrim) prophylaxis. Then it was really important to work with them to desensitize them so they could take it again and avoid the complications of the reaction, because it would prevent PCP.

MILLER: During your internship and residency, slowly antiretroviral drugs [ARV] were becoming more available, so you got to see the spectrum between HIV with no drugs and as drugs were being developed. What an interesting time --

MERMIN: It was in 1995 when protease inhibitors were approved by the FDA [U.S. Food and Drug Administration]. that really was the beginning of the complete 00:13:00change in HIV care, and at that time I moved to CDC.

MILLER: Do you remember how you felt at that time? Infectious diseases wasn't supposed to be like oncology, but here you were taking care of people that were dying, a lot of them. Do you remember how you dealt with that?

MERMIN: Everyone has mixed emotions. Sometimes just caring for someone and being a kind and thoughtful person to people's families made a difference. Sometimes you helped people resolve many years of conflict at the time that they were dying or very sick, because their families came and you could help people resolve things before the death of a loved one. I also felt there was always something to do. I did have tools, and sometimes I had patients who fought in 00:14:00positive ways and sometimes in negative ways regarding their illnesses. I think there was an understanding that just being a physician who embraced you and accepted you as who you are, and was not afraid to give you a hug (was important). And (someone who was) not afraid, in fact, (who) enjoyed spending time with you because you had HIV or because you were someone who was an individual who was a fellow human made a big difference. I found a lot of rewards in the work and a lot of pain. It was tiring. It was difficult to have people who were young have such serious illnesses. I think mistakes are always made as a physician in training and in practice, and they stay with you.

MILLER: You were doing public health in many ways. How did you decide to come to CDC?

MERMIN: I don't know how I first heard about it, but CDC has internships for 00:15:00medical students. I signed up and I did a six-week internship with the Malaria Branch out in Chamblee, the way Chamblee was, not what Chamblee is now. They had a softball game in the dusty grassland that was there, and I'm pretty sure the offices were in a bunker.

MILLER: Yes.

MERMIN: Yes, and [Dr. Laurence] Larry Slutsker and [Dr. Richard W.] Rick Steketee were there, and they had had a collection of data from a study that they'd done in Malawi. It looked at pregnant women and where there is an association with malaria in infants if the mothers had HIV. I remember being presented with this information and (being told) I want you to use Epi Info and figure out what was going on. It was extremely exciting, because it was the first time we were able to show that association and a lot of aspects of it that led to prevention and prophylaxis, how you could prevent women from both having 00:16:00malaria in pregnancy but also in their infants. The colleagues were great. They were kind people who were also really smart, and I loved at that point the magic of epidemiology. I loved to think that you could take numbers that represented things and put them together, and they could end up giving you results that seemed to be true.

MILLER: Then you came to CDC as an EIS officer. Where were you assigned for EIS? Did you go to work on AIDS, or did you pick something different?

MERMIN: I picked the Foodborne and Diarrheal Diseases [Branch].

MILLER: Can you tell us about that experience?

MERMIN: Fantastic. I think, as most people at CDC, I really found EIS an exceptional time. First, I had mentors who were great-- [Dr. Patricia M.] Patty Griffin, [Dr. Robert V.] Rob Tauxe, and [Dr.] Eric [D.] Mintz. I worked with 00:17:00people who knew what they were doing, who wanted to make a difference. It was outbreak focused, so much of it was outbreak focused. I went to Tajikistan for a multidrug-resistant typhoid fever outbreak of 10,000 people during a civil war. The entire U.S. Embassy had been evacuated except for the Ambassador and his political officer. We went out with colleagues and interviewed people and found out that it was associated with the water supply. The intervention was actually to stop people leaving their taps open so that you could build up water pressure so you wouldn't have backflow. We also got the Ukraine to provide the chlorine that they had stopped providing because Tajikistan couldn't pay anymore, and it made a big difference. It was exciting, and it was challenging. I had other opportunities with E. coli [Escherichia coli] O157 in lettuce.

MILLER: You were in Cameroon, and then you had to go to Tajikistan. Did you have 00:18:00a history of wanting to do international work? Did this just fall in your lap, or was this part of a master plan?

MERMIN: My interest actually started in medical school with Reuben, who had done a lot of international work beforehand. We met the first day of medical school and he said, that's what I do. I said, sure, I do public health. Let's get together and write a proposal to go to Cameroon. I think that started my interest, and it also, to some extent, led to EIS. I always felt that if I were going to go overseas, I wanted to have skills. I needed to have the skills and the independent thought and an understanding of epidemiology that would allow me to know enough that I would be useful.

MILLER: Moving along, you then got an MPH [Master of Public Health] degree and 00:19:00did a preventive medicine residency. Then comes Uganda in 1999. What made you decide to go overseas to Uganda, specifically?

MERMIN: I had been looking to do that. At that time, I was with [Dr. Rebecca E.] Becky Bunnell in California. She was working with the Division of STD Prevention.

MILLER: Who became your wife. Were you married then?

MERMIN: We were at some point, but that's another story which I may have to tell, if you ask, again. In fact, we were--Becky was pregnant, intentionally, and we were living together in California. I received a call from [Dr.] Eve [M.] Lakritz from the International Activities Branch in the Division of HIV-AIDS Prevention at that time. She said, we need someone to go out to Uganda to really 00:20:00help start a CDC field station related to HIV. Would you be interested? Then someone also called Becky and said, we need someone to take over [Dr.] Elizabeth Marum's job as the CDC assignee to USAID [United States Agency for International Development] in Uganda. Would you be interested? At that time, we still hadn't figured out if they knew we were together or not, but international positions were very rare. Becky had spent so much time overseas that she wanted to come back, find a husband, and do good work. She said, there's only one country I would ever go to again, and that would be Uganda. Meanwhile, I'm like, this is it, this is a gift. So, we wanted to go out. I flew out on an exploratory mission when she was eight months pregnant. I passed out these things to my brother and my best friend, called cell phones that had just been invented, and said, if anything happens, you (had) better be there. Because CDC was a poor organization at that time, they wanted USAID to cover the housing. The USAID 00:21:00management officer there was talking to me about this and said, if you're not married, I won't let you into the house. We went home and Carlos [M. Kent] Campbell said, "if" you get married, we'll buy your program a car. We thought, we're going to need a car if we go out there, so we'll get married. So, we got married, and then we went out together to Uganda.

MILLER: Was this setting up a CDC office in Kampala?

