Dr. R. J. Simonds



MILLER: This is Dr. Bess Miller, and I am here with Dr. R.J. [Robert James] Simonds. Today's date is July 12, 2018, and we are in Atlanta, Georgia, at the Centers for Disease Control and Prevention [CDC]. I am interviewing Dr. Simonds 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. Simonds, do I have your permission to interview you and to record this interview?

SIMONDS: Yes, you do.

MILLER: I've worked for you and with you since the very early days of PEPFAR, R.J., and it's a pleasure to be able to reflect on this with you today. During your career at CDC, you've had a leadership role in many different aspects of HIV/AIDS treatment and prevention, both domestically and internationally. For 00:01:00today's interview, we'll focus on your work on prevention of mother-to-child transmission, or PMTCT, that began pre-PEPFAR, and then your positions leading the implementation of PEPFAR. Let's begin with your background. Would you tell me about where you grew up, your early family life, and then where you ended up going to college?

SIMONDS: Sure. Thank you, Bess. I grew up in Pittsburgh, Pennsylvania, actually a suburb of Pittsburgh [Mount Lebanon], where my parents moved when we were very young children. I grew up in a family of initially five, and then we had a foster brother move in with us to make a sixth child. It was a busy and very educationally oriented family, in a school district that was competitive and really brought the best out of its students. I went from there to the University 00:02:00of Pittsburgh for one year. One of the areas that I was interested in in high school was Chinese, and I went on to begin to study Chinese in Pittsburgh. After one year in school at the University of Pittsburgh, I decided it was time to get out of town. I transferred as far away as I could find at the moment, which was the University of California at Berkeley. I drove across country in order to continue my Chinese studies there. When I got there, I realized that all they were teaching was classical Chinese, which didn't have any interest to me. I ended up quickly changing my major to geography, because I'd seen what a beautiful country the United States was on the way out. I graduated with a degree in geography, which I think appealed to me at the time as being a way of looking at patterns of things, how the Earth becomes what it is and the way 00:03:00humans interact with the Earth at a population level. I believe (it) piqued my interest eventually in epidemiology as another way of looking at patterns of things.

MILLER: What did you do next? Where did medicine and medical school come in? Were there doctors in your family?

SIMONDS: There were no doctors in my family, except my older brother became a doctor, so there now is one other doctor in the family. Both of my parents were English majors, which ended up being more important than I realized at the time. But there was no history of that (medicine) in my family. To me, it emerged in a rather circuitous way. After graduating with a degree in geography, which I realized did not really lead to very many jobs, I wanted to re-pursue my interest in Chinese. I went to Taiwan to study Chinese and teach English for a 00:04:00period of time. Back then, when you traveled internationally, you bought a student ticket that had defined start dates and end dates, and although I liked my time there, I had to come back on a certain date. I came back to Pittsburgh, drove a taxi, which actually did use my geography skills, and earned enough money to return to Taiwan.

On my way to Taiwan, though, I stopped over at the University of Hawaii to attend summer school in linguistics, which had become an interest, having studied languages. That's important for a couple of reasons. One, one of the courses I took was neurolinguistics, the interface between the brain and language. That was my first introduction to the human body and the inner workings of the human body. It also introduced me to my wife, which was very 00:05:00important for the whole rest of my life. In terms of getting me from geography to medicine, it was the link with neurolinguistics that then led me to go back to school to study something that I thought I could get a job in, which was doing EEG [electroencephalogram] technology, measuring--being the person who puts electrodes on your head to measure brain waves. That was interesting because of the neuro side of it, but it also got me into hospitals for the first time and that exposed me to the world of medicine. At some point, whereas before I'd perceived doctors as a different species of people, I realized I could probably do that. It ended up that I was working as an EEG technologist back in Hawaii because my wife continued her schooling in Hawaii. I ended up going to 00:06:00the University of Hawaii School of Medicine because we were living there and because I had been introduced through my EEG world to there (University of Hawaii). That got me into medical school, which was--because of all the circuitous pathways, I was an older student. I realized that that was very useful, because rather than being out doing the mating game, I could be studying and raising our son and being very diligent with my studies to get through medical school.

MILLER: That's fascinating. How (did you get) the international bug, wanting to study Chinese and go to China? Just deep within, were there refugee grandparents?

SIMONDS: Thank you, no. No refugee grandparents. My parents were very liberal and open-minded. We were in a community where--this was in the 1960's when there 00:07:00was a lot of social activism. My parents were involved in a lot of the social movements at the time. In particular, there was a lot of interface with international groups through our church and some exposure to the international world. I think the Chinese studies actually came from the offering of Chinese in my high school by a former French teacher who was there. He was a very likable and very impressive teacher. I took Chinese in order to study from Mr. [Arthur A.] Manion, who was the French teacher. It was a rather serendipitous move into international world.

MILLER: That's just incredible. After med school, what happened next?

SIMONDS: During medical school I came across the opportunity--I came across an advertisement in a newspaper or a magazine for doing an elective at CDC. You 00:08:00could do a student elective at CDC. I said, that's interesting; I think I'll apply for that. I actually came to CDC when I was a senior in medical school. I spent two months, first in the Division of Viral Diseases, working with trying to do some analysis of Kawasaki's disease. Then I got involved in--there was an outbreak investigation opportunity, so I was able to be an active participant in that. It turned out to not--unlike most of the outbreaks that took you to far-flung places, this was an outbreak in Atlanta, but it was an interesting outbreak of cryptosporidiosis in daycare centers in Atlanta. I got to see both the mechanics of outbreaks, also some of the politics and sensitivities of dealing with diarrhea in wealthy communities and how that gets addressed and 00:09:00some of those issues. It was from that that I realized that this is fun, being able to do investigative-type work and solve problems. It was not lost on me that the lifestyle of an epidemiologist, at least at that time, did not involve night call, and it had a relatively defined day. That turned out to not be the case later on, but at the time, that was an appealing factor as well.

With that as the backdrop, I decided I wanted to work at CDC. I wanted to get into the EIS [Epidemic Intelligence Service] program, but I also realized that I wanted to have some sort of clinical background. Having already had one child 00:10:00and others on the way, I decided to go into pediatrics to get a background in pediatrics before moving into public health. I did four years of pediatrics residency, with an eye towards wanting to end up at CDC. I was fortunate in that I was able to make that leap to CDC.

MILLER: Wow. Your preparation for CDC almost has a biblical proportion. Very impressive. Then, you came to CDC, and this is 1990. By then over 100,000 cases of AIDS have been reported in the United States. We're getting reports of HIV [human immunodeficiency virus] from Africa and Asia but don't have any idea of the magnitude of this. By then AZT [azidothymidine] had been approved, including 00:11:00for use in children, but there really isn't any significant movement in the treatment of AIDS in the U.S. Tell us a little bit about your EIS assignment. Where were you assigned for EIS, and what did you do?

SIMONDS: Okay, thanks. I was assigned to the Division of HIV/AIDS. Getting into EIS, as you know, involves a matching process. When I was going around to all the groups to match, I was looking for something that could align my pediatric interest and experience with something useful at CDC. I was looking at vaccine-preventable diseases and diarrheal diseases. There was a position open in the pediatric section, Pediatric and Family Studies Section of the Division of HIV/AIDS, and I went to talk to them. I remember talking to [Dr. James W.] 00:12:00Jim Curran and [Dr.] Martha Rogers, and they seemed very nice people. I expressed the fact that doing my pediatric residency in Pittsburgh, Pennsylvania, I had very little exposure to AIDS in children. In fact, I had two patients that I had ever taken care of with HIV. I said, I really don't know anything about HIV. I remember Jim Curran saying, "Oh, R.J., don't worry about that. A few years ago, nobody knew anything. You'll catch on."

I ended up matching with the Division of HIV/AIDS in the Pediatric and Family Studies Section, which was led by [Dr.] Margaret [J.] Oxtoby. I joined that team. I had replaced--there was an EIS Officer before me, and I replaced her. I began my EIS work doing a few projects related to HIV in children. One of them 00:13:00in particular, early on, was on data on PCP in children. Pneumocystis carinii pneumonia [PCP] is one of the opportunistic infections that was commonly associated with immunosuppression in HIV, and in children it was the most common AIDS-defining condition. Doing an analysis of the AIDS reporting data, a very simple analysis of looking at the age at which children were diagnosed with Pneumocystis carinii pneumonia, showed a very dramatic and interesting pattern: there was a huge peak at three to six months of age when children got PCP. If you look at all of the cases of PCP in children, the majority of them were occurring in this rather narrow age group, which had important implications for 00:14:00policy. It was my first link to the experience of having data shed light on policy and how we could make that link.

