Ending HIV/AIDS in America and Confronting the Resurgence of Measles: CDC Director Dr. Robert Redfield on Public Health Solutions

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Female : Welcome to C onversations on H ealth Care with Mark Masselli and
Margaret Flinter , a show where we speak to the top thought leaders
in health innovation, health policy, care delivery and the great minds
who are shaping the health care of the future. This week, Mark and
Margaret speak with Dr. Robert Redfield, D irector of the Centers for
Disease Control and Prevention, better known as the CDC. They're
spearheading a program aimed at eradicating HIV / AIDS infections
within a decade. He'll also ad dress the rise in measles outbreaks and
other infectious disease emergencies due to the anti - vaccination
movement and the need for better compliance worldwide.

Lori Robertson also checks in Managing Editor of FactCheck.org looks
at misstatements spoken abo ut health policy in the public domain
separating the fa ke from the facts . We end with a bright idea that’s
improving health and well being in everyday lives. If you have
comments, please email us at [email protected] or find us on
Facebook, Twitter, iTunes or wherever you listen to podcasts. You can
also hear us by asking Alexa to play the program C onversations on
Health Care . Now stay tuned for an interview with Dr. Robert
Redfield, D irector of the CDC on C onversati ons on Health Care.

Mark Masselli: W e're speaking today with Dr. Robert Redfield, Director of CDC the
Centers for Disease Control and Prevention. Dr. Redfield was
F ounding D irector of the Department of R etroviral R esearch in the US
Army Medical Corps and C o - founded the University of Maryland's
Institute for Human V i r ology serving as C hief of I nfectious D iseases.
He's also V ice C hair of Medicine at the University of Maryland School
of Medicine. Dr. Redfield has advised the National Institute of Health
on HIV . Dr. Redfield earned his bachelor's of science and his medical
degree from Georgetown, Dr. Redfield w elcome to C onversations on
H ealth C are.

Robert Redfield: Thank you very much, Mark.

Mark Masselli: You’re known as one of the world's leading experts and researchers
working on the HIV / AIDS epidemic . Y ou carry that expertise to your
current role as D irector of the CDC and your agency is recently part of
President Trump's really bold initiatives. W e just got to get a shout
out, ending the HIV epidemic plan f or America a nd it seeks to reduce
the number of new HIV infections by 90% within a decade. I wonder if
you could just tell our listeners about who's involved in the effort and
how you're planning to tackle this complicated challenge?

Dr. Robert Redfield: W ell, this really is a once in a generation opportunity. As you know
President Trump in the State of the Union highlighted his initiative to
be able to bring an end to the HIV epidemic over the next decade,
with the goal of reducing new infections by 90% o v er the next 10

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years under the leadership of Secretary Azar. R eally all of the agencies
within HHS, the CDC, U RSA, the Indian Health Service and NIH have
really come together to put together this plan. When we looked at the
new infections that were occurri ng in the United States between 2016
and 20 17, we were all surprised to find out that more than 50% of the
new infections, there's about 40,000 new infections a year , 50% of
them were in only 48 jurisdictions, the District of Columbia and San
Juan, out of the more than 3000 jurisdictions in the country. I t was a
very geographically focused outbreak.

W hen we looked even closer at the demographics of it, most of the
new infections that are occurring in the United States are actually in
African American men wh o have sex with men or Latino men who
have sex with men , of those that are between the age of 25 and 34 , so
it’s very demographically focused. W e have a very focused strategy
initially to target these geographic areas and these demographic
groups to have f our key strategies diagnose , you know about 15% of
the p eople in our country with HIV infection still haven't been
diagnosed p rior to this initiative ? I t turns out that almost 50% of
them, one in every two has been infected for at least three years.
Probab ly 70% of people that were infected diagnosed last year
actually had seen a health care facility the year before, but not been
diagnosed.