MERMIN: It was in Entebbe. [Dr.] Robert [G.] Downing, a really seasoned and dedicated laboratory scientist, had been working there already with a few Ugandan laboratory technicians on some initial work, but the assignment for me was to build it into a field station.

MILLER: Quite a bit was known about the AIDS epidemic in Uganda by that time. Eastern Africa had just been overrun. Can you tell us a little bit about the situation regarding HIV in Uganda when you got there?

MERMIN: Sure. The prevalence of HIV in Uganda had just started to decrease. It was one of the first countries, with Thailand, that showed decreases in prevalence for the first time, and that was a celebration. That happened a few years earlier, and there was a lot of scientific and political discussion about what was causing that decrease.

MILLER: What was it? What are we talking about? What was it in antenatal clinics? What was in the urban areas? What are we looking at in terms of the approximate --

MERMIN: Probably about 10% or higher, depending on what populations you're 00:23:00looking at, and a higher proportion in certain populations. I do know that the average Ugandan could name 40 people who had died of AIDS, so it had devastated the country. It was the leading cause of death.

MILLER: What was the feeling among the Ministry (of Health)? This is in the time of a little bit of antiretroviral therapy, but certainly not full scale. How were the clinical situations? Were they just overrun with dying people? What was it like when you first got there?

MERMIN: That was the case. One of the things is that Uganda had established the first indigenous AIDS organization in Africa, called The AIDS Support Organization, or TASO, and it was a juggernaut in the world of being able to 00:24:00help people and support people with HIV. It was social support, and it was community support. At that time, they didn't have clinical support because they didn't have prophylaxis implemented and they didn't have antiretroviral therapy.

MILLER: What was the social support like? In so many countries, again, they were just going to the hospital and dying, (with) wasting syndrome, so many-- obviously (with) the opportunistic infections. What were some of the early initiatives there in terms of just supporting people?

MERMIN: I think communities rose to the occasion to try to help people. Every TASO center had a singing group, and they would develop songs together about HIV. They would have a space where people could come and have company and support, and they would provide what minimal health assistance could be provided 00:25:00to people.

MILLER: Was there some assistance with food and palliative medication? Who was doing that?

MERMIN: Yes. TASO was the lead in that as well, and then the main hospital in Kampala, Mulago Hospital [Mulago National Referral Hospital] also provided minimal services for people. As you know, most people in Africa pay for their services, pay for their drugs, and actually have family members provide them with food while they're hospitalized. I should say--you asked about prevalence. Later on, we were able to establish routine HIV screening at Mulago Hospital and other hospitals, and what we found was that 40% of people who were in the hospital had HIV infection.

MILLER: What were your priorities when you first got there? Did you need to hire 00:26:00people and get things moving? Were there some initial colleagues that were with you that began to develop your portfolio?

MERMIN: Uganda was an exceptional place, first, because of (the) people. There was a triumvirate of [Dr.] Fred Wabwire-Mangen, [Dr.] Nelson Sewankambo, and [Dr.] David Serwadda, who had been working at an international level for HIV research for many years. There were also collaborations with binational organizations. Like the Medical Research Council and the Rakai Project [Rakai Health Science Program], where a lot of very high-quality research had been done and capacity building of individuals who had either done NIH Fogarty [National Institutes of Health - Fogarty International Center] grants or were just very experienced in HIV, so you had experts in HIV who could lead the way.

MILLER: Ugandan nationals.

MERMIN: And be complete compatriots in this. You also had these global partners, a lot from the United States, but also (from) other countries who had been working there for some time on collaborative work.

MILLER: Who were some of the global partners that were in Uganda?

MERMIN: Like the Medical Research Council, the Johns Hopkins-Columbia -based Rakai Project, and Case Western [Reserve University] was doing a lot of tuberculosis work, especially TB and HIV. And then there were programs and projects that were led by Ugandans and from the Ugandan government that were very supportive. One was the JCRC [Joint Clinical Research Centre], where [Dr.] Peter [N.] Mugyenyi was running a program that initially came out of the military but was the first program in Uganda that was offering antiretroviral therapy for about $10,000 a year at that time. People had to pay for the medication, so very few people could afford it. But it started the idea that at least certain people had experience with the medications, and there were places where the government was also supportive. They were very open to HIV. HIV was a priority for the President and for the Ministry of Health and for USAID and 00:28:00others, so it was natural that CDC would be focusing on HIV. We had people, and we had an exceptional time, because there was a desire to make a difference. There was an appreciation for the importance of good-quality science, and there was a welcoming of people who wanted to work with the community and work with Ugandans as leaders.

MILLER: You were fairly young when you went there, really. It sounds daunting to me. You came there to head up a CDC office in a situation where there were so many senior people floating around. How did you begin to identify some things that you thought would be--who did you report to back at home? Was there anybody 00:29:00that you could bounce ideas off?

MERMIN: It varied. Initially, it was [Dr. Timothy J.] Tim Dondero, and then when GAP, the Global AIDS Program, started, [Dr.] Eugene McCray was here and [Dr. Timothy D.] Tim Mastro. There was a whole program of smart and experienced people that developed over time. A lot of it was that we were surfing a wave. There was an exceptional time where first you would go meet with all the people, you meet with the Ministry, you meet with the National AIDS Program, you meet with the other researchers around and TASO and the AIDS Information Center, which was the largest program for HIV testing in Africa, and you learned from them. You hear what are their obstacles, because that's going to tell you where science can solve some problems, and then you also listen and see where some of the new science may make a difference. They're incredibly supportive, but you try to fill gaps.

MILLER: You come back to science quite a bit. Can you tell us a little bit about 00:30:00your thinking there? There was a great programmatic need, a huge thirst, but not as many drugs yet as you needed. What was your thinking about science versus program versus evaluation?

MERMIN: Initially when I arrived, there were six staff, including myself. There were a lot of other things going on, but we were primarily asked to do research that would make a difference. After a few weeks the LIFE [Leadership and Investment in Fighting an Epidemic] Initiative provided resources; that was focused on prevention of mother-to-child transmission. Soon after that we had resources from PEPFAR, and we were able to lay the groundwork so that when PEPFAR started, we were cruising along. I would say that we always believed in the continuum of public health. A solid organization looked at applied research 00:31:00and did the applied research if it needed to be done. When that was finished and you had results, you could do pilot programs and operational research so that you could figure out how it could be done well. Then once you'd done those, you implemented policy, and after the policy you implemented full-scale programs. The work we did-- if the gap was at the level of needing to do the primary science, we did that. If the gap was taking existing science and applying it, we changed policies. Some of the work we did we would change the policy working with Ugandan government, but then we would also work with WHO [World Health Organization], and they would change global policy.