One of the important issues with HIV in children is the diagnosis of HIV it requires. Whereas adults can be diagnosed with a blood test that detects the antibodies to HIV in the body, and in adults that equates with infection, in children, the antibodies pass on from their mothers if their mother is infected. In the case of children without any intervention, about a third of them will get infected with HIV, but about two-thirds will not. The antibody test doesn't tell you definitely. In fact, it's not a very good marker of infection up until about eighteen months of age.

MILLER: It could still be the mom's.

SIMONDS: It could still be the mom's infection. You can tell if the mother has infection, but you can't tell without doing special testing of the virus itself whether the baby is infected. Here you have these--and you could prevent PCP by using trimethoprim sulfa or Bactrim as a drug. Figuring out how do you prevent HIV in children, before you can even diagnose HIV in children, became an issue. We recognized that the only way you're going to do this is by aggressively using these viral tests, the PCR [polymerase chain reaction] tests in particular, which measures the DNA [deoxyribonucleic acid] of the virus. It's only going to be by doing that early on, shortly after birth, that you're really going to be able to definitely detect infection in order to start children on prophylaxis to prevent PCP. Initially that was impractical, because you just couldn't do it. 00:16:00The policy approach was to actually start all children whose mothers were HIV infected on the prophylactic medicine, the trimethoprim sulfa, and if they were diagnosed as not having infection, then you could stop the prophylaxis.

MILLER: Continuously for months at a time.

SIMONDS: Yes, regardless of--and in most cases it's not going to be doing anything because the child is actually not infected, but you don't know that.

MILLER: Was this a part of U.S. Public Health Service guidelines that came out?

SIMONDS: Yes. There were several sets of guidelines, particularly as diagnosis got improved. You could do different things, but it got me involved in a watchful way, rather than the active policy-maker way, to see how you came up 00:17:00with the right set of recommendations that were balancing these different things of sensitivity and specificity of the test, of over-treating versus missing cases, and all that. I got involved with helping writing those guidelines and then also doing additional research in that area.

MILLER: Was it controversial among AIDS pediatric clinicians at the time? Was that broadly supported? Do you remember what some of the thinking--this is before it was possible to easily do PCR testing of babies.

SIMONDS: Yes. The beginnings of the ability to do PCR testing were there. I think they have studies showing that this was actually a good tool for diagnosis around 1989-90. I think Chin-Yih Ou and Martha Rogers were writing papers on 00:18:00that, but it was not available widespread and so not the most standard approach for diagnosing HIV. If you diagnosed HIV in a pregnant woman, and if you had the proper linkage to care of the baby, you could start prophylaxis on the baby. Some of the controversies were not really around the therapy; the prophylactic treatment itself was not terribly controversial. It was cheap and it didn't have much side effects, but the operational issues of identifying and providing that to the children's caretakers on the basis of the mother's diagnosis was more complicated than it might seem. One of the things it did do, though, was push the issue. It contributed to the controversy around testing pregnant women for 00:19:00HIV when there was no treatment. This was a time when there was no effective treatment and no widely available treatment and not knowing what to do in the context of pregnancy. By now, having something that you can do to help the health of the child added to the positive side of the equation of getting tested for pregnant women. (They) might otherwise be thinking, why should I do this if it's going to lead to stigma, discrimination, loss of job, if people find out. Now you have more reason to be testing during pregnancy, which ended up being an important forerunner to when you really had the opportunity to prevent transmission to children. You needed a system that was able to be diagnosing women well.

MILLER: Moving on to preventing mother-to-child transmission. Later on, in your 00:20:00EIS or just after that, I know you were involved in several multisite studies on prevention of mother-to-child transmission in the United States. Can you tell us a little bit about those studies and how it led to which recommendations?

SIMONDS: Sure. There were a number of--it was recognized pretty early on in the AIDS epidemic that children got HIV, children could be infected with HIV through pregnancy or childbirth or breastfeeding. Clearly there were children getting infected, and it was very closely linked epidemiologically to their mothers being infected. So that was known. What wasn't so clear-- in fact, I still think it's not entirely clear -- is why most children don't get infected. Why is it that only about a third of children who were born to HIV-infected mothers 00:21:00actually get infected themselves? The basic issues needed to be sorted out: what is the rate, what is the risk of infection to a child born to an HIV-infected mother, what percentage of children get infected. Measuring that to some level of precision was useful. What are the risk factors, what do we know about mothers who are more or less likely to transmit to their children, what happens to children who are HIV infected, what is their clinical course, how long do they live, what symptoms do they have? All that required epidemiologic study, so a number of multisite studies were formed--they were beginning before I came to CDC--multisite studies that brought together enough patients that could get enough of a size to get the right estimates for some of these things.

CDC had a multisite study called the PACTS study, I think it was Perinatal AIDS 00:22:00Collaborative Transmission Study or something like that. (There were) five sites: Atlanta, Baltimore, a couple in New York and somewhere else -- five sites that collaborated on measuring, on reenrolling women, measuring factors about them and then following their children. [Dr.] Nathan Shaffer, when I started CDC, was the project officer on that. I joined up with him, and when he moved off to work in Thailand in mid-1990's, I took over as the PI [principal investigator] on that study. That was very important, because those studies were being done at the time when in 1994 the seminal study on preventing mother-to-child transmission, the NIH [National Institutes of Health]-funded 00:23:00ACTG-076 [AIDS Clinical Trials Group] study came out. That study showed that, by giving mothers the drug AZT during pregnancy, from early pregnancy until the end of pregnancy, giving them intravenous AZT during labor and giving the child AZT for six weeks, you could reduce the risk of HIV transmission from mothers to children by about two-thirds. It was that finding that led to huge--many, many, many things that I think we'll be talking about. Having these studies available, having these research collaborations in place, allowed you to begin examining lots and lots of other factors related to preventing mother-to-child transmission that you couldn't have done if you were just starting from scratch.

MILLER: The findings of your multisite studies on maternal transmission, were these with an intervention or just observation?

SIMONDS: These were observational up until the intervention became--when the 076 study came out, then suddenly policy changed. Practice and policy immediately changed, so you could actually look at the intervention itself and how it was being utilized in these cohorts and the impact it had over time. You could also look at this issue of infant diagnosis. It allowed you to have a population that you could test the sensitivity and specificity of ways of doing this early diagnosis by measuring the DNA or the antigens in the children.

MILLER: So, these multisite studies were not controlled trials. They were really out there--

SIMONDS: No, they were observational studies.

MILLER: And then you added the intervention when it became--

SIMONDS: Right, right, right. Of course, the 076 study itself was a similar 00:25:00observational study, but it provided that--it was a placebo-controlled study and provided the intervention to half of the women. CDC was not doing that type of study in the U.S. around that.

MILLER: OK. So, again, at this time, '95, '96, in the U.S. there's still a very limited scale of treatment.

SIMONDS: In 1996 the treatment began improving a lot. The use of triple drug combination therapy and the recognition of the ability of new drugs to dramatically reduce viral load in people with HIV infection led to rapid growth 00:26:00in the coverage on treatment in the U.S. For pregnant women it was the AZT that began to be the intervention that would be used because of its preventing mother-to-child transmission benefits. In the initial times of treatment, there were CD4 [t-cell test] cut-offs for using treatment. People who were relatively well, asymptomatic, would not be started on treatment because the treatment was reserved for the sicker people. In general, pregnant women were not in that category, just by the demographics and who gets pregnant. It was a relatively small proportion of pregnant women who would have been started on treatment initially.

MILLER: Interesting. More to come on that. Then you went to Thailand, is that 00:27:00right? How did that come about?

SIMONDS: How that came about, there are a few important landmarks. With this 076 study in February of 1994, at that time I had become the Chief of the Pediatric and Family Study Section. Our section, particularly working with the Surveillance Branch in the Division of HIV/AIDS, was looking then at our surveillance data and saying, okay, what do we-- (We looked at) two aspects of the surveillance data. One was the case surveillance of AIDS. Can we see what's happening now as women are starting to use AZT? Are we seeing a drop-off in cases of AIDS in children? Remember that the epidemiologic curve of AIDS in children was very front-loaded because of all the PCP cases. Children got--the 00:28:00time between infection and AIDS was much shorter in children than in adults. The opportunity to see the impact of stopping prevention, then, was very high in children, because you could see pretty quickly (whether) you are making a dent in the number of AIDS cases.