O ne of the areas is to really enhance diagnosis and try to reinstill in
the health system fervor for diagnosis. To tre at people that have HIV
infection, we now know that it's pretty straightforward now how to
treat with the new antiretrovirals that we have. Th ey’re highly
successful unlike the earlier drugs where we struggled with
resistance. I f we can get people to viral loads that are undetectable ,
n ot only does that mean that the disease won't progress in them, it
also means that they're not capable of transmitting the infection to
somebody else . T he phrase that’s been used is you equals you.
U ndetectable means that you 're un infectious to somebody.

The ability to protect that is prevent new infection acquisition , today ,
n ow we also have what we call pre - exposure prophylaxis using
medication itself and individuals at risk for HIV that will prevent them
even if they're exp osed by method known to transmit HIV, they will
not become someone with HIV. C ombine that with other
comprehensive prevention strategies, particularly, say syringe
programs. T hen finally, we have a fourth pillar, which is to respond
when we do see hotspots that we can rapidly identify them and help
the local public health community be able to respond in a way to
prevent expanded transmission. We're seeing that in a number of
counties because of the comorbidity with the drug use epidemic that
we have. T hat's really the plan that we fully intend to succeed so that
by the year 2030 the epidemic as we know it will no longer be here.

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The purest definition of that is to bring the new infections down to
less than one in a 100,000 Americans. Obviously the goal is to go as
few new infections as possible, but the epidemic would then be over.

Margaret Flinter: Well, Dr. Redfield, I think it's always worth saying this epidemic has
taken 700,000 American lives since the early 80s a nd 1.1 million
Americans living with the disease. I'm not sure that everyone
understands this idea of how effective the drug regimens have
become and getting people's viral loads down to undetectable levels
and t his advent of the prep drug protocol to protect no n infected
people from being infect ed. M aybe just a little more about that for
our listeners.

Dr. Robert Redfield: It's really been exciting having been in this field really since the early
80s. To see the progress that science has provided and to see that go
from no r eally therapeutic opti ons to see then different early options
where we could prolong survival, but many people still develop drug
resistance and treatment failed. I can remember back in the 90s,
some of my patients were taking 30 , 40 pills a day. Today, there's
multiple regimen ts where you can take one pill or two pills a day. The
current regiments really are as close to , and I like to use the term
bulletproof , t hese are very, very highly effective drugs now that are
available to treat HIV infection . M ost individuals can really take them
and most individuals with HIV infection today can anticipate t o live a
near normal life span .

I f you're 20 years old today and you get HIV infection, the data would
reject you to live somewhere between 74 and 75 years of age. T he
therapy really is highly effective and the ability to g et viral loads to the
undetectable level is now the r ule . Not only does that change the
disease progression in the individual, but some of the real exciting
data is it really now definitively shows that if your virus i s detectable
by the current laboratory techniques, you really are not able to
transmit this virus to somebody else. That means the treatment ’ s not
only good for the individual ’ s long term health . T reatment of people
living with HIV is a major prevention st rategy. We could actually
diagnose everybody, get everybody on treatment, get everybody's
viral load undetectable, that in of itself would end the HIV epidemic in
America.

Mark Masselli: D r. Redfield I was thinking about the strategy that you're going to
h ave to employ. You were saying, w e've got to get people to enhance
their diagnosis, but we also have t o have t his fervor for people who
want to treat this population . O f course, you know, community health
centers play a vital role in treating HIV and AIDS and here in our own
organization we've had a lot of success . T ell us how you will scale this
program up nationally , a nd how do you see the CDC and its partner
agencies working at this local level?

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Dr. Robert Redfield: I've been very involved in the PEPFAR program from the beginning
where we had really to go into S ub - Saharan Africa and the Caribbean
a nd actually, we had to figure out not just how to provide treatment,
we really didn't have a health infrastructure. The beauty of this
initiative is we're looki ng at multiple different health capacities in this
nation. M uch of which made this so doable was the fact that there's
12,000 community health centers throughout the United States , and
many of them in these jurisdictions that we're discussing right now , s o
that the potential to expand the capacity by bringing in HRSA’s
programs for those individual at risk for HIV infection , t hat is the
c ommunity h ealth c enter s a nd get them engaged to help diagnosis
and then those individuals that have diagnosed HIV infecti on , that is
the Ryan White P rogram .