MILLER: One of the early efforts was to try and get counseling and testing. Voluntary counseling and testing was the modality they were using, a long 00:32:00interview phase and so on. What was the status of that in Uganda when you got there? Was there much of an uptake? There wasn't yet too much to offer people, so how was that going?

MERMIN: The vast majority of people with HIV in Africa at that point did not know they had the infection. There was a human rights movement that emphasized that you have a human right not to know your HIV status. We had to change that. We had to say--really to move people to the point of saying, it's a human right to know your HIV status. That was a big change for many people because there's stigma. There can be discrimination against people with HIV, but people had a right to know. Why? Because they didn't want to infect the people they love, and people were inadvertently infecting partners because they didn't know they had 00:33:00HIV themselves.

MILLER: Was that a hard sell? Was there a huge stigma in Uganda for HIV?

MERMIN: There was a stigma, but the hardest sell, as usual, is the providers, the researchers and the politicians. It's us. What we found was that when you offer HIV testing, you have remarkable uptake. I'd like to give some examples of that. It was one of those situations: we were doing a study of the human herpes virus #8. It was a community study, where we initially were trying to figure out what proportion of the Uganda population had HHV-8. It was one of the areas in the world that was thought to have the highest prevalence, and it's the cause of Kaposi's sarcoma. We went to a community, we worked with the local community, and we went door-to-door for over 3,000 people. We offered testing for HHV-8, but we also said, it's our obligation to do HIV testing as well. We had 99% uptake of people who actually were available at the time. That meant that 94% of 00:34:00the community ultimately knew their HIV status and their HHV-8 status.

MILLER: You went back and told them the results.

MERMIN: We went back and told them the results. That led us down a path of realizing that if you make it normal, people will want it, and you have an obligation to let people know what's happening. Later on, we did a cohort study to try to see what were the interventions that would make a big difference in people's lives. In that study we also had people who were enrolled from TASO who had HIV infection, but we said, what about their family members? We went to their homes with their permission, and we offered HIV testing to their family members. Ninety-nine percent said yes, and of those, we had about 7.5% infected, including kids. Half of the spouses had HIV, and 75% of the people who had HIV 00:35:00did not know it and had never been tested for HIV, including all of the children under ten years of age. That really reminded me of the idea that in America we cherish the individual. It's your individual right to have privacy. But in Uganda there's a community culture and a family culture. We are part of a larger group. For us only to do things for individuals was a gap. When we adapted to the family and the community, we started to see remarkable things. When we started to do the routine testing in hospitals and found 40% of people had HIV, we also provided testing to the family members who were providing food who were at the bedside. Those people also agreed to get tested because they also wanted to. When we made it regular and normal, it was normal for people. If it's exceptional, it's much harder.

MILLER: In the case of discordant couples, if you were doing couples counseling 00:36:00and so on, did Uganda suffer as much as some of the other countries in terms of husbands leaving their wives or serious implications for a woman or a young girl to have HIV?

MERMIN: One of the best types of science you do is science that answers the questions of the naysayers, because they may be right. When people argued against HIV testing primarily of women or their partners, they always said, there may be domestic violence. You could theoretically say, is it better to die and not know you have it (HIV), but the real point was people have a right to know. There's a way of doing this that will help people without those complications, but we have to find out. So, we did. In all these home-based screenings that we implemented, we offered couples counseling and individual counseling, and people at the same time and--

MILLER: That was innovative for the time.

MERMIN: Very innovative. We talked to people about what it meant. Most people would do it (test) together. Some people would do it separately, but it allowed us to explain to the spouse, you know, it doesn't mean your spouse had an affair. Many people got HIV when they were younger, before they came into the relationship-- it could be a silent infection. That actually led to mass programs. We had literally entire provinces of over 500,000 people who through programs would ultimately have home-based HIV testing. Again, the vast majority would accept the testing and get their results. At that point we started to give prophylaxis and other interventions. I think you had to answer the questions related to what you were saying, so that when we were done we did evaluate the incidence of potential domestic violence, and it did not increase over time. We were able to show that that was really the truth. If it had been a different result, we would have accepted that as well and how to resolve that.

MILLER: Pre-ART [antiretroviral therapy] or pre- the ability to really roll out 00:38:00ART, you formulated a basic care package. You ended up doing quite a bit with that and publishing that. Can you tell us a little bit about that, and maybe some of the scientific work you wanted to do. The work you did, I'm aware how much impact it had beyond Uganda globally, so maybe tell us from your vantage point.

MERMIN: Looking from that realm of continuum of public health, we saw a gap. What do we provide people with HIV that will help them live a long and healthy life? We did cost-effectiveness analyses of testing, whether it was testing in the hospital, testing the family members of people with HIV infection or 00:39:00door-to-door testing, or traditional voluntary counseling and testing. All of them were cost saving, even in the environment of Uganda, which is rare. We were able to show not only that something was effective, but that you save money at the same time. You do good and you save money. The question was, what else can we offer to people, and we realized that we needed to inductively create that basic care package. What's the standard package of services that would help people stay alive and help them not transmit to others? First, testing: you have to know whether you have HIV or not. The second was condoms, because we know condoms have been associated with reduction in HIV transmission. You had to supply people with enough condoms so that they can actually use them to prevent transmission. You have to provide people with information so that they know how not to transmit to others.

MILLER: Were you getting funding for this from the LIFE Initiative?