We did careful analyses of the AIDS surveillance data. The childbearing women's survey that was in place that helped measure the prevalence of HIV in women, in pregnant women, became an important tool to give you the estimates of how many people needed this treatment in the United States, and those kinds of analyses. Looking at the international side, then, what CDC also did was launch two parallel studies, taking the intervention that was used in the ACTG-076 trial, 00:29:00AZT, which was cumbersome in its length and its cost and its use of intravenous formulations during labor, and trying to see if you could also get an impact if you reduced that down to make it a more feasible oral and shorter and cheaper intervention. So, two studies were launched to look at a shorter version of AZT to see if it could prevent mother-to-child transmission also. Those two studies, one was done in Thailand and one was done in Côte d'Ivoire, were launched around '95, '96. They continued for about two years before they were able to show that in fact, yes, even a shorter version of the AZT regimen could reduce 00:30:00transmission from mothers to children. My career change on this was that right around the time-- the study in Thailand, which Nathan Shaffer was the PI on, wrapped up in early 1998, showing that, yes, this worked.

MILLER: And these were placebo-controlled.

SIMONDS: These were placebo-controlled trials. There was a lot of pressure on that, because you now had to balance getting a quick and definitive answer about what magnitude of reduction and transmission you would have by comparing this short-course intervention to the standard of care, which at the time was no intervention. Or do you compare it to the ACTG regimen, which was not being carried out in these countries and was unlikely to ever be the final policy in 00:31:00these countries? You wanted to make sure that everybody got something, and it was a very controversial period in time and (there were) very interesting debates around that. This led to, obviously, for many reasons, a pressure to try to make sure these trials get done in time and get done accurately and show definitive results. Fortunately, they did. The government of Thailand quickly moved this into national policy, and I was fortunate enough to be able to take a position--Nathan's term ended in Thailand in 1998 right as the trial was ending. I came behind him, taking the CDC position in the CDC office in Thailand. I worked closely with the Ministry of Public Health on scaling up their program for doing a regional program and showing it could be implemented, setting up a 00:32:00national monitoring system, doing some research around women's attitudes towards treatment, how to do proper counseling and issues like that. (There was) lots of implementation science-type work.

MILLER: Before we had this interview, I was going to ask you, wow, why Thailand? Where did this international bug come from? But now we know it was there in you for a long time. Still, this represented a huge commitment, and you had how many kids by then?

SIMONDS: Three. Teenagers.

MILLER: Teenagers. How did that go, in terms of getting everyone over there and committed? Your wife, was she supportive? How did that happen?

SIMONDS: Very good question. It happened--the idea of going to Thailand for our family clearly originated with me. None of my kids came up with that independently. My wife, being Japanese, had a more favorable openness to moving to an Asian country than maybe she would have had to moving to an African country. None of my family had been to Thailand before. I had been a couple of times, and I sent pictures, told them about my stories. It represented, obviously, as you said, an important change for my family. I think--my wife and I thought this would be an opportunity for our children to see something new while they are at an age where they could learn a lot from it. We also were 00:34:00aware that we're very privileged when we do our overseas assignments with CDC. We get taken care of, we're allowed to attend international schools, and the educational opportunities were more positive than negative for the children to be going to an international school. As parents, we agreed that this would be a positive family move. The kids took a little bit more convincing. My daughter, who was old enough to be very articulate already, asked me, Dad, did you have a choice in going to Thailand? Was it your decision to take your children, rip them away from their friends and send them to a foreign country or what? We had to have some diplomatic discussions about this. In the end all of my family was very, very appreciative of the opportunity that CDC provided to be living 00:35:00overseas, to be exposed to a new lifestyle, to make new friends that now are still friends after many, many years and to really, in Thailand in particular, learn about what great people the people of Thailand are. It's been from a family perspective. Although getting into it took some negotiation, everyone sees this as having been a very positive experience.

MILLER: So that's 20/20 hindsight. What was it like when you first got there? I should say you were joining the U.S. Thai Field Station in Thailand, which had been established in 1990. Was [Dr.] Bruce [G.] Weniger still--

SIMONDS: He was not there. He'd started it-- [Dr. Timothy D.] Tim Mastro followed him. Tim Mastro was the country director when I arrived there.

MILLER: So, he was your boss?

SIMONDS: Yes, he was my boss.

MILLER: How did (it go) just getting going (with a) totally 100% new world 00:36:00experience? Had the kids traveled at all?

SIMONDS: They had traveled. They had been to Japan, for instance, so they--

MILLER: And their mom was Japanese.

SIMONDS: Yes. I didn't mention that as maybe part of the--that maybe is an outcome rather than an input for the--

MILLER: Yes.

SIMONDS: Like you say, everything was new for everybody. Moving into a new house, living in a townhouse that was directly across the road from our school, was very convenient. New money, new food, new language. It was tough. My wife was a professor at Georgia Tech [Georgia Institute of Technology], and we were going for a three-year term. We agreed as a family that was probably about the right amount of time. She could only take two years leave of absence, so the 00:37:00first year she came but had to go back for the school season and was gone a lot of that time. Fortunately, there was a lot of support. We had a live-in maid who cooked and cleaned for us, which was obviously a blessing. Being in the neighborhood of the school, there were a lot of families, and the kids could walk to school back and forth with no problem. There were solutions to most of the challenges.

At work, to me it was just like all this exciting new stuff. Programmatically it was really cool to be doing something extremely positive in terms of program implementation, which was no longer just research but actually doing something. (It was exciting) being a manager of people from another culture and just 00:38:00learning how to talk to people and what works and what doesn't work and trying myself to learn Thai as best that I could.

MILLER: So, you were there not doing a study, you were doing implementation of programs.

SIMONDS: Both, both.

MILLER: What were you studying? What were some of the implementation science--

SIMONDS: The short-course AZT study that I mentioned that was done in Thailand. It actually followed a prior observational cohort study. As I was mentioning before, having these observational studies up and running was a prelude and an opportunity to really move quickly to inserting an intervention, and in the case when I got there of then observing what happens when the intervention is being used. We developed a strong collaboration with the children's hospital [Queen 00:39:00Sirikit National Institute of Child Health] in Bangkok and Siriraj Hospital in Bangkok in particular with a defined organizational structure for research and research nurses that were posted at the sites. Just lots of--there was a real infrastructure there for continuing the next phase of things to look at what happens. We were looking at issues like some of these testing issues, what can we make available and (how can we) utilize the PCR testing effectively, how are women dealing with infant feeding. In Thailand as a national policy infant formula was provided so that HIV-infected women did not breastfeed. We wanted to know how was that going, did it work. Those kinds of things--how was the implementation being used in people attending these major hospitals in Bangkok.

We also did a regional implementation study, where we implemented this regimen in one of the twelve health regions in Thailand. We observed and collected data on the uptake, how many women got tested of the estimated number that were there, how many got started on treatment, what were some of the reasons they didn't get started on the AZT, that kind of thing. And we also set up a national monitoring system for these indicators, and actually one of the things I'm most proud of is that's still in place. It started in 2000, and now nearly twenty years later they're still using that system.

MILLER: That system would monitor--

SIMONDS: Would monitor the uptake of the use of the interventions in the women. In Thailand it's always very high numbers, 95%, 98%. (It enabled us) to look at the hospitals, which hospitals are not doing so well or which regions are not 00:41:00doing so well.

MILLER: Just to step back from those specifics, what was AIDS like in Thailand when you got there? What were people seeing in the hospitals in general? What was healthcare delivery like for people with AIDS in Thailand? Many of us know Africa pretty well, but perhaps not as well what was going on in Thailand.

SIMONDS: First of all, the epidemic in Thailand was fueled by--I think the initial really explosion of the HIV epidemic in Thailand was due to its rapid transmission through both sex work and injecting drug use. Then, with increasing 00:42:00numbers of infected people who then were having sexual contacts with people outside the risk groups, the infection was spreading into the general population. Thailand was also famous for having had very good interventions to reduce transmission, particularly in brothels, through combining the police and the brothel owners and the public health world to come up with 100% condom use policies. Anyone going into a brothel, it would be standard practice to be using a condom. If that didn't happen, you had the police or the owners, everybody was conspiring to have better health in that setting. That led to a decline in these high-risk groups, but you then had a more general population that was already becoming infected. Because of its starting with the high-risk groups, like you 00:43:00would see in every country, the stigma associated with the risk groups immediately transfers into stigma associated with HIV. The idea (was) that if you had HIV, it probably means you were doing something that was socially unacceptable. You had a lot of the issues of hiding your infection, not telling your husband if you're an infected woman or needing help to do that, keeping information from the schools, even keeping information from healthcare centers.

