I agreed to tell the story partly to present an appeal for support from TPAN readers. Your donation of $10, $100, or $1,000 to Project HOPE—at www.projecthope.org, or at 1–800–544–4673—could change the lives of people living with HIV around the world, like the women in the Xai Xai and Chokwe Districts of Gaza Province in Mozambique whom I’ve just met. Half of these women are caring for orphans—an average of two per household—and another half are caring for a dying family member…but I’m getting ahead of myself.

From local …

Much has been written about the early days of AIDS in the U.S. and in Chicago, the days before HIV. I write instead to note the lessons that we learned, and that we are still learning around the world. It’s particularly for young people at risk of HIV, and for young doctors and nurses who didn’t experience this terrible time. They need to hear how it was.

In those dark early days, AIDS was a fearful mystery that first killed gay men in the midst of a powerful silence of denial, even while the cases doubled every six months. AIDS shed equal light on the secrets of the gay community and a powerful homophobia. This was not news to the gay community, but it was a shock to see that the death and dying of gay men only intensified the stigma. It was hard to tell which of the epidemics—AIDS, or AIDS stigma and discrimination—was more painful, and more virulent.

Within a year at Cook County Hospital, from 1982–1983, we saw the early shape of the second wave of the epidemic of Chicago—AIDS in women and children, injection drug users, and increasing proportions of African Americans and Latina/Latinos. The brush of AIDS stigma broadened, and sometimes brought these diverse communities into conflict with one another.

The other lesson was action. Specifically, Gay community action, because no one else was acting, or even cared. And hospital action—at Cook County Hospital, Illinois Masonic Hospital, and the many others—because people with AIDS were suffering and dying. The rapidly escalating crisis demanded a response, and collaboration among responders—and, let the record show, the collaboration in Chicago was better than most cities. Chicago gained a reputation as the city that works among people who watched AIDS. This was no small matter when it came to competing with other cities for Ryan White funding.

It quickly became clear that the community, the city and county health departments, along with the hospitals, and the activists, would have to work together to care for the sick and dying, to prevent new cases through education, to support people living with AIDS and their friends and families, and to advocate for the civil and human rights of those affected and at risk.

These were the lessons: It takes a village to raise a child, and it takes a community to respond to AIDS. Effective AIDS responses are “all of a piece,” so to speak. Human rights, stigma reduction, care and treatment, support, education and prevention, and advocacy each depend on the other to gain traction. And each depends on individual and collective action—of community leaders, health care providers, public health leaders, and government—in order to make painstaking, gradual progress in the fight against AIDS and HIV.

I can’t think back to those days in Chicago without pausing to wonder, do young Chicagoans know the people who fought these AIDS battles, and what they did? Like John Hammill and Harvey Grossman at the AIDS Project at ACLU?

Or Joan Harris, Bill Young, Marshall Fields, Ron Sable, Marcia Lipitz, Karen Fishman, and others at the AIDS Foundation of Chicago? There are so many others, too many to list, like Tracy Baim at Windy City Times, David Blatt and David Moore at Illinois Masonic Hospital, KT Reddy and Chet Kelly at the Chicago Health Department, Cathey Cristeller at the Chicago Women’s AIDS Project, Bill Mannion at Howard Brown Health Center, David Lye at Erie Family Health Center, Dan Bigg at the Chicago Recovery Alliance (needle exchange), Wayne Wiebel and Norman Altman at the University of Illinois School of Public Health, Carol Reese at the AIDS Pastoral Care Network, Nathan Linsk and Barb Schechtman at MATEC (Midwest AIDS Training and Education Center), Tom Tunney at Ann Sather’s restaurant, Sam Clark at Meals on Wheels, and the clinical study units (ACTG and ARAC) at County, Rush, St. Joseph, Northwestern, the University of Chicago, and Children’s Memorial Hospital. And the most powerful bonds of all were with my many friends, colleagues, and patients at County Hospital, like Ron Sable, Mardge Cohen, Jim Delacerda, Jim Lovette, Rogelio and Isabel Cadena, Edith “Nurse” Jackson, Robert Washington, Paul Hook, Ida Greathouse, Ginny Cohen, Mildred Williamson, Liz Gath, Jack Kowalski, David Siebert, Gigi Nicks, Paul Hook, Caroline Teter, Chuck Sternberg, Ruth Rodriquez, Joe Pulvirenti…the stories of their commitment and service deserve to be heard. Ask an old AIDS dinosaur about these folks sometime; you won’t be disappointed.