MERMIN: Yes. Eventually we started to do programs through PEPFAR, but we also worked with USAID. As CDC we worked with the Ugandan government that was receiving money through other means as well and using their own resources. The question became, what about cotrimoxazole prophylaxis? This is an antibiotic, trimethoprim sulfamethoxazole, which had been shown to prevent Pneumocystis carinii pneumonia in the United States and Europe and a few other places. Two studies had just been published from the Ivory Coast, one of which was done by [Dr.] Stefan [Z.] Wiktor, which showed that when people who have TB and HIV infection take cotrimoxazole, they're less likely to die. Another was for all people with HIV, and it showed that maybe (for) people with certain CD4 counts [T lymphocyte cells], it reduced morbidity. The question became, what about East Africa? I went to the Ministry of Health, to [Dr.] Alex Opio, and I said, Alex, 00:41:00what about this cotrimoxazole? Should we implement it? In other words, should it be that part of the continuum; should we develop a policy? He said, no, because we're concerned. In East Africa we have very high rates of trimethoprim-sulfamethoxazole resistance in diarrheal pathogens. Malaria actually can be resistant to sulfa drugs, so we don't know if it's going to work. Even though it's ten dollars a year for daily cotrimoxazole, that's a lot for our country. That's more than our expenditure per capita in all of our health system in the government. So we conducted a study that had to be a study design that we felt was ethical. It wasn't randomized, but it followed people for a period of time and then introduced cotrimoxazole and then followed people afterwards. We had to monitor them at this point every two weeks. We would go to their home and ask them about diarrhea, because apparently you only remember your diarrhea for about two weeks. We asked them about other factors, and we monitored mortality. This was in the district in Uganda that had the highest 00:42:00rates of diarrhea in people who are part of TASO, the AIDS support organization, so we picked the hardest place. It turned out to be a place where seven languages were spoken. It was very difficult to work there. The study went great. We also at that time evaluated a simple plastic water vessel and chlorine to allow people with HIV in their families to have clean water. This had been developed by [Dr. Robert E.] Rob Quick at CDC initially many years ago, but he'd taken it on the road. He'd done it for cholera outbreaks in South America, and he'd done it everywhere else. No one knew if it worked for people with HIV. The chlorine could be manufactured locally, and the vessels could be manufactured locally. So we randomized that, and what we found at the end of that study was that there was a mortality reduction of 70% because of cotrim, that it also prevented malaria, diarrhea and respiratory infections, and that it slowed the 00:43:00CD4 count decline in people with HIV and leveled off their viral load that was normally increasing prior to the time of cotrim. We also found that the water vessel prevented diarrhea in people with HIV and their family members. Because that study was ensconced in the family and community, we were able to ask and answer some other questions. One of them was, what was the effect on the family of people taking cotrimoxazole? What we found was that if an adult with HIV took cotrimoxazole, there was a decrease in death among their HIV-negative children, and we put HIV-positive kids on cotrim. We also found there was a decrease in malaria in those (HIV-negative) children, because people with HIV were so susceptible to malaria that by taking cotrim, which prevented them from getting malaria if a mosquito bit them, it wouldn't actually transmit to their family members. We were curious about why that was happening, and later we were able to 00:44:00look more closely at those data as they continued over time in the cohort. What we realized was that when your parent died, you as a child were twice as likely to die over the next year. Keeping parents healthy and alive ended up keeping kids alive, and this was the effect of an antibiotic which costs about $10 a year, which was also cost-saving in Uganda.

MILLER: Did the community respond to finding that out? We remember those years, and a lot of the feeling is before ART and then after ART became available. How did the community respond? Was it noticeable that so-and-so was living longer, that things are going better?

MERMIN: Cotrimoxazole was embraced. First of all, the studies were done in 00:45:00collaboration with TASO and the Ministry of Health, so once the results came out, policy was changed. Everyone who was a member of TASO suddenly was offered cotrimoxazole prophylaxis for free. When we did our district-wide HIV testing programs, if you were positive, you were referred to the local TASO or clinic to then get cotrimoxazole prophylaxis. We did other studies of it--it wasn't just implemented, but they had operational research that showed that it actually worked in practice, not just in our study, to decrease mortality rates. We did the economic analyses to show that it saved money. So, it made a big difference. I should say, Bess, there are limits. The total extended life expectancy from taking cotrimoxazole was still in a matter of months, it wasn't in a matter of years. So, it helped people, but there were limits. But we developed this basic 00:46:00care package, and it became standard. When you got diagnosed with HIV--and this was in collaboration with the Ugandan government and the U.S. government--you would be provided with a package that had condoms, that would get you cotrimoxazole over a long time, that would get you a water vessel and chlorine, that ultimately would involve INH [Isoniazid] prophylaxis, so if you were eligible because you had HIV, that would prevent tuberculosis. It became a standard, and we worked with WHO and others who shared this information. Soon after we did it, [Dr. Barbara J.] Barb Marston, who was in Kenya, said, wait, cotrim worked there? We have the same (antimicrobial) resistance, and we'd like to work with our ministry to implement it, too, first in Kisumu and then in other parts of Kenya. There was a rapid exchange of information, partially because there weren't that many people working in the area and partially because people were so desperate to do anything that would be effective.

MILLER: This is early 2000's, and folks in the U.S. are already getting ART and 00:47:00doing well, so you had that in the back of your mind. You've got to hold on to this until we can get ART into these populations. Then PEPFAR came to you. One thing I remember, and I wanted you to tell us about it, was when Secretary of Health and Human Services, Tommy [G.] Thompson, Dr. Julie [L.] Gerberding, the Director of CDC, and about a hundred other people visited Uganda. Was this the beginning of PEPFAR as the grand visit? Can you tell us who was there and what was it about?

MERMIN: Sure. The story started with the idea that we wanted to build on the basic care package to include antiretroviral therapy. When I had arrived in 00:48:00Uganda, there was a program going on called the U.N. [United Nations] AIDS Drug Access Initiative. Paul [J.] Weidle was leading that from the CDC side. It involved some countries where people were paying for their antiretroviral therapy at cost. They were being monitored, usually for CD4 counts, and health to see how well they were taking their meds and whether they were able to do it well, whether the system was able to support them and whether they were living longer. He initially had done that, and I remember looking very skeptically. I was involved to help support him, but I also thought, it's $10,000 a year, (while) I'm dealing with $10 a year for cotrimoxazole prophylaxis.

MILLER: The Drug Access Initiative was in Ivory Coast and maybe one or two--

MERMIN: Exactly, and Uganda. Then what happened is, we said, this is one of those places where we need to do the applied research. We had already in Tororo 00:49:00District, had already had that water vessel/cotrimoxazole study going on. We said, it's time to evaluate whether antiretroviral therapy will work, because what you do now in research lays the groundwork for three to five years from now. If you're answering a question now that everyone's asking, you're too late. We had to say, what would the future hold? Maybe the cost will go down. There was a big global movement for the Treatment Action Group and others to try to decrease the cost of antiretroviral therapy globally, especially in Africa, which was so deeply affected by the epidemic. This was an opportunity for us to 00:50:00do this study. This is a time, by the way, when the USAID administrator had said that people in Africa can't take ART because they can't tell time. It was an intimidating prospect with the numbers, if you added up the cost. And the healthcare infrastructure in many countries wasn't used to chronic diseases where you have to take medication frequently, including ones where you have to take it very regularly or your viral load rises and you get sick again.