I t really -- sitting there that it's there, the execution plans for this
initiative are going to need to be developed by each jurisdiction ,
b ecause what we're trying to do here is to figure out how does the
health system now engage a component of individuals that are either
at risk or living with HIV? How do we engage them effectively into the
health system ? W e would argue that community health centers as
well as community groups themselves are going to be the key
stewards of understanding how we do this, as I said, by the
community, for the community and the community. T he community
health centers are going to play a very, very, very important role.

Margaret Flinter: Well, Dr. R edfield that prompts me to say we've had, I t hink a little
over 20 years mark of stumbles and falls evolving a model of highly
effective care and treatment for our patients with HIV . A long the way
other challenges emerged hepatitis C, arrived on the horizon.
U ltimately, we now have medication t o actu ally cures hepatitis C .
You’ve dedicated some of your formidable decades of research to the
quest for a vaccine for HIV to o. T his has proved daunting for everyone
in the field. Is the quest for a vaccine for HIV still on that list, or are we
really looking at preventing new cases and effective treatment of the
ones that are develop ed?

Dr. Robert Redfield: Well, Margaret for the United States to be able to actually end the
HIV epidemic, we have the tools, diagnos e and treatment developing
viral loads that ar e un detectable and comprehensive evidence based
prevention strategies including perhaps unsafe syringe programs .
T hose tools can bring an end to the HIV epidemic in the United States.
I c an say, for the world to bring an end to the HIV epidemic, we're
goin g to need to have an HIV preventive vaccine. I've always said that
when you look at trying to end eradicate an infectious disease,
whether it's smallpox or polio, the key to that is having a vaccine.
We've eradicated smallpox, we're on the verge of eradica ting polio .
La st year, we only had three cases in the whole world. T o bring in a
true global into this epidemic, it is going to require an HIV vaccine . I 'm

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confident that science will continue and eventually succeed in
developing the scientific understandi ng that's required to develop an
efficacious preventive HIV vaccine. But I can tell you as a young doctor
who was at the bedside of a 27 year old individual tha t was dying of
HIV infection in, s ay 1984 . N o one predicted that would become a
lifelong treatab le disease , a nd yet I would say one thing I always have
had strong confidence in is the power of science. I always had
confidence that science would find solutions. I started some of my
early work in non - A, non - B hepatitis , w ho would ever believe that
we'd actually be able to cure that . W e need to continue to invest
significantly in the development of an HIV vaccine, but we should not
wait for the HIV vaccine to bring an end to the AIDS epidemic in
America.

Mark Masselli: We're speaking today with Dr. Rober t Redfield, Director of the Center
for Disease Control and Prevention. I want to pull together two things,
one, the power of science, and then vaccines . W e're in this incredible
throes of something that none of us would have imagined just a
couple of years ago, this dramatic resurgence of preventable diseases
like mumps, measles and chickenpox. There's an anti vaccination
movement that j ust simply doesn't accept the science. Many families
across the country are intentionally choosing not to vaccinate their
children , a nd that's obviously causing a public health crisis in many
communities. I wonder if you could talk about this anti - vax
movement. I was thinking, as you are talking earlier about, hey we've
mapped out w e’re the bolus of this population . What do w e have on
the data about the anti - v ax population, if you're going to try to target
them , th is is a group of people that can be identified , what's the CDC
doing to try to find common ground with people who simply can be
bright and talented and educated and for some reason, they're off the
track on this particular issue? How are you handling?

