by Dawn Brazell
Sweat, Ph.D., gives a nod at his trendy
treadmill desk tucked into the corner of
his office, commenting that he actually
does use it. He has to – to maximize his
Sweat recently was
named co-prinicipal investigator of a $15
million HIV study funded through the U.S.
Agency for International Development,
heralded by some as forthcoming landmark
research that could turn the tide of the
Sweat has to balance his research work
in Africa with his duties at MUSC, which
include being director of the Family
Services Research Center and the Center
for Global Health. Visit http://tinyurl.com/c6d56sy.
It's an ambitious
project he'll be coordinating with Deanna
Kerrigan, Ph.D., Johns Hopkins University
as well as four other institutions,
including the Department of Defense, the
Imperial College of London, the Tanzanian
Primary Health Care Institute and The
Muhimbili University of Health and Allied
Sciences in Tanzania.
Holding appointments as
director of MUSC's Family Service Research
Center in the Department of Psychiatry and
Behavioral Sciences and, more recently,
the director of MUSC's Center for Global
Health, Sweat said he decided to take on
the additional challenge of being
co-principal investigator because it's
such an amazing study.
The study will be
conducted in Iringa, Tanzania, with
support from the U.S. Agency for
International Development and is part of a
suite of three large studies examining
what is termed "HIV Combination
Prevention." These studies will examine
the combination of HIV testing and
counseling, antiretroviral therapy, male
circumcision and targeted behavioral
intervention at the community level with a
goal to deliver them on a large scale to
an area hardest hit by HIV.
have asked what would happen if all these
therapies are combined and brought to
scale. There have been quite a few papers
showing that if you do these
evidence-based practices, you can stop an
epidemic," Sweat said. "It creates a
perspective that this is something that is
doable, and we can get actually get ahead
of this curve and stop a pandemic, so
these are very high profile projects. It's
like we've hit a tipping point."
Scaling up is critical,
as mathematical modeling indicates that to
achieve a significant reduction in new
infections of HIV very large proportions
of the population need to be reached.
"It's hard with this
many people to coordinate. The challenge
we have are the numbers are so huge with
thousands and thousands of people. But if
this works, it'll be the game changer.
It'll be the future of how we approach
doing treatment and prevention and care."
Tanzania is a perfect study area. An
estimated 1.2 million people aged 15 and
older, or just more than 5 percent of the
adult population, are living with HIV. In
Iringa, the prevalence is estimated to be
as high as 16 percent, illustrating the
enormous lessons to be learned overseas,
he said. "When you do these studies in
places with really large numbers of new
infections, you can do things you can't do
here in the U.S. When new infection rates
are rare as they are here in the U.S., to
mount a study to show efficacy would
require millions of people to mount a
trail. It's unaffordable."
The global research,
though, can benefit those in the United
States, such as a recent finding that
treatment leads to prevention. In the past
four years, there have been promising
trials regarding the effectiveness of
certain interventions, with a big
breakthrough last year that showed the
impact of treatment on transmission, Sweat
"That was a home run.
They found a 96 percent reduction in
transmission of people on treatment. That
was a really big thing. Suddenly no longer
was treatment, which is expensive,
competing with prevention. It was
prevention. That was big news –
international news that gave hope to a lot
of us in the field. It energized people
and the politicians with the hope that the
pandemic could be stopped."
Much focus hangs on
this research, given the state of the
nation's economy and the global economic
crisis. Donor fatigue has set in,
consuming much of the foreign aid budget
for health with questions being raised
about the sustainability of this level of
effort, he said.
"There is a feeling
that if we don't show a big impact can be
done, donors will move on to something
else, is my guess. This will become just
another background tropical disease that's
considered unsolvable at a huge
humanitarian cost. Millions of people will
die from this."
Sweat, of course,
doesn't know how these studies will turn
out, but he feels hopeful based on the
growing literature about what is working
to stem the spread of AIDS. The studies
will combine many interventions, including
providing male circumcision with a recent
study showing it has a strong impact on
HIV transmission, cutting the acquisition
rate among men by half.
Sweat uses an office treadmill to stay
healthy while keeping up with work.
vulnerability of young women and female
sex workers also will be a focal area. The
research is being done in an area crossed
by the TanZam highway, the main trade
route linking landlocked Zambia to the
major Tanzanian port of Dar es Salaam.
"What's driving the pandemic in Iringa is
the TanZam highway that runs through
there," he said.
"There's a saying that
there are three risk factors for HIV –
sex, blood and asphalt. It's so true. You
get truckers and men separated from their
families, and there's a lot of sex going
on. There's a cash economy there with a
lot of plantations."