MILLER: What were the drugs that you used, and where did you get them?

MERMIN: At the time, the decision was made by CDC that this was an acceptable study to conduct, but it had to go through not only the CDC and local IRBs [Institutional Review Boards]. For the first time ever, CDC asked two outside ethicists to review the protocol to ensure that we were not coercing people because we provided antiretroviral therapy, instead of what you almost could 00:51:00imagine now would be the opposite: doing a study without it. At that point, is it ethical to provide ART in a study? They said yes. The decision was to purchase medication from FDA-approved U.S. manufacturers, until that was changed under PEPFAR. The drugs were still FDA approved, but they could be produced outside the United States.

MILLER: How did you get the cost down?

MERMIN: For the study, the costs weren't down, but by that time PEPFAR was able to support some of the work, and it (the cost) eventually declined over time. So, we were able to implement the study. We had very careful monitoring from lay people because, again, we thought we can't have people travel to the clinic very frequently. We had done a calculation from data we had collected from 00:52:00interviewing people in their homes, and the average person in rural Uganda had 25 cents per day to spend.

MILLER: You're talking about the rural areas.

MERMIN: Yes, right.

MILLER: A tremendous opportunity. Can you tell us a little bit about where that (Tororo) is, and what the life is like? I remember hours and hours of riding from the capital on a very bumpy, hugely bumpy cavernous road. It's probably better than that now, but can you tell us a little bit about--

MERMIN: Be delighted to. Tororo is a rural district with multiple different tribes and languages, on the border of Kenya. It is about 4-7 hours from the capital of Kampala, depending on how the roads are. Because of this study that we were doing, looking to see whether people could take ART, whether it would 00:53:00decrease mortality, when [Dr.] Mark [R.] Dybul, the new PEPFAR coordinator, came to visit, we took him out to Tororo. He and others had also visited the program and felt that it showed possibilities. When he went home, he talked with Bill [William R.] Steiger [Director, Office of Global Health Affairs, U.S. Department of Health and Human Services] and Tommy Thompson, who was then the Secretary of Health and Human Services. When they wanted to go on a visit to Africa, because PEPFAR had just started, he suggested they come to Uganda, and he told us we also have to go to Tororo.

MILLER: How many people were in those groups? Are we talking 50, 60?

MERMIN: There were over a hundred and--

MILLER: Were they congressional staff?

MERMIN: It was a disparate group: there were heads of companies, the head of Becton Dickinson, Pharma, and [Dr. Anthony S.] Tony Fauci from NIH. There were many people, and they were visiting Uganda and Kenya. At one point there was a 00:54:00big change in their plan while they were flying over, and they came to Uganda early. Becky Bunnell was the control officer for this visit, and at 2:00 in the morning she got a call that said they're coming in six hours. You can imagine this is a situation where we don't have hotels that can put up that many people that quickly. It was a miracle. She got up, she started working with everybody, the team came together, and the majority but not all of the people from that trip came to Uganda. Some went to Kenya, and Julie Gerberding was there, the head of CDC. We took them to both the Entebbe Headquarters of the Uganda Virus Research Institute, where we had our headquarters, but also to Tororo. I think it was, as you mentioned, Bess, very moving for people. We're walking out to people's homes--these are adobe mud homes with thatched roofs--and someone could 00:55:00come out and say, yes, I have HIV. My CD4 count is 226, but it used to be 50, and I take my meds every day. My husband has also been tested. He's negative, so we take precautions. It's an extraordinary experience to sit in that environment.

MILLER: Tell us about how they got the medication. I remember motorcycles--a dedicated group of people who were delivering medicine. Can you describe that?

MERMIN: We were concerned both that people would be able to take their medicine regularly and that we'd be able to monitor them with lay people, because we knew there weren't enough clinicians in the country or most countries in Africa to provide ART the way it's normally done. We also had that mechanism set up from the prior study, so every week someone would drive on a motorcycle to a set number of homes. I believe people generally had about 50 homes that they went to in a week, and they would ask the question, how are you doing? If you were very 00:56:00sick, they would help you get to the clinic. And they would also deliver your medication. I should say that--

MILLER: Would they do it home-to-home, or would they do it in a group home and then this neighbor gives it to this neighbor?

MERMIN: No, this was directly to the home, partially for privacy reasons, although later, as you're hinting at, there were communities in practice who decided that they would send one person into the capital to get the drugs for the other ten people. That's become very positive, almost a shared confidentiality, which was part of both how families work and sometimes how communities work. It was very effective. I should say that the results of that study, which were known pretty quickly, showed us two things. One was that mortality rates were dramatically reduced, and we had the highest viral load suppression rates ever reported. In addition, we also thought we'd collect 00:57:00sexual practice information from people and also viral load information. The Rakai Project had previously published a study that showed that transmission of HIV was associated with your viral load. If it was high, you were much more likely to transmit HIV. If it was low, you were less likely. We thought one of the unknown biases was sexual practices. If you don't have sex with someone, you don't transmit HIV to them. If you do, you may be more likely. We combined the data from viral loads and sexual risk behavior, and we looked at what happened. What we showed was that the estimated risk of HIV transmission would be reduced by 98%. We also looked at the number of transmissions. There was one (study that showed), during the initial three months that someone was actually (receiving ART), in these couples their viral load was just reducing. That later on about 00:58:00matched the rate that [Dr. Myron S.] Michael Cohen's study of HPTN [HIV Prevention Trials Network] 052 showed (with) much higher numbers of couples, showing that there was about a 96% reduction in people in studies who adhere well to their medication. It also turns out that more recent studies up to this day that have followed couples, whether they're heterosexual or gay or bisexual, what we found was that if your viral load is truly suppressed, you have effectively no risk of transmitting HIV. That study was one of the initial places where we combined the cutting-edge laboratory science and clinical science with behavior.

MILLER: In terms of assessing sexual practices, what was that like in Uganda? In so many countries even to this day, it's been very difficult to talk about those 00:59:00things with populations, and there are different populations in Uganda, different languages and so on. How did that go in terms of either Tororo or elsewhere, where you tried to assess that?

MERMIN: People welcomed questions. I think the interviewers were well trained. Becky Bunnell is a behavioral scientist by training and had lived in Uganda for many years. She was deeply trusted by the head of TASO, who is one of her best friends. She had worked at TASO for two years prior to joining CDC, and she knew most of the people in the Ministry during the time--

MILLER: Is that why you married Becky?