Dr. Robert Redfield: Well, this is really a very, very important question , Mark, and
particularly very timely now. T he WHO this year actually listed for the
first time v accine hesitancy as one of the 10 greatest global health
threats f or the world . N othing saddens me more than to see the
power of science left on the shelf. When you think some of us , I
remember polio, I remember measles, I remember a number of these
diseas es pertussis and dip h theria. The challenge that many of the
younger parents have toda y is they don't remember polio, t hey don't
remember measles. This is one of the reasons I've asked the
grandparents to get involved in maybe helping understand, they may
s ee certain issues with vaccines, and they don't understand the true
horror that these diseases that these vaccines now prevent.

When I look at the reasons for people not taking advantage of
vaccines, I think it's important to stress that 94 , 95% of parents
vaccinate their children. But unfortunately, there are a number of

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people that have chosen to not accept vaccination. Some obviously
for medical reasons, but others less so either religious or in some
states now, just philosophically, they don't agree wit h having a
vaccine. We have great data on what the state vaccination rates are.
But within that state, there may be schools or communities or pockets
where the vaccination rates are very, very poor. T hat's what you're
seeing, for example, in the state of W ashington with the recent
measles outbreak . A ll the state of Washington is very good overall
childhood vaccination rates.

I've actually seen some data from some schools where the vaccination
rates are under 30% , some different jurisdictions along the Unite d
States. I do think there's an advantage to get a better handle on
exactly what the regional vaccination rates are so that there can be
more targeted interventions. The ultimate goal is to get individuals to
embrace vaccination as a critical tool to prote ct themselves , to
protect their families to protect the communities . I think there’s really
four groups that need to be reached. The first is the anti - v ax group,
which is I think a very small group and I do think will be very difficult
to reach. It's impor tant that we negate their message , a nd this is why
I've said very clearly in the recent New York Times, op - ed that I did .
V accination does not cause autism , period. Vaccines are safe , period.
The diseases that they prevent are not safe. They're complicated , and
they can cause significant morbidity and mortality.

Now when you look at the people that don't get vaccinated, it turns
out some of them are misinformed, because the anti - va xxers do have
significant information that's available on social media , peopl e have
different editorial systems now and how they get the information and
so there's significant disinformation . W e need to try to counter that
and CDC has a site that I encourage people to go to cdc.gov / vaccines
and we have a parent portal they can get in and get a lot of questions
answered. Secondly, I think they need to sit down with their health
care professionals and have a dialogue . H ealth care professionals
have to take the time to listen to them and listen to their
misinformation and not ridicule it, but take them through and try to
let them understand how they're misinformed.

Now, many more people that are vaccinated, they don't want to do
something that might harm their child. They hear all this stuff that
maybe the vaccine can do this , a nd they' re just -- that paralyzes them
from making the proactive decision. Again, health care professionals
ha ve got to step up and not just say, do you want to get the vaccine ?
T he parent says no, and then they say, o kay, why don't we have your
next appointment i n six weeks? Now , t hey're go ing to say, wait a
minute, why don't you want the vaccine?

Margaret Flinter: Dr. Redfield , t hank you so much for that. We've been speaking today

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with Dr. Robert Redfield, D irector of the Centers for Disease Control
and Preventio n. Learn more about his work by going to CDC.gov or his
particular effort by going to a HIV.gov. Dr . Redfield, we thank you for
your very important scientific work, your commitment, and your
quest to support the health of the public , a nd thank you for join ing us
on C onversations on H ealth C are today.

Dr. Robert Redfield: Thank you, Mark and Margaret.

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Mark Masselli: At Conversations on Health Care we want our audience to be truly in
the know when it comes to the facts about health care reform and
pol icy . Lori Robertson is an award - winning journalist and managing
editor of F act Ch eck . org, a nonpartisan, nonprofit consumer advocate
for voters that aim to reduce the level of deception in US politics . Lori
what have you got for us this week ?