In terms of the care, the healthcare system in Thailand is well organized. Down to the district level, you had health centers and you had places where you could do the kind of primary care needed, such as HIV testing. You didn't have to go 00:44:00somewhere else to get a test. You could get tested relatively locally, and that was an important feature. The system itself is organized, which allowed the scale-up of the PMTCT interventions relatively quickly. You had an authority structure that went from national to regional to provincial to hospital, and people generally follow guidance. If you had the right guidance and the right incentives and enough resources, the system itself worked well enough to be able to implement--

MILLER: Were there enough resources? What was the economic situation during those years?

SIMONDS: Thailand had a big--and the rest of Asia--had a big crash around 1997, shortly before I got there. It was coming out of that during the years when I 00:45:00was there. So, there were never enough resources. That was always an issue. But there was generally an openness to addressing the AIDS epidemic. There was nobody saying, let's not address this. It was very helpful to have quantifiable needs: how many people do we need to test or how many doses of drugs do we need or how much infant formula do we need to buy. Some of these monitoring systems were useful in providing that kind of data, so that a planning cycle could eventually improve the ability to meet the needs. There was also a very strong and useful component in the NGO world. Particularly the Thai Red Cross was actively addressing HIV infection, and they could raise funds through private 00:46:00means. One important aspect in Thailand is its royalty. It's a kingdom, (centered on) the respect that the royalty receives. The Thai Red Cross was very linked in with the hierarchy in Thailand, so it received a lot of support. (It was helpful) having that NGO [non-governmental organization] component there as well. I think there was external technical input, but the U.S. didn't support the implementation. We supported the technical aspects of this, but we weren't supporting the buying of the commodities or the hiring of all the staff and all that. That all came indigenously. (There were) some small grants from organizations, but in general it came from the government. It was really for me a good combination of things, where you could use technical input, but you 00:47:00didn't have to be dealing with all the money. You didn't have to be advocating for large sums of funds back to anybody, because they were being generated indigenously.

MILLER: Did you end up becoming friends with Thai staff there? Was there acceptance of you and your family and other U.S. "expats" from CDC and elsewhere?

SIMONDS: I think CDC had, and still has, a positive image. It's one of the bigger--in fact, it may be the biggest U.S. government presence in Thailand, in terms of all of its staff, including its locally employed staff. The staff that 00:48:00work--since the office has been there a long time, as you mentioned since 1990, there are people who have been there for a really long time. In fact, some of my close colleagues that were there, starting around the same time that I started, are still there. I'm still in touch with them and they're growing through the system; they're leaders in the system now. I met a lot of people that I stay in contact with. When I get a chance to go to Thailand, I see colleagues regularly. It added a large layer of new friendships and colleagues to my career richness.

MILLER: What about the embassy? Did you relate to the embassy? Was that a big 00:49:00part of CDC life in Bangkok?

SIMONDS: For me, no, for a couple of reasons. One, the CDC office was housed in the Ministry of Public Health, which was a bit of a hike from the embassy. On a day-to-day basis, I wasn't going to work at the embassy or I wasn't living near the embassy. I would go there for things like going to the commissary or doing administrative things or the medical office, but in general not so much. Then my position was not--I wasn't representing CDC at meetings. The director would be going to those kinds of meetings, so I wasn't having that kind of contact. I had a fair amount of contact and knew a lot of people there, but I felt a lot more like I was part of the CDC family or even more of the Ministry of Public Health family, just because of who I saw every day.

MILLER: Anything else you want to tell us about your experience in Thailand? It sounds like it was wonderful.

SIMONDS: Yes. To me it was very important for my life, my career. My family, I think, gained a lot from it, from having friends and colleagues that are lifelong and actually not purposefully. It ended up being that experience of scaling up PMTCT in Thailand, then became, later on, what the United States was assisting with in many, many other countries. Having the experience of, first in the U.S., dealing with scaling up in the U.S., although we didn't really call it 00:51:00scaling up, but the growth of the interventions in the U.S., then working in Thailand scaling up, really gave me a kind of unique exposure to a bigger structure of what it takes to do a public health program than maybe what it takes to take care of a patient or what it takes to even run a hospital. At the time, I was just doing my job every day. Then in retrospect you realize that you were seeing and participating in a system that needs to be changed or that needed to be changed in order to address the AIDS epidemic. Then later on it became an important experience to be able to apply it to bigger things that were going to happen.

MILLER: You came back at an interesting time as well. At that point it was the 00:52:00pre-PEPFAR beginning of the LIFE [Leadership and Investment in Fighting an Epidemic] Initiative. CDC and the U.S. government had really made very minimal efforts towards global AIDS in the '90s, dealing with our cases. This was prior to 1999, and then things began to change in 1999. At that time President [William J.] Clinton launched the so-called LIFE Initiative, which was a U.S. government HIV/AIDS initiative. Can you tell us just briefly about what that was and what was its main focus?

SIMONDS: The LIFE Initiative, which was happening (already), it wasn't so 00:53:00related to--it started when I was in Thailand. It didn't connect directly with Thailand, so I wasn't personally engaged at the beginning of it. What it ended up doing was providing CDC with funding, I think, in the $35 million range, to be able to start new offices and presence and activities in a larger number of countries. As you say, before then we had a relatively small presence overseas. We had a Thailand office, Kenya, we had somebody in South Africa, we had Uganda, Côte d'Ivoire, but not that many. The LIFE Initiative provided the resources to start. I think we had about thirteen country offices in total that either got a boost with these funds or allowed us to actually place new people to new sites, to new 00:54:00countries. At the time, a lot of the issues were operational, just how do we find people and how do we operate in a larger way in many different countries. We were relative amateurs, probably more than relative. We were amateurs in this field of operating overseas, having just a few countries and a relatively small number of people that knew how to do this. We were scaling up our own capacity to work overseas, to become part of the embassy families, to work in an interagency way.

MILLER: The big player in international health was USAID [United States Agency for International Development].

SIMONDS: Yes.

MILLER: Did they have a big part of this LIFE Initiative funding?

SIMONDS: Yes. Most of the funding went to USAID. Some of the funding went to CDC, and I believe a little bit may have gone to the Defense Department, but I can't recall for sure. It allowed both agencies to expand our activities in HIV 00:55:00overseas, and it allowed--not knowing the future and it was not like there was a commitment to ten years of more and more and more funding. It was really all about getting started, and that allowed both field offices to be set up. Then it led to a structural change at CDC headquarters of finding a home for international HIV/AIDS. The Global AIDS Program initially was the Global AIDS Activity. CDC often does this, pulling people from various places, then eventually formalizing an organization. The Global AIDS Program was launched in the LIFE Initiative period as a focal point, and with central leadership in the 00:56:00global HIV work linked to in the same center as our domestic program, but now (it was) a self-governing external, globally facing organization. When I came back in 2001, that Global AIDS Program was just starting up, and they were just starting the formal structure of that. I think there were four branches, and I was named the Prevention Branch Chief. Prevention included prevention of mother-to-child transmission, as well as other blood safety and sexual transmission and youth and STD [sexually transmitted disease] treatment. I came back then into a branch chief position to help us do stuff.

MILLER: Who were your bosses? Who was the program boss, the center director boss? Who was even the director of CDC at that time? Was there support for this move towards a bigger effort in HIV?

SIMONDS: Yes. The Division Director of the Global AIDS Program, but it operated as a division, was [Dr.] Eugene McCray. He had begun the leadership of this and then formally was the leader. [Dr.] Helene [D.] Gayle was the Center Director, and she was very supportive. Carmine [J.] Bozzi was her Deputy, and he was very involved in making all this happen and interfacing with the [U. S.] State Department and doing all the interagency work required to allow this to happen, 00:58:00allow CDC to be doing work in new areas and getting along with the other agencies and doing all the operational parts of this. The feeling was very much of a new thing, a good thing, an interesting thing. A lot of people had some international experience and were brought into this from the International Health Program Office or other places. Others were just new to the field and quickly learned on the job about how to make things happen overseas.