MERMIN: Exactly. It improved my professional career. But it's true that she was out there soon after the [Apollo Milton] Obote regime had ended and 500,000 people had been killed. The country was in a very difficult time, there were very few foreigners working there. She had become trusted by the people she knew 01:00:00there, the Ugandans who knew when it was not a commonplace experience. I think in general, if you come and you're part of a study, or you're giving people clinical care and you help people and you have dispassionate ways of interviewing people, they will be open to you. We found people were pretty open about information, and it was obviously essential for some of the studies we were doing. For some of the programs you don't need to ask questions about sex; you just need to provide people with the care.

MILLER: I remember a key study that you did. I think it was looking at home-based care, where you looked at different methods of monitoring. That was a very big issue at the time. It was very expensive to assess blood chemistries and so on. Can you tell us a little bit about the arms of that or the approach to that study?

MERMIN: Sure. We wanted to always answer the questions from the perspective of a 01:01:00person living in Uganda. What would they need to know if they were going to take ART regularly, and how could we have a system put the simplest thing in place that would still make a difference? One of the questions was monitoring. Pretty soon after the changes in PEPFAR's purchasing of antiretroviral therapy, the cost went down a lot, to about $300 instead of $10,000 a year.

MILLER: Were you getting drugs from India and China?

MERMIN: Sure. (From]) multiple places where they were producing medication. It would be purchased through the governmental system that existed within Uganda. CD4 counts and viral loads at that point were fairly expensive. In fact, viral loads alone, per the recommended three-monthly, or every quarter measurement, would be more than the cost of the antiretroviral therapy itself. We wanted to 01:02:00do a study that actually evaluated and compared just clinical monitoring, which was what was mostly done. Most of the time, people, if you just got the meds, you couldn't come in--With CD4 count alone, (compared with) monitoring with CD4 count and viral load and clinical monitoring, so we could compare across these three arms. I think it reminded of us of two things. One is you always have to answer the practical questions, and the other is that all important science has an expiration date. At that point what we found was that laboratory monitoring did improve the clinical outcomes, so morbidity and mortality were reduced in people who had either CD4 count or viral load compared to clinical monitoring alone. (Without labs) you can't tell when people's virus is either becoming resistant or elevated. The second (finding) was that there was no difference by 01:03:00adding viral loads. In other words, CD4 counts were enough. That was actually really important, and I think at that time it supported at least this transition to try to introduce CD4 counts. Now, I should say that mortality reductions compared to no ART were tremendous, and they were tremendous even in the clinical-only arm. If you add nothing, get the meds out. If you had the ability to do CD4 counts, you should do it. Soon after that time, though, there was increasing information that viral loads were becoming more of a standard in the United States, because they show failure of either adherence or resistance to medication by the virus sooner than CD4 counts. They became cheaper and cheaper, and they became more available. CD4 counts had to be conducted relatively quickly after blood draw. In fact, we did a study to show how long you could wait, because they used to say within 48 hours. It turns out you can wait five days and it's still fine, but five days is not that much to transport things and 01:04:00to collect specimens.

MILLER: Were you collecting specimens in the home doing blood draws?

MERMIN: Yes, they were, and it turned out that ultimately-- I think much of the world since then, and this is 15 years later, has transitioned to prioritizing viral loads. At the time it was really important to show that both the priorities of just getting medication to the people who need it, but also that CD4 counts might be enough.

MILLER: Can you talk a little bit about the laboratory in Uganda? I think that was a real strength that you had, that I'm remembering at that time didn't exist everywhere. There were (only) a few countries that had outstanding laboratory support and were able to do CD4 counts and viral loads, in Kampala and Entebbe. Can you tell us a little bit about that?

MERMIN: We really understood the importance of having accurate laboratory testing, whether it was for just HIV diagnosis or whether it was for some of 01:05:00these more complicated tests. Robert Downing was really a stalwart advocate of not only having the ability to do it, because it is the base for so much of the research, but actually having a reference laboratory in the country. We worked with the Ministry of Health to establish an HIV reference laboratory. At the same time, we cared about other diseases, too, like tuberculosis. There was a very strong TB program in Uganda, and we also supported a new TB laboratory, because diagnosing TB can be complicated, as you know. That was established and was supported by both the Ministry of Health and CDC. We used it for some of the national serosurveys that ended up providing a lot of important information for the nation, as well as checking on the quality of the laboratory testing that was being done in some of the rural hospitals, where there is no electricity sometimes. We were constantly thinking about what kind of equipment could be 01:06:00simplified enough that tests could be actually conducted in some of these environments. Laboratory testing was always very critical, and slowly we were able to bring it out to regional areas and then district hospitals, then ultimately to the homes, as you mentioned.

MILLER: CD4 counts, for example, what was the progression? Was there a spoke in the Medcenter and everything had to come through the center, and then slowly you moved CD4 counts? You could get more with FACS [fluorescence-activated cell sorting] counters out at the periphery?

MERMIN: Exactly.

MILLER: Do you remember what regimens you were using and toxicity? I think WHO was recommending the standard regimen; is that right at that time?

MERMIN: Yes. We were following WHO's standard regimen (with) AZT or d4T-- stavudine.

MILLER: So, zidovudine [AZT] or stavudine, lamivudine, and nevirapine.

MERMIN: Thank you. But the idea that we were--one of the complexities was that d4T stavudine did have some potential toxicity, so there was a debate about its use and its efficacy. Some of the initial regimens recommended by WHO were actually not the first-line regimens in the United States or Europe anymore. But they were available and they were at low cost. We were able to show the very high efficacy of those regimens, but we also were monitoring for toxicity. There were occasional events of toxicity, both for studies as well as for programs that started to implement antiretroviral therapy.

MILLER: (Was there) toxicity such that people stopped taking the drug?