Sweat said they also
will be doing community interventions with
groups of men and women to address
economic vulnerabilities and safe sex
issues. "We work intensely to address the
gender norms that make adolescent girls
vulnerable. One strategy that has shown
promise is cooperatives where young
females can work together and market goods
and generate income."
Believing in the concept of social
capital, Sweat said there's a huge social
component to the study. "There are
benefits of social connectedness. The
networking helps you to get jobs and helps
you have self-assurance. There's
well-developed literature that shows that.
A lot of times when you see big health
problems here in Charleston, it's because
people are very socially disconnected. The
strategy is to build up these networks
around the girls and challenge gender
norms and build up some income."
A behavioral change
scientist, Sweat's main theoretical focus
is called ecological theory. Most
interventions have historically been based
on a one-on-one model, such as counseling
or education. However, multiple studies
are now showing that what really drives
behavior is not just the individuals and
what they're thinking cognitively, but
it's the environment that they are in, the
social and ecological environment that
they live in day to day, he said.
"What drives pandemics
is being disconnected from people, having
economic vulnerability or being in an
environment where things like gender norms
are not to your advantage – that's where
you get problems. This intervention
strategy where you look at the ecology of
things and the social structure – you
don't just focus on the individual – you
look what's going on around the individual
and intervene at that level. That is so
compelling to me. That is actually where
the field is moving more and more."
Sweat was drawn to MUSC
from where he served on the faculty of
Johns Hopkins University because of the
social-ecological focus of MUSC's Family
Services Research Center, which is a world
leader in this work. He feels his work at
the center and his global research
converge in this theoretical approach.
"Tanzania is a great
example. Trying to address the problem at
multiple levels – the biological,
behavioral and community level all at the
same time. That's a link to what goes on
at FSRC. That's what this group is really
To have MUSC become involved with a global
research project of this scale is good for
the institution, he said. Several faculty
now are involved, and it brings in funding
and training opportunities as well as
opportunities for other projects.
interest in global health work here that's
unmet right now. We can also tap into all
sorts of training programs to bring
foreign students to campus, which is good
for the school and adds to the diversity.
All in all, it's win–win."
Beyond that, he thinks
it's just the right thing to do.
"We live in a global
world. An uncontrolled AIDS pandemic is a
humanitarian crisis that has consumed
millions of U.S. dollars as we try to step
up to that," he said, adding that it also
is an issue studied by the CIA as
pandemics can destabilize governments and
lead to huge social challenges, such as
the alarming growth of orphaned children
vulnerable to exploitation.
"There is a cost
savings to the U.S. taxpayer. If we can
figure out how to do this
cost-effectively, we end up saving on our
foreign aid budget. And, there's a
humanitarian aspect to this. As a leader
in the world, we have some responsibility
to use our expertise to help the rest of
the world. That's good for our country."
a policy changer in fight against HIV
Michael Sweat, Ph.D., is a patient man.
Almost a decade from the start of
Project Accept, a study done that was
conducted in 34 communities in Africa
and 14 communities in Thailand, the
results are in, showing how to best
approach HIV prevention in the U.S. and
stop HIV's spread worldwide.
Sweat shares highlights from the
What was the significance of the study?
The study showed
that with mobile HIV testing and
community mobilization you can get very
large proportions of the community in a
rural setting to learn if they are HIV
infected. This allows people to access
life-saving treatment. The study also
showed that this kind of large scale
testing reduces HIV risk behavior and
lowers the number of new HIV infections.
What was our involvement?
MUSC was one of
four institutions selected to run the
study, together with UCLA, Johns
Hopkins, and University of California,
San Francisco. I was the principal
investigator at MUSC and ran the
Tanzania part of the study. This project
ran for more than eight years and MUSC
received more than $11 million in
support from the NIH for the project.
How will this be a policy changer?
There is now a
movement to take advantage of fact that
we now know that HIV treatment reduces
HIV transmission. This means that
treatment equals prevention. But this
model only works if you can get people
to be tested for HIV and get those
infected into treatment. The study shows
that even in rural areas in Africa it is
possible to get large numbers of people
to be tested. I would expect that now
foreign aid donors will put more money
into mobile HIV testing programs. It
also demonstrates that in itself,
testing for HIV reduces HIV
What kind of collaboration does this
scale of a study require?
between MUSC and Muhimbli University in
Tanzania has lead to many opportunities
for MUSC and Tanzanian scientists to
learn from one another. The kinds of
learning experiences that the project
facilitated are really profound and
meaningful to all involved. This
partnership also helps MUSC in
establishing the capacity to do other
important research work in Africa and
access funding for this kind of research
in the future. We are already now
starting a new study, and have plans for
other projects – and that never would
have been possible without the study we
To read more about the
To learn more about Project Accept, visit
March 15, 2013