MILLER: The CDC Director was?

SIMONDS: The CDC Director at the time was--at the time of the LIFE Initiative starting, I believe it was still [Dr. Jeffrey Koplan] Jeff Koplan. Dr. [Julie L.] Gerberding started--I believe Dr. Gerberding was there when the formal 00:59:00launching of the Global AIDS Program--but

MILLER: In general, the Office of the Director, was supportive also of this?

SIMONDS: Yes. I think everybody at CDC was either actively or passively supportive of this. It wasn't--people weren't fighting too much over this. Any time you start (something new) you pull things away, but having this be in the same center, with the Center Director being very supportive, I think smoothed things out. Later on, fast forward in history when the Center for Global Health was developed and growing and involving moving now large divisions from one center to another, those (moves) are never easy. Those require a lot of 01:00:00negotiation and discussing what the relative values of keeping everybody doing work in HIV together versus everybody doing work globally together. You have to make decisions.

MILLER: What came next? There was a large funding for a PMTCT initiative that followed soon after. Can you put that in the context of PEPFAR--

SIMONDS: For the LIFE Initiative, starting 1999-2000, personally I began in the summer of 2001 getting a new division together, getting offices together. That was occupying everybody--figuring out what a strategy is, what are we really doing. We were all busy doing that. (There was a) new election. President 01:01:00[George W.] Bush comes in, and we started getting some discussions, like data requests-- how many people do you have out in the field, and what's your budget? What do you think we can do, and what could we do if there was more money? A lot of things, and this is not uncommon in new administrations to start getting some ideas floating around.

MILLER: I should say, just to interject a point here, that one of the big issues was that the price of drugs was beginning to be negotiable and come down, because the cost of treating AIDS at that time was $10,000 to $15,000 a year in 01:02:00the U.S. I think at some point you might want to comment on that--

SIMONDS: That's actually very important, and the LIFE Initiative was all about prevention, (which) was the focus of it. There was little appetite for thinking about treatment in resource-poor countries at that time. There was very little experience with it, the costs were very high, and there was just maybe some lack of imagination or lack of thinking that this could be possible. And that led to-- when the LIFE Initiative was in place, the notion was--at the same time people realized there is treatment available in the U.S., and there's need for treatment (to be) available in other countries. (There was) a lot of interest in what can we do, can we help people, can we provide treatment for people. There 01:03:00was a tension about how far we could go with treatment under the LIFE Initiative, because there were opportunities like UNICEF [United Nations Children's Fund], which had some small funding for pilot projects that you could start to see what treatment could be done in small populations. We were helping provide some technical assistance around that, but we really were not in a position to be--the U.S. government was not in a position to really be talking about treatment, because we as a country didn't want to say, yes, we can do this. People in power at the time did not think it could be done.

That's what changed. The drug costs beginning to come down, the development of generic drugs, just a continued improvement of drugs, formulations-- there was a 01:04:00steady improvement along those lines, such that there were people who began to see the future. This big gap was only getting bigger as more and more people were infected, particularly in Africa, that were not on treatment, and this (gap) is only going to get worse. There were beginnings of concern about how this could become a security issue if the productive segments of populations were dying off, (if) the teachers, the soldiers, the business people were getting sick. This could have much bigger implications than just public health. The evangelical community saw this as a need that needed to be met, the idea that people were sick and dying when there was the possibility of treating people.

A lot of these factors came together that led to--eventually it led to PEPFAR as a concept that was doable. We began hearing about--there were discussions with HHS [U.S. Department of Health and Human Services] about what could be done, et cetera. Then in the summer of 2002, to everyone's surprise, there was an announcement that the U.S. government is going to do a $500 million preventing mother-to-child transmission project in fourteen countries. USAID and HHS were going to be the joint leads on this. There were targets for how much prevention we're going to do, and a structure was set up for how to govern across these agencies 01:06:00and how to work with the countries. That changed a lot. That was a lot of money.

MILLER: Do you remember about how much CDC got--

SIMONDS: No, but probably around a third or fourth, something along there.

MILLER: Which is a lot of money.

SIMONDS: Yes. It was a big important factor in CDC. Because we had these countries (that) were chosen such that CDC--these countries were chosen in a way that ended up being--CDC was present in most of the places that were selected for this. That had not been (the case) even before the LIFE Initiative, so we were pre-positioned almost to be able to be participants in the PMTCT Initiative when it came along, working together with USAID. This formed a real way of 01:07:00actually doing programming together. You had resources-- you just had to figure out how to work together as agencies to implement (the project).

MILLER: Why CDC? USAID has this long history, they have offices in country, they have a long record of health system strengthening, healthcare infrastructure, and nutrition. What did CDC bring to this?

SIMONDS: CDC is the nation's prevention agency. In terms of the AIDS epidemic in particular, we had great experience in responding to many issues about HIV in the U.S. We had a fair amount of--although we didn't have offices in places, we 01:08:00had a lot of international experience working with USAID. We were often seconded with USAID or WHO [World Health Organization]. We had a lot of experience overseas, and we were deemed to be technically highly qualified to understand the issues. We had laboratorians, we had biomedical scientists, we had all the technical capability that was needed to do that. The idea that we should marshal all of the assets of the U.S. government to do something as big as this was, I think, the philosophy behind this. We were there, we had something to contribute, and we should be doing it.

MILLER: Then in 2003 President Bush announces PEPFAR. Do you want to say a little bit about what the goals of PEPFAR were and the budget, and then maybe 01:09:00your earliest role in PEPFAR?

SIMONDS: PEPFAR was announced in the State of the Union address in 2003. Again, (it was) a very extremely well-kept secret before that announcement. If there were people at CDC who knew that was going to be announced, I never met them or they never said. I was watching it, as were other people, and we're like, okay, I get it, we're going big. What was announced was briefly--and, like a lot of these initiatives, you get a paragraph in the State of the Union address, but it's followed up by fact sheets and more fleshed-out ideas. The basic construct of PEPFAR was that fourteen countries were identified as focus countries. There was a commitment of $15 billion over five years that the President was going to ask 01:10:00Congress for. There were targets with this funding in these countries. The expectation was that two million people would be put on treatment, and that was in comparison to an estimated 50,000 that were on treatment before that, so a huge increase. Seven million infections would be prevented, and ten million people would be provided care, including orphans, orphans that were orphaned from HIV.

There was going to be a structure in place that had a central coordinator in the State Department. President Bush wanted a go-to person who would be accountable for results and who had the authority to allocate the funding, to develop and maintain our policies around PEPFAR to represent the U.S. in the international 01:11:00forum around HIV issues. So, there was a defined structure, there were goals, there was money, and (there were) lots of pieces. Then what was not stated but what was also present was, there were a lot of pent-up passion and energy and interest in help trying to solve the HIV epidemic, and suddenly now you could do it. Suddenly it wasn't an issue of, we need more money. Now it's an issue of, oh my gosh, how do we do this? How do we actually build up the health systems to enable to provide this kind of service? My role in this initially--because I was the prevention branch chief that oversaw the PMTCT team and because it turned 01:12:00out that the PMTCT, the initial initiative was linked--I don't think it was preplanned this way, but the experience that was gained from that was a bit of a trial balloon, to see could we really expand and could the U.S. government work together as a team and carry out something bigger. I had been involved in the PMTCT initiative, the steering committees and the various parts of making that happen. Then when this came along, when PEPFAR was announced, we had a lot of mobilization that had to occur. We were all getting involved and figuring out what is the structure of this, what are the technical working groups and how do I plug in, how does everybody plug into this. (It is) a whole new structure of things. As one of the branch chiefs, I was--everybody was involved-- what is 01:13:00this? What are we supposed to do? And all those things. I (was involved) pretty early on, I think around the summer, maybe about six months after the announcement of the initiative.