… to global

While we struggled in Chicago and patched together a leaky but credible HIV service system, the virus spread silently in Africa, in Asia, and in most of the developing world—a story we all know too well now. The breathtaking reversal of the epidemic by HAART (highly active anti-retroviral therapy) in 1996 in the U.S. and Europe, dramatized the stark differences between the north and the south. During our period of international negligence and inaction, millions died, and millions more were infected.

Now, two thirds of cases are in sub-Saharan Africa. Half of the 1,800 daily new infections are in women, and half are in young people aged 15–24. And still the epidemic “is running faster than us all,” as Peter Piot has said. One quarter of new cases are in Asia, and India now has more cases than any other country in the world. Nearly one million people in the developing world are on ART (anti-retroviral therapy), which is far below the 3 million target set by WHO, but far above recent levels. On the other hand, less than 5% of children with HIV in the world are on ART, which is a repetition of the lower priority placed on children in the U.S. when AIDS began. Women bear an increased risk that is out of their control, as well as the burden of caring for the sick, and for orphans and vulnerable children. Children are increasingly vulnerable, with orphan rates of 10–20% in sub-Saharan Africa, and rates of vulnerability of children exceeding 50% in many communities.

Project HOPE

So two years ago, after 25 years at Cook County Hospital, I left with a lifetime of experiences, lessons, hard knocks and great friends, and I took the job of Director of HIV/STI/TB at Project HOPE. My hope was to take the lessons from Chicago and put them to use in other parts of the world. At the same time, Caroline Teter, my friend and colleague, also came to Project HOPE as my associate.

Why Project HOPE? First, because Project HOPE has trained over 2 million doctors and health workers around the world for the past 47 years. Project HOPE started as a hospital ship that sailed from port to port providing care and training health workers. In 1972 Project HOPE became an international NGO (non-governmental organization) based in Northern Virginia. It currently has 46 programs in 32 countries around the world, and half include an HIV-related service. Project HOPE has superb technical expertise in infectious diseases such as TB and HIV, in pediatric hospitals, in maternal child health, in health systems management, in humanitarian assistance, and in physician education on such topics as cardiovascular disease and diabetes. From sophisticated hospital care to community-based primary care, Project HOPE’s leadership in health provider education was a natural fit.

Since joining Project HOPE, Caroline and I have conducted health worker trainings on HIV with regional Project HOPE staff in China, the Western Balkans, Northern Africa, and Honduras. The most fully developed is a model program in Hubei Province, China, in partnership with Dr. Gui Xien of Wuhan University and the Hubei Province Centers for Disease Control. The ability to collaborate with local partners and respond to the invitations of the national health ministries is another Project HOPE trademark. In Wuhan, we used a “training of trainers” model with 20 Chinese “master trainers” with some experience in HIV care. Over the past year with this method we have trained more than 4,000 physicians and health care providers in the hardest hit counties in Hubei Province.

This strategy was dictated by the epidemiology of HIV in China; because of improper plasma donation techniques in Hubei Province in the 1990s, HIV spread in poor farmers in the villages and townships, with a secondary spread to their wives and children. For this reason, doctors and nurses in rural areas most needed training in HIV care, although trainings before 2003 were exclusively conducted in major cities, bypassing those who needed the training most urgently. Our trainings also coincided with the decision by the Minister of Health in Beijing to provide free HIV therapy to all people living with HIV and the arrival of generic nevirapine, zidovudine, didanosine, and stavudine. (Lamivudine has since become available.)

Our approach to the urgent need for rapid scale up of antiretroviral therapy and HIV care has been to train health ministry personnel who are embarking on small and large scale ART programs for the first time. This has allowed the emphasis to be on training, capacity building, and technical assistance rather than direct implementation. I believe this method to be the most cost effective. One of the lessons of the bold Gates-Merck ART initiative in Botswana has been that a high level model of ART care and support may not be sustainable when the external grant support runs out. Cost-effectiveness and sustainability are not just buzz words. The lives of people living with HIV depend on them.