MERMIN: Sometimes. Most of the time you'd just switch one of the agents to another agent, and we did have access to second-line regimens soon. As you know, the single most important reason that people have failure of their regimen, especially when they start antiretroviral therapy, being naïve, is because of poor adherence. There are all sorts of reasons. People can have poor adherence because they couldn't afford to come to the clinic and get their medication, or because they were worried about someone seeing them take their medication, or (because) they forgot it when they made a trip and then they couldn't get back home to get their medications. But there are a lot of reasons why that can happen. To some extent you have to examine and talk to someone in a nonjudgmental way (about) what might be going on. Sometimes just helping people adhere better actually ends up working perfectly and having their viral loads again become suppressed. Sometimes the viruses become resistant, and they need 01:09:00to go to a second-line regimen. The United States was going through a different experience at that time. Many people in the U.S. with HIV had started initially with monotherapy AZT or AZT and DDC or DDI, dual therapy, and then switched to triple therapy. A lot of folks are now on quadruple therapy or third- or fourth-line agents, so it's a much more complex manner. Most of the people in Africa started with very effective triple therapy, and so what you ended up seeing is, for those people who adhered, almost universal efficacy.

MILLER: I think it was in Côte d'Ivoire, if I am not mistaken, there were a lot of private providers providing ART. I think there they did have some issues with people using a variety of regimens. Was most of the care for your patients in the public sector? Did you have much of a private sector in Uganda that you needed to work with?

MERMIN: I think some of the early adopters are always going to be in the private 01:10:00sector for any new technological intervention or one that's expensive. So, there were those. There were some hospitals and some physicians that ran their own private practices that would also be able to provide people with effective medication, and they would be at the forefront of some of it, so we did work (with them). But we saw our prime goal as (helping) the average person living in Uganda. How can we help the nation as a whole, help everyone, including those who were poor and normally don't have the ability to access good quality clinical care? The Ministry and others were very supportive of that. That was the basic premise for TASO. It was an AIDS support organization for the people.

MILLER: Was that then the bulk of the patients?

MERMIN: The vast majority of patients were in the public sector, depending on how you consider TASO. TASO was a nongovernmental organization. In fact, I think 01:11:00some of the reasons Uganda was at the cutting edge, and that I was so lucky to be there, was because it had a very vibrant nongovernmental sector, both with the AIDS Information Center that was able to put in some of the initial TB prophylaxis and treatment for people with HIV, as well as being the large-scale implementer of HIV testing throughout the nation, along with TASO and others. By the way, we also were able to work with some other groups that were collaborations between international organizations and Uganda organizations. There was one called Reach Out that was in an urban, very poor part of Kampala. That was where the first person in the world who received PEPFAR-supported antiretroviral therapy was. They were able to implement it in this very poor area very effectively, using some of the same community-based models that we 01:12:00were doing with the home-based AIDS program in Tororo. Then Mildmay, which was a pediatric HIV center that was one of the first places to implement treatment for pediatrics, really set the stage for changing the way people thought of things. I can't overemphasize, Bess, how many people at that time didn't want to treat children with HIV. It was seen as a waste of resources, because the kids were going to die anyway, and the adults were more important. [Dr.] Denis Tindyebwa was one of those foresightful people. In the beginning when I first got to Uganda, I was visiting all the partners. I went to Mulago Hospital and I met him. He was in this small rundown building with literally the roof collapsing 01:13:00and rain dropping in. That was their pediatric HIV clinic. They didn't provide cotrimoxazole and they didn't provide antiretroviral therapy at the time, but he said, we really need help. He convinced me, and we started to work. Initially he started to expand and be one of the first places to do pediatric antiretroviral therapy later, alongside Mildmay. There's always this idea that there are these early adopters, either within the country framework or in the global collaborations, but that they can set the stage for what needs to be done. Then you can also see some of the problems that need to be addressed if you're going to have it go at full scale.

MILLER: Were you able to go to full scale while you were still in Uganda for a number of these interventions? How about the scale-up of ART, for example?

MERMIN: Yes. I think the basic care package, for example, became full scale. Cotrimoxazole was standard practice in Uganda and was provided and still is for 01:14:00people who need it. The ART, by the time I left in 2006, was being provided to several hundred thousand people with HIV. It had really become large scale, but (did) not (reach) everybody. There were still rural areas that couldn't access it, and there were folks within the urban settings who would find either difficulty being enrolled because there were waiting lists or because they didn't know where to go. I think there were also a lot of people who didn't know their HIV status. When we did a national survey for the first time, we asked a question. We asked people, do you have HIV or not? Have you been tested for HIV, 01:15:00and do you have HIV? We were able to look at what proportion of people in the country with HIV actually knew it.

MILLER: Was that part of the AIDS indicator surveys?

MERMIN: It was.

MILLER: You've talked about those. Can you say a little bit more about those?

MERMIN: There's a long history, supported by CDC and USAID in different countries, to look at HIV in a nation, to get a better understanding of the prevalence of HIV in different populations and regionally. (The studies) usually were finger-stick and filter paper-based. You'd collect some blood. We had several innovations at the time. I think you can sense from how the program and how CDC was working in Uganda that we really wanted to think about what it meant for people who were participating. First, we wanted to allow people to have access to their HIV results, so we went back to provide people with their results.

MILLER: Were some countries doing AIDS indicator surveys in an anonymous fashion without telling patients?

MERMIN: All of them were. The second issue was we wanted to know--anyway, we also tested for syphilis. We were interested in thinking about other things that might be useful for people. But part of it was asking that question. That would tell you what proportion of people in Uganda who had HIV also knew they had it, and then also whether they were taking ART or not. Those have become somewhat of models. When we were in Kenya, Becky and I, the program in Kenya ended up actually drawing blood and also doing viral loads, so you could actually do the first time what's called the continuum of care for HIV. It was striking when we were in Kenya, as I remember stepping back and saying, we just did a nationally representative survey that also had regional data. In this survey, many articles 01:17:00came from it, but it showed the continuum of care, how many people lived in the country with HIV, what proportion (knew) of their status; of those, how many were taking ART and of those, how many were virally suppressed. For that moment in time, that was the best data anywhere in the world, because everyone else had to piece it together through different systems. It was very exciting to be able to think about that simple way to get that done.

MILLER: You had a couple of other publications of interest. One was looking at the effect of cotrimoxazole and insecticide-treated bed nets on the incidence of malaria, in The Lancet. Can you comment on that? I know you did quite a bit of work on malaria.

MERMIN: Malaria is a big problem in Uganda. It was one of the leading causes of 01:18:00death in children and morbidity in adults. People got malaria frequently, and there had been larger efforts to try to get bed nets out to people, but mostly it wasn't really addressed. Yet we had done some work and others had done some work, showing that people with HIV are really susceptible to malaria. We also had done a study that showed that if you had malaria and you had HIV, your viral load increased, so it was bad for you to have malaria. Naturally the team said, well, shouldn't bed nets be part of your basic care package? They did end up becoming part of it, so we said, but how do we know? People aren't going to spend the money on insecticide-treated bed nets unless you could show that they work, because you always have to answer the question does it work? The naysayers are going to say, I don't know if it's going to make a big difference,, especially for adults, because adults generally don't die of HIV although it's 01:19:00serious for people with--I mean die of malaria--but it's serious for people with HIV. Again, we had this system in place where we had been following this cohort of people with HIV.