The announcement initiative didn't mean the flow of the funds started. Congress had to enact a law, the money had to get to the agencies There was a period where this was an idea and a construct that needed to be done, but there wasn't actually the money yet to do it. There was some start-up time there. But I had the opportunity. I got called by [Dr.] Mark [R.] Dybul--Mark Dybul worked in [Dr. Anthony S.] Tony Fauci' s office in NIH, and he was detailed to the HHS Office of Global Health Affairs to help develop and actually to be the HHS representative for the PMTCT initiative, the HHS lead on the PMTCT initiative. 01:14:00He had been asked then, when PEPFAR started, to be detailed in to serve, I believe it was initially as the Deputy Coordinator, but anyway to be a lead person in the new Office of the Global AIDS Coordinator. That left vacant his position as the HHS Coordinator of this new growing HIV initiative. He said, can you come up and help us with this, maybe for a few months? I said, sure. I ended up being detailed up to Washington to work in the Office of Global Health Affairs under the Director of the Office of Global Health Affairs, [William R.] Bill Steiger, as the Coordinator of the HHS agencies. I was the technical representative to all of the growing interagency structures in Washington that 01:15:00were leading this. I ended up doing that for a year. I stayed living in Atlanta, but Monday through Friday every week we'd go up to Washington. I used to see the same guys on the plane in the morning. I was doing that every week for a year.

MILLER: Wow. We can't let that go by. You just blithely said, sure, I'll come on up. That sounds like it was quite a shift in what you'd been doing and an incredible challenge.

SIMONDS: Yes, that was a slight truncation of the story. Obviously, the idea of CDC deploying somebody up to do this was a larger discussion than just my personal situation, and others were supportive of CDC being involved. They saw tremendous value in having CDC being represented in the interagency discussions 01:16:00and being in the department. They thought that I could, having been involved in the other stuff and being on a scale from being diplomatic to being a jerk, they felt like I was far enough along on the side of being trustworthy up in that environment.

MILLER: What about your personality? I've known you, but can you say what about your personality worked for you in this setting, and what it took to deal with the conflicts, the politics involved?

SIMONDS: I try to think about that, because I feel like your personality is part of you. It's part of what people see about you, and it's part of--in an effort like this, and actually all public health, where you're working with teams, the ability to work in a team and move things forward and to attract people to work 01:17:00with you, making the environment friendly for work, solving problems that can avoid conflicts, or dealing with conflicts in a way that's productive, I think those are all very necessary things. While I'm not an expert in any specific ones of those, I think I've got some natural background or some natural God-given abilities in being tolerant. I've had an interest in humor and seeing the value that telling jokes has in the right situation at the right time, and the wrong times. At the right times it's useful. I actually developed some personal interest in learning about how does this all work, or why is it that 01:18:00people like to work with people who are more upbeat than downbeat. In my hobby time I was doing some reading and studying around that.

I think I had an interest in the science of working in groups, some abilities in that, and then I had a day-to-day laboratory of saying, what does it take. I realize that a lot of the work is based on relationships and trust. Particularly in this interagency environment, that if you have the right--if you can build up trust, people give you the benefit of the doubt. If you've lost that trust, they assume that you've got another agenda, and they'll withdraw. Building up that trust becomes an asset that should be treasured and respected and developed. I think appreciating that myself, and then seeing how I can help others to see 01:19:00that, has been part of one of the learning aspects, and I think one of the sharing aspects that I've had the opportunity to do.

MILLER: How was it working for Bill Steiger and all that went on in that office?

SIMONDS: Very, very interesting. What I had known about Bill Steiger before going up there was, he was the guy who was making us have every trip that we have taken internationally approved, have every personnel decision approved, running a very, very tight ship, tighter than we felt was needed for us down at CDC. I came in with a bit of apprehension about that, having seen that--barely having met him--I had met him but hadn't worked with him closely. Even after 01:20:00working with him for a long time, many of those personality traits were still present, but I really realized the value that he brought, both in terms of his intensity and his personality. Also, the fact that he was a political appointee in a position of authority in an initiative like this was extremely valuable. His own personal abilities aside, which were tremendous, he also brought an authority with him by virtue of being connected to the White House and leadership (there). People were aware that if he said something was going to happen, he could make it happen. Whether he really could, we never really tried to test that, but the feeling was that his word was very important. I learned in this that when your mission is aligned with the political structure, it's 01:21:00extremely valuable. It's not to be poo-poo'd as something not technical or not scientific. It's real. Working in an office where you could be helping to guide that power through getting things done was just very interesting and dynamic. At the same time the Global Fund [Global Fund to Fight AIDS, TB and Malaria] was starting, and he was very active in that as well. It was a lot of learning for a guy from Atlanta to see how Washington works. I hadn't had so much day-to-day experience with that before.

MILLER: Do you have any particular recollections of meetings or politics, financial issues that stand out in your mind?

SIMONDS: There were a lot of meetings, and there were--some of the things that were most memorable for me were some of the--I was able to be involved, or at least a participant, in some high-level meetings, like briefing Secretary [Tommy G.] Thompson on PEPFAR and joining lunch with Secretary Thompson and the Global AIDS Coordinator, Randall [L.] Tobias, and Bill Steiger. Having lunch, a foursome for lunch, and those kinds of things, which to me was like, what do they talk about? You learn what people really talk about and that kind of thing. And then there were meetings like I was--one of the things in my role at HHS for that year was the development of the structures of PEPFAR-- for example, the Deputy Principals Group brought together people that were the leadership group in agency, not the super leadership but the program leadership, who connected 01:23:00the policy to the staff, to the personnel structure, to the field work, and who could really solve problems because they could navigate all the different angles. You had the people from different agencies getting together every week to go through all the issues.

MILLER: And you represented CDC?

SIMONDS: Yes, I was at those meetings from the beginning, and they were, again, very fascinating. The agendas were wide-ranging, from dealing with specific policy issues like how are we going to do this, to the budget decisions, to just developing the guidance for how do we plan, how do we structure a planning process, what forms do we use, what indicators are we using for success, interpreting the data and making decisions and getting input from the technical--just everything came together in a somewhat structured but also 01:24:00somewhat nascent and developing way.

MILLER: What were the feelings then about CDC's role? You were representing CDC. What did you want to get across, or how do you think CDC fared in those -- in that forum?

SIMONDS: CDC, I felt like, was always struggling for appropriate recognition. We tend to, being in Atlanta, tend to not be quite as facile or as present in just a variety of ways. Our kids don't go to school with the kids in other agencies, or you don't see people quite as much. We're not quite as good, I think, at playing the world of getting things done in Washington. At the same time, we are 01:25:00obviously an extremely powerful and important organization who knows a lot of stuff. I felt like we were--one of the jobs was to be recognized for our capabilities. Another job was to really try to understand better what differences we bring to the table from what, say, USAID brought to the table and just really trying to understand that, so we could find common ground and not be battling. (It was) like speaking different languages and not knowing even what's driving them as an agency, and them not knowing what's driving us as an agency. I felt like we had to really get everybody to know what CDC does and then just constantly-- when you've got growing resources, people are always fighting over resources, and there are always tricks that people play or games or slight spinning of things. (I was) just always having to be vigilant about what's 01:26:00really happening now, what are we really talking about here, and what are the implications (for CDC) of some of the decisions that are being made.

I felt always very proud of being--if I looked around and said, which agency would I like to be representing here, there was no question that CDC was the cool agency that had so much capacity back home. We were junior in the field, and I thought we really had a lot to learn. There were a lot of legitimate critiques about how we operated, partly in ignorance of knowing all the rules of the road in terms of the embassies and how management is done overseas, but also may be coming more from the technical perspective than the diplomatic perspective. I think the problems that people had in the field were usually not 01:27:00because they didn't know their technical world, but because they didn't know how to behave themselves or operate or be smooth enough to develop the relationships overseas. Recognizing that and being able to communicate back, and everybody was realizing this, that we really need to make sure that we've got the right combination of technical expertise and human emotional intelligence that it takes to operate.

MILLER: For our people in the field.

SIMONDS: Yes, for our people in the field.

MILLER: Were you in a position to try and advocate for resources for CDC, or was that at the higher level?

SIMONDS: The way the PEPFAR planning process went, most of the resources were allocated on the basis of country-developed plans. The allocation of most of the resources was to the countries: this much money went to Tanzania or this much money was allocated to Côte d'Ivoire. It was up to the country teams then to come up with plans that utilized those funds. The real negotiations were more at 01:28:00the country level than at the headquarters level, although when things got rolled up, the headquarters had to be really looking at each of the countries. Then there were central projects that we were needing to advocate for--it wasn't so much to get money, it was to be able to do the activities that we thought were important to do and to maybe not spend money on things that we thought were not useful. It really wasn't the amount of money as much as making sure that the approaches that we thought were important to do could be funded enough to do them, and they would be overseen by people who were technically qualified enough to oversee them.