Community programs

Project HOPE is also known and respected around the world for its work at the local level with families and communities. This week in Mozambique, I met the women in Xai Xai and Chokwe who show the need for family support in the spectrum of comprehensive HIV services. I met them in their groups of 10–20 women in the Village Health Bank (VHB) program that caught my attention before I joined Project HOPE because of another lesson from County Hospital. AIDS isn’t a very high priority for poor people compared to knowing where their next meal is coming from, or where your children can sleep at night. Poverty is a more immediate threat than AIDS, and it’s pointless to throw money and drugs at people with AIDS—in Chicago or in Africa—while ignoring poverty.

The VHB is a micro credit and health education program that provides loans of $80–100 per family at four month intervals. The loans are managed by the groups of 10–20 women, including repayment of the loans with interest. Since these programs began in 1996, over 50,000 families have been served in eight countries on three continents, including Malawi and Mozambique, with 98% repayment of the loans. Among the demonstrated benefits of the VHB are increased income and savings, improvement in family nutrition, increase in retention in school for the children in the household, and empowerment of the members.

Project HOPE received a grant from USAID in April 2005 to use this intervention in the service of 75,000 orphans and vulnerable children in Mozambique and Namibia. The VHB program is being modified to provide health education, counseling, and referrals to partner organizations needed to meet the diverse needs of the children in these families.

There are many other programs in HIV and in other areas that I could describe. In Namibia, Malawi, and Mozambique, Project HOPE has conducted workplace programs on HIV that have received international recognition. Youth HIV prevention programs are in place in Thailand, Mexico, Russia, Ukraine, and Mozambique. Cross-border initiatives have addressed mobile populations—such as gold miners, truck drivers, and Roma—in Malawi, Mozambique, and the Western Balkans.

Project HOPE helped to build and operate two of the finest pediatric facilities in the world in Shanghai, China—the Shanghai Children’s Medical Center—and in Krakow, Poland. Project HOPE has recently begun a campaign for its 50th anniversary in 2008 based on the development of Health Centers of Excellence around the world.

In several instances, Project HOPE programs have been adopted as national programs. In Russia, the HIV education program and curriculum in vocational and secondary schools have been adopted as national templates. In Honduras, the Project HOPE Home Based Care manual and program have been replicated at the national level. In the five Central Asian Republics, Project HOPE is the main technical advisor and implementer of tuberculosis control programs.

Project HOPE has a history of program development and capacity building followed by integration of the program into the region and then our withdrawal. Such sustainability is increasingly important as donor resources diminish. In the Dominican Republic, Project HOPE partnered with the Order of Malta to conduct a primary care clinic. Over time, the clinic generated revenues that allowed it to be economically self-sufficient, and both Project HOPE and the Order of Malta handed the clinic over to a local non-governmental organization (NGO). In Ecuador, the largest VHB in the Americas became economically self-sufficient over a period of seven years, and formed an NGO to conduct its own financial affairs. In both cases, Project HOPE withdrew when the local capacity was established.

In each country in which it is active, Project HOPE has played an important advisory role to the Ministry of Health. Where there are HIV programs, Project HOPE staff have participated in the Central Coordinating Mechanisms for the Global Fund, and on national HIV planning bodies.

Chicago

I often talk about the lessons learned from Chicago and Cook County Hospital as I travel around the world. Much of the work is in stigma reduction and breaking the silence of AIDS and HIV, of homophobia and discrimination towards drug users, commercial sex workers, and others at risk of HIV. When it gets discouraging, and even surreal, to watch as the rest of the world struggles with so many of the battles that have been waged in the U.S. and Europe, I return to the early days at County, and call upon the spirits of Ron Sable and Gigi Nicks, and of Ida Greathouse and Jim Delacerda, and the many patients and colleagues who were on the front lines in the 1980s. It’s a comfort and a powerful resource. We lived through it, and most of us are still here. It gives me hope that it can be done again, like before, with your help: www.projecthope.org, or at 1–800–544–4673.

Dr. Sherer is also with the Section of Infectious Diseases at the University of Chicago Hospitals.