MILLER: Was this mostly in rural (areas), or was that a broader--

MERMIN: This study was still part of the Tororo study. That's why we were able to look at data that we had collected to say, right, initially that time period before anyone had received cotrimoxazole. When we introduced cotrimoxazole prophylaxis, then we introduced ART and then bed nets, and we were able to look at the added effects. What that showed was that each of the interventions made a difference. Cotrimoxazole reduced your malaria substantially, but you still had some. ART also reduced your malaria because your immune system was improved, and then bed nets went even farther. Then obviously one of the benefits is that we also helped the children, so everyone in the family benefits from having bed nets. The basic care package provided two bed nets, so you'd have enough to 01:20:00cover most of the people in the household.

MILLER: Can you give us an update on how things are in terms of HIV in Uganda today?

MERMIN: I'm not completely up to date, but my understanding is that Uganda did very well in reducing prevalence and then incidence as a part of that. You can reduce prevalence because people are dying, and you can reduce prevalence because you're reducing incidence. Both, I think, were occurring. They reduced mortality, but they also were able to decrease incidence. My understanding is that things may be imperiled.

MILLER: Right now?

MERMIN: Mm-hmm.

MILLER: In Tororo has it benefited from a stronger healthcare system? Are they still in mud huts?

MERMIN: I haven't been out to Tororo in many years, but there's been some interesting work done that looked at the effects of PEPFAR, essentially well-resourced HIV systems, HIV-focused systems, on the rest of the healthcare 01:21:00system. Because there had been a question: are we hurting everything else by implementing things for HIV, building up HIV testing in the laboratories and distracting from other things. And it turns out, no. It turns out there seems to be a benefit, at least when they looked at it, for example, for reproductive care for pregnant women and infants, that actually building up a good prevention of mother-to-child transmission of HIV program actually resulted in improved outcomes for mothers and their infants. I think in general we've seen improvements in systems in most of the countries where PEPFAR has worked. One of the challenges of HIV (is that) it is a chronic and incurable disease and it's infectious. So, you can't give up. We see that in the United States as well, 01:22:00that we have not yet been able to completely tackle HIV. We have reversed its direction, we've seen 18% reduction in the past 6-8 years, but there are still 38,000 people getting infected with HIV every year, and that's too many.

MILLER: As we're beginning to close, you of course had many other important positions, one as Director of CDC Kenya and then Director of the Division of HIV/AIDS, and now of the Center. (Is there) anything you would like to add about those, for example, CDC's role in addressing AIDS in Africa?

MERMIN: I feel incredibly fortunate. The people I've been able to work with, the meaningful work, and the excitement of really feeling like you're making a difference at the science and the program and the policy level. It's something 01:23:00that people really look back on when they are retired and writing letters to the New York Times complaining about the world. They remember (these) as being some of the best times. I think the work that I've been able to do at CDC has been tremendous. It is always challenging. There's always something new that you have to figure out. There are always committed people. This field draws people who care about reducing disparities, who care about having a meaningful difference in people's lives, and I feel very fortunate that I've been able to do that. I think the niche that CDC has is that the folks at CDC are committed. They understand science, care about science and want to use science and evidence as the core of their argument, but we're also humble enough to recognize when we don't know the answers and we've got to answer them. The fact that we are the 01:24:00public health agency for the United States means that we understand what a lot of our partners are going through in other countries. So, we are a natural friend, and I found that very useful.

MILLER: Was it tough leaving Africa and coming back to the U.S.? Some people have found that very difficult, culturally and every other way.

MERMIN: I really enjoyed my time in Africa, and I've really enjoyed my time here. I think as long as there are challenging work, great colleagues and some of the energy that you really expect out of working at CDC, then you can thrive. I have found it very rewarding. It's also frustrating. There's no doubt that many of us were not built for bureaucracy. When I reflect back at Uganda when we 01:25:00were first there, the email would go down for two weeks. We were basically given resources and responsibility and support and told, good luck, tell us how it's going later. The oversight now for everybody, because of electronic communications and because of a normalization of the engagement between headquarters and the field, has changed. There is great opportunity, but on the other side, we have great communications with the highest levels of the U.S. government. It was a pleasure to be able to work with people throughout our government in Africa and here and to be able to work together to make a difference. There may be slightly different partners: now I'm working with HRSA [Health Resources and Services Administration], I'm working with the Centers for Medicaid and Medicare Services, and I'm working with the OD [CDC Office of the 01:26:00Director] and HHS on trying to solve problems domestically. I feel that knowledge that if you can't partner and do it together as a team, you're not going to succeed, and that you as CDC play a role in that, has been really rewarding.

MILLER: You've mentioned your wife periodically in this interview, but what about the kids? How did they do in Uganda, and then how did they do when they came back? Did you come back for the kids to go to school here?

MERMIN: CDC or HHS, I think, has a rule that you have to come back from being overseas if you're there for more than eight years. I don't know if it's still in place, but they made an exception for (us for) ten years, and then it was time. My eldest daughter, who was born just a month before we left, grew up in Uganda, and then the second daughter obviously grew up there too for several years. They loved Uganda and Kenya, and it made a big difference in their lives. 01:27:00They've gone back and taught at a rural school in Uganda during their summers. My older daughter is actually going to go back this summer in between college years to actually do some research. They really feel tied in with the experience there. Of course, now as a parent, I regret that I ever made them interested somehow inadvertently in living away from me, but we have to accept it that they've caught the global bug. I also think that when they came back, they had some challenges, I think. First, it's a different culture coming to the United States. We did recognize that, for any family that grows up outside of the country of their parents, you have a question of whether you want your children to be third-culture kids, where they're most comfortable with other people who have grown up outside of the native home of their parents or their adopted home. 01:28:00We felt fortunate that they are fully ensconced in American culture. They understand American culture, in its delights and drawbacks, and I think that has allowed them to fit in, but they also feel tied to what they experienced as children. I think it made a big difference for them, just like it made a difference for me and Becky.

MILLER: Any burning thoughts?

MERMIN: I appreciate your questions.

MILLER: Thank you.