MILLER: In these Deputy Principals meetings, did you feel you were looking out for CDC, looking after CDC, defending CDC?

SIMONDS: Yes, some of the time. I would say more of the time was spent feeling like part of a start-up organization that was not so much defending our piece of it as much as figuring out how the whole thing should work. I feel like there was a true spirit of--Ambassador Tobias used to say, take your uniforms off at the door in PEPFAR and come in, not really there to represent your agency as much as to be part of a bigger effort. I think you can only go so far with that, but I felt like we went pretty far with that and got to a point where you could have a conversation with your peers in other agencies that wasn't always tainted by a feeling like you're trying to get something from me, but rather trying to say, how can we make this work the best, because the stakes are high. We were 01:30:00really trying to help people's lives, and there's a bigger mission involved than trying to make sure your agency is getting the right--I guess I always felt confident that we were always going to be playing a strong role, and that if we did the right--if the whole mission was successful, that our part in it would be part of that. While there was energy spent on defending the agency, that wasn't the dominant feeling. The dominant feeling was one of really figuring out how do you do a large, difficult interagency mission, working in multiple other countries, with real human beings operating, representing and benefiting from the program.

MILLER: This was a strong political climate, as is often the case. Can you tell us a little bit about how the political and social environment (affected) PEPFAR, maybe primarily in those early years, in terms of prevention, drug use, prostitution and so on? How did that play out in terms of the policies for PEPFAR and the first PEPFAR?

SIMONDS: PEPFAR is part of--what it brought to the world, part of it was resources, part of it was the strength of U.S. government and the influence that the U.S. government can have. Part of it was bringing the science that had developed on how you can prevent HIV transmission and how you can treat people with HIV infection. The technical guidance was important, although WHO provides 01:32:00its set of guidance and we contribute to that. In terms of the guidance towards what we are going to fund to implement, PEPFAR said, we are going to support these interventions because they have a science base to them.

In general, there was not much controversy over most of what we were doing. I think the biggest controversy was probably over the issue of prevention, and the allocation of funding that was assigned to specific approaches to prevention that involved the famous ABC program of Abstinence, Be Faithful, and use Condoms. There were restrictions-- there needed to be a percentage of the funds 01:33:00that was allocated to that area. There was controversy over that, particularly the controversy over whether this was more of a public health-supported approach or more of a socially oriented approach. Are we implementing morality or are we implementing public health? There was data that would suggest that maybe abstinence in many environments is very difficult to implement, because of the dynamics that were happening and the sexual encounters that were leading to transmission. There was not so much voluntarism to that perhaps, or the opportunity to implement that strategy may be very difficult in many environments. There was controversy over how much funding should go to the ABC 01:34:00component of this, but I felt like it was not a major piece. It wasn't a show-stopper in terms of being able to get everybody to agree that PEPFAR is a good way forward. Yes, you could disagree that maybe we could do better with our approaches, but it was really a relatively smaller part of what we were doing. Over time, I think, when you have data and you then are able to show what you're doing is effective, you really can convince people who were having their opinions in play that there are evidence-based ways of doing this. So, I think that was one area. There was concern when Ambassador Tobias was named to be the coordinator. Having been the CEO [Chief Executive Officer] of Eli Lilly Company, 01:35:00there was a buzz in the very beginning of PEPFAR that this is all a big scheme for the pharmacy industry in the U.S. to be getting a lot of money, because they're going to put all their money--they're going to buy all the U.S. drugs, and all this money that's helping these countries is actually going through the drug companies. That led to the beginnings of feeling of, I wonder if we should really trust this initiative. It took effort to squash that, but I thought a very interesting effort, which was to work with the--have the FDA [United States Food and Drug Administration] say that--because there were two issues, with the choice between going with the innovator companies, the major drug companies, versus the generic drug companies. The generic drugs will be much more 01:36:00inexpensive. For the innovator drugs, these companies have invested heavily in the research needed to develop these drugs, and they need to recoup those resources.

MILLER: And the generic drugs were primarily from India--

SIMONDS: India, and some from Brazil, and South Africa started making (drugs) at some point. WHO had a system for--so the issue was, is the quality--are we dealing with a quality issue, or are we dealing with an intellectual property issue? I think PEPFAR cleverly dissociated those, too, by saying, we really want to make sure we're not providing lower-quality drugs to people in Africa than we are to people in the United States, because that's not right to do. We're not going to do that, but we're not going to insist that all the drugs that are used 01:37:00be licensed by the FDA for use in the United States, because that's not what we're doing with PEPFAR. Furthermore, that would be very disruptive to our pharmaceutical industry, and it would be disincentives for continuing to innovate and develop new drugs. By using the--WHO then had a system for qualifying drugs on their technical merit.

What PEPFAR did was work with the FDA to develop a new classification for drugs that would call them tentatively approved, meaning that they passed the technical qualifications for being an effective drug. They had the right components, their formulation was correct, they were handled in a safe way that didn't degrade their quality, but they're not necessarily licensed for use in 01:38:00the United States, they're not fully qualified for that use. By differentiating those, and then by saying PEPFAR is willing to invest in these tentatively approved drugs, means that PEPFAR can assure the quality and PEPFAR can be providing the low cost. Furthermore, we can squash the rumor that this was all about bringing funding to the drug companies. I think that then allowed more drugs to be bought, more treatment to be provided with the same amount of funding. It really was a clever way of doing it, and it also isolated off the--it didn't threaten the drug companies so much by saying, everything's going to be generic. There was still some control over the intellectual property side 01:39:00of things.

MILLER: Fascinating history. You came back to Atlanta, and at that point you assumed a leadership position in managing the Global AIDS Program. Can you tell us a little bit about your role when you returned to Atlanta?

SIMONDS: Yes. I was in Washington 2003 and 2004. I was a branch chief in the Prevention Branch, and then I moved to the Care and Treatment Branch. I did some shuffling around and then was taking a stint as the deputy director, as an acting deputy director, at the time when the selection was made of a new director. Eugene McCray was director. He stepped down, and there was a period of an acting director while recruitment was undertaken for a new director. A new 01:40:00director was brought in from outside of CDC, from the U.S. military HIV program. Ambassador [Dr. Deborah L.] Debbie Birx--she wasn't ambassador then, but Colonel Debbie Birx or Debbie Birx, was chosen to be the director. At the time I was acting deputy director. She eventually asked me to stay on as the deputy director, so that was my official role, as deputy director for the program. What that meant was, I was working with Dr. Birx as the Office of the Director and managing this whole thing. I continued being on the Deputy Principals group. We split up, or we together managed the headquarters operations. We figured out--or 01:41:00we split up the countries, in terms of figuring out who all is going to be overseeing the country activities.

MILLER: At that time, about how many people were working for you?

SIMONDS: Probably--in terms of U.S. direct-hire people at headquarters and the field, probably two or three hundred, and then maybe hundreds more local staff. It was a big operation. There were a lot of countries.

MILLER: How many countries?

SIMONDS: I don't know. A lot. There were your focus countries of PEPFAR, there were fourteen and eventually fifteen, and then probably another ten or so that we were pretty active in, that were not the (focus) countries, so in the twenties of countries around the world.

MILLER: At its peak, I think about 40.

SIMONDS: Quite possible.

MILLER: So, a huge infrastructure.

SIMONDS: Yes, and lots of different--I thought of them as different fronts. Like any other division at CDC managing all its headquarters people--you know, that means their PMAPs [Performance Management Assessment Program] and their recruiting and their pay and their authority and their organizational structure. Then you have, as an interagency mission, you have engaging with other agencies and working together with all the agencies. You had a Washington front and all that takes to make that work, and then you had this huge field operation. You've got field offices, and some of them are in vulnerable and difficult situations, where people are getting shot at or other things are happening that you need to be on top of. You're needing to help make it work, make the program work in these countries.

MILLER: Did you like the management aspect?

SIMONDS: Yes, I liked the management aspect. I think I moved from--I think 01:43:00probably around the time when I came back from Thailand, that was probably my inflection point between really feeling like I was on top of any particular technical area and moving more into management and making things work. I like that. I think there are always interesting challenges. You can bring a human element into it because we're always dealing with people, so you've got all those complexities to deal with. Those are often very difficult but real, real things.

MILLER: You traveled quite a bit during those years also, to fields, to countries.

SIMONDS: And to Washington every week for the Deputy Principals meeting. Every Monday I used to go up at 7:20 and come back at 6:00.