Lori Robertson : T he measles outbreak in the United States and around the world has
sparked misinformation on social media. One false Facebook meme
blamed illegal immigration from South America, but the virus was
eliminated across both North and South America in 2016. Th e recent
outbreak is due largely to inadequate vaccination rates in some
communities. M easles was eliminated in the United States in 2000 ,
a nd as mentioned from the entire North America and South America
continent s ix years later . E limination means cases c an still occur but
that the disease hasn't been continuously spread for a year or more.

Recently, the virus has been brought into the US by people who have
traveled to places where there is an outbreak or where the disease is
still common, such as parts of Europe, Africa, Asia and the Pacific
a ccording to the Centers for Disease Control and Prevention. From
those travelers, the disease can then spread in US communities that
have unvaccinated people . Th e Pan American Health Organization
said the measles outb reak in New York City, which started in 2018 and
spread in the Orthodox Jewish community was brought on by
travelers who had been in Israel where a large outbreak is occurring.
The CDC has said this year marks the largest number of measles cases
since the disease was eliminated in the US , and it said misinformation
about vaccines was, “A significant factor contributing to the
outbreak. ”

Similarly, the Executive Director of UNICEF and the Director General
of the World Health Organization issued a joint state ment that cited
online misinformation about vaccine safety as a contributing factor in
the rising number of measles cases in high and middle income
countries. Some major social platforms have recently taken steps to
curb this spread of misinformation. Face book announced in March
that it would reduce the visibility of vaccine misinformation. YouTube

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said in February that it would prevent users who promote vaccine
misinformation from running ads. T hat's my fact check for this week.
I'm Lori Robertson, Managin g Editor of F act C heck.org .

Margaret Flinter: F act C heck.org is committed to factual accuracy from the country's
major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania . I f you have a fact that you'd
l ike checked e mail us at C H Cradio.com , we’ll have FactCheck.org’s Lori
Robertson check it out for you here on C onversations on H ealth C are.

[Music]

Mark Masselli: Each week C onversations highlights a bright idea about how to make
wellness a part of our comm unities and everyday lives. One in five
Americans will suffer a diagnosable mental health condition in a given
year, and most often don't seek treatment. For those with serious
mental health conditions t he consequences can be devastating , loss
of job or ho me or even early death. Seeing a rise in mobile apps
aimed at behavioral health entering the marketplace, University of
Washington R esearcher De Vrouw Vanzelf [PH] thought a
comparative effective analysis study would be a good idea .

De Vrouw Vanzelf: H avin g a head to head comparison between a mobile health
intervention for people with serious mental illness called focus and
more traditional clinic based group intervention called WRAP or
Wellness Recovery Action Planning . T he study really gets at some of
the core differences between mobile health and clinic base care . The
second thing we wanted to see is after people complete care, what
are their subjective ratings of their experience and treatment? Are
they satisfied with both interventions ? A re there differ ences ? 90% of
the individuals who were randomized into the mobile health arm
actually went on to meet a mobile health specialist to describe the
app to them and train them how to use it and use the intervention
app that's assigned to them at least once. Wh ereas in the clinic based
arm, we saw that only 5 8% of the participants assigned to that clinic
based intervention ever made it in for a single session.

Mark Masselli: Both groups of patients saw roughly equal results from their
completed treatment, but th e mobile group was more likely to
engage in therapy. Vanzelf says this suggests that mobile therapies
may provide a useful tool for clinicians having trouble getting those
with serious mental health issues to engage with the clinical
interventions.

De Vrou w Vanzelf: W e know that the very existence of a group can be quite helpful. But
for others the interaction is anxiety provoking .

Mark Masselli: A targeted mobile app aimed at facilitating access to clinical care for
those experiencing serious mental illnes s symptoms, improving access

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to intervention for behavioral health needs. Now that's a bright idea.
[Music]
Mark Masselli: You've been listening to C onversations on Health Care , I'm Mark
Masselli.
Margaret Flinter: And I’m M argaret Flinter.
Mark Masselli: Peach and health.
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