MILLER: What did you find in the countries during the early years, 2003-4 and so 01:44:00on, before the big scale-up of antiretroviral therapy? Do you have any particular memories of certain countries?

SIMONDS: To be honest, most of my work, because I was more in management at that point and also because of the roles that CDC plays, we're not really the hands-on doctors taking care of people, usually. We are usually several layers removed from real people. Saying many opportunities, so most of my observation of how the epidemic was really playing out was usually staged. I would go on site visits and see people. I'd go to places and see people, but they were hand selected--it was an environment that was probably not exactly reflective of the 01:45:00real world. But you also do see the real world. You see clinics where people are waiting all day long for care, patiently waiting, a huge flow of patients through systems, facilities that don't have some of the basic things like handwashing or privacy or shade. (These were) just really difficult environments where people were nonetheless coming for services and being cared for by overworked staff. You definitely got a feel for the struggles of implementing something as complicated as HIV and treatment in environments that were not used 01:46:00to that and having to really build up those capacities at every level.

MILLER: Did things improve? Do you remember things improving as the years went by? Were you out and about enough to notice that?

SIMONDS: Yes, there were things like recordkeeping, where you move from logbooks that were very cumbersome to much more efficient data systems. In the facilities themselves, I definitely saw a trend towards improvements in facilities, where you've got paint and normal flow. Then (there was) just the chance to talk to doctors and nurses. You saw people really, I thought, very quickly learning what they needed to learn, knowing about patients. Perhaps it was staged, but I don't 01:47:00think so. You can talk to people, and they'll know their CD4 count or they'll understand what the viral load is. Really you do get a feeling like this is working, things are getting-- information and procedures are getting disseminated in a way that's leading to the prevention of HIV.

MILLER: Before we move off that, is there anything else you want to say about your time as Deputy Director of the Global AIDS Program?

SIMONDS: It was fascinating. Personally, working with Ambassador Birx was a real treat. A real treat--part treat, partly overwhelming. She brought a vision to the work and a confidence in people that was higher than even they had in terms 01:48:00of what they could do. She really had a knack for pushing people to their limits to get this job done, and a real passion for stopping the AIDS epidemic. Just observing her and trying to--I played a role sometimes just translating her vision into practice, because she sometimes was cryptic. She had a very clear image of what she wanted to do. She might say it very quickly and expect it to be done, and people didn't even hear it. I'd sometimes be playing the role of (interpreting) what did she mean, what are we supposed to do, which I didn't always know myself, but I would help to do that. Then (it was a treat) just seeing her vision and her strategy work. I think personally that was an exhausting but really interesting time, to learn a lot about leadership and 01:49:00strategic thinking and human elements. Once we flew out to the West Coast for like four hours to deal with a personnel problem, and then came back to Atlanta, bringing somebody in from an overseas site to talk about a personnel issue. (That she had) just the willingness to go to any end to solve problems was fascinating.

MILLER: There's so much more, but before we end-- you left CDC in 2010, I think. Do you want to tell us a little bit about what you did after that?

SIMONDS: Yes, I was in the Commissioned Corps [of the Public Health Service]. I had completed my twenty year commitment to the Commissioned Corps in 2010. I was 01:50:00around fifty-six years old at the time, and I was thinking if I'm ever going to do something else, now would be a good time to do it. I ended up going to the Elizabeth Glaser Pediatric AIDS Foundation. Because my work often was involved in their mission of stopping AIDS in children, I was very familiar with the organization and thought it was a good one. It was involved in our Track One Treatment Program, for instance. I thought this would be an interesting place to work, with an interesting mission. I feel like I would know what they're doing but really have a new perspective to offer.

MILLER: Can you tell us when and why it was created?

SIMONDS: Yes. The Elizabeth Glaser Pediatric AIDS Foundation--It was named after 01:51:00Elizabeth Glaser, who was herself infected with HIV through a blood transfusion. She then went on and infected, unbeknownst to her, two of her children. One of them died. One of them is still alive and healthy on treatment. At the time -- this was early in the epidemic in the early 1980's--there were no interventions for children, and so she was an advocate. She was plugged into Hollywood and politics through her husband, Paul [Michael] Glaser, who was an actor in Starsky and Hutch on TV, and so she had access to soapboxes. She herself was just a very strong advocate. So the combination--

MILLER: And she died.

SIMONDS: And she died of HIV herself, but not until she was able to launch a 01:52:00mission to address AIDS in children. I think it's working in an organization where you have that kind of starting story that continues to draw people in to work on it. It affects people personally-- they want to help contribute to that. That was part of its attractiveness and part of its effectiveness as an organization. It allowed me to see how the U.S. government doesn't quite have that kind of mission statement. We're a very different kind of organization. Having a smaller organization and a strong mission and being a little bit more flexible in terms of how you can influence things than the U.S. government, all of those were very attractive and I think a very positive part of that experience. I got to see CDC from the perspective of somebody who gets money and needs to follow CDC regulations and--

MILLER: How was that? How was it getting money from CDC and needing to follow their regulations?

SIMONDS: One thing I realized, working in a nongovernmental organization like 01:53:00that, is you're always needing to think about where your next dollars are coming from. In the U.S. government we have a different flow of resources through Congress and a different process. In an NGO like this, it's always like, okay, we got a grant for this period-- we've got fifteen grants we're putting together. You're always trying to find business, so that's one aspect of it. But the other is, you're really on the ground more, at a closer level than the U.S. government is. You're hiring the people in the clinics, you're buying the equipment, you're really in the thick of things. I actually saw more about the AIDS epidemic in my field visits with Elizabeth Glaser Pediatrics AIDS Foundation. (I saw) a different aspect to it there than I ever did from CDC. So it was very good. I ended up coming back to CDC because it was geographically difficult to work in 01:54:00Washington. My wife kept her job in Atlanta, so we were doing some commuting that didn't make sense.

MILLER: You must have had a lot of frequent flyer miles over the years. Did you become a platinum?

SIMONDS: Yes, I'm getting close to three million miles on Delta.

MILLER: Then you came back to CDC, and now currently?

SIMONDS: Yes, I came back to CDC in what's now the Division of Global HIV and TB, the descendant of the initial Global AIDS Program, as a regional manager. We developed a structure of a full-time position overseeing the offices in a number of countries. I was overseeing the Asia and Europe offices. I did that for a couple of years, and now I'm in the process of transitioning to be the Country Director for CDC's office in China. China is now developing its own economy, 01:55:00allowing it to have the resources to run its own public health system. They're still interested in seeing how they can be global health players themselves, and they look to the U.S. CDC to be teachers in a way of helping the China CDC to develop their global health capacity. We'll be working in that kind of environment with another global health player in China.

MILLER: So (you have) come full circle from your early studies of Chinese to --

SIMONDS: Yes.

MILLER: How is your Chinese? Is it functioning for you at all in terms of communicating?

SIMONDS: I noticed that since I started studying Chinese I've gotten older.

MILLER: It's much harder to learn a language--

SIMONDS: It's harder to even remember the English words and the English names, but we'll see. Come back in a couple of years and ask me. I've got a base that 01:56:00hopefully I can draw on, and we'll see.

MILLER: Yes. In conclusion, you've played a leading role in so many aspects of the HIV/AIDS epidemic. Any concluding thoughts on how this has affected you and your family?

SIMONDS: Personally, I just feel like I've had a very lucky career. Like coming into working on HIV/AIDS at the beginning of my CDC career, being present in a time when you began having an intervention to prevent children from becoming infected, and the opportunity to help with that in the U.S. and help with that in Thailand. That experience itself in Thailand contributed to the confidence that the U.S. government had in investing more heavily. Preventing 01:57:00mother-to-child transmission became an important key to unlocking the resources for HIV/AIDS. (I had) the ability to be following all that through my career and applying my epidemiology initially. My intracultural abilities that developed along the way and my management experience (allowed me to) apply different things in different components of that. It has just been very rewarding.

My family had to put up with a lot of absence of me. That's never easy, but fortunately this parallels the history of email. I remember getting my very first emails from my kids when I did my first visits to Thailand. I think the communications helped, but there are sacrifices that your family makes when you 01:58:00are engaged in something as all-consuming as this. It's a balance of being part of something big that's very important and trying to play the unique role that you have as a father and a husband all at the same time, but you do what you can do.

MILLER: Yes. It sounds like you've done a pretty good job. Thanks very much.

SIMONDS: You're welcome. Thank you.