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From research to action
Preventing the spread of AIDS in Thailand
|by Rebecca Costello|
Dr. Tim Mastro '75 is dedicated to finding ways to prevent the spread of AIDS.
Since 1993, he has been director of the HIV/AIDS Collaboration in Thailand, a
joint project founded in 1990 by the U.S. Centers for Disease Control (CDC) and
Thailand's Ministry of Public Health. The collaboration, whose home is in the
Bangkok suburb of Nonthaburi, has carried out groundbreaking studies on HIV
infection and AIDS in the Thai population and has established intervention
programs that are making significant progress toward preventing and controlling
this devastating disease.|
When Mastro took Philip Crook's course on "man and microbes" and Ted Herman's East Asian cultural ecology class, he was a biology major with an eye toward becoming "what my mother would call a `real doctor.'" While the two classes didn't necessarily "wire" him for the path he chose instead, Mastro has made a career of the epidemiology of infectious diseases, primarily in Asia.
In 1983, after finishing his residency in internal medicine in New York City, Mastro followed his sense of adventure and desire to work overseas to a one-year position as a physician for the American Refugee Committee in Thailand.
"That was my introduction to worse-than-third-world health care and tropical disease," Mastro remarked. He was one of only three doctors for a camp of 50,000 refugees fleeing the war in Cambodia. In the bamboo hospital building with its dirt floor and thatched roof, Mastro treated patients, set up disease prevention programs and trained Cambodian medics. It was a career-changing experience. Rather than returning home to practice internal medicine, Mastro found himself drawn to issues of public health.
"I loved being a clinician, but I had found an exciting and stimulating arena where there were pressing needs." He took a position as medical coordinator with the United Nations Border Relief Operation in Thailand. From 1984 to 1985, he worked with 12 non-governmental organizations providing Cambodian refugees with direct medical care and establishing programs for needs such as tuberculosis control, immunization and infant feeding. At that time, he met his wife Pradhana, who was also working for the U.N. operation. Then, after a brief return to academic internal medicine in New York, "I quickly realized I wanted to get back to international health care." He joined the Centers for Disease Control in 1988.
Mastro became an officer for the CDC's Epidemic Intelligence Service, which National Geographic called "The Disease Detectives" in a 1991 article. He investigated pulmonary disease outbreaks throughout the country, such as Legionnaire's in a residential hotel for the elderly in Los Angeles and pneumococcal pneumonia in a large jail in Houston.
He gained his first hands-on experience with the global AIDS crisis as a medical epidemiologist for the CDC's international HIV/AIDS division beginning in 1990.
"The mortality is overwhelming. In Africa, for example, where most adult medical wards are filled with AIDS patients, hospitals are places where you go to die," he said. "These are people in what should be the most productive years of their lives."
Then Mastro and his wife, with son Alex (now 11) and daughter Alisa (now 9), moved back to Thailand in 1993 when he took the helm of the fledgling HIV/AIDS Collaboration.
"The first few years were extraordinarily demanding," he remarked. "It was like starting a new business." The partnership has since been making notable progress in Thailand, where nearly one million Thais are currently infected with HIV.
Mastro is responsible for the research operation, which employs five Americans, a Dutch scientist and an Australian statistician, as well as nearly 70 Thai physicians, research coordinators, data managers, nurses and assistants, a lab chief and technicians, an administrative section and a fleet of vehicles and drivers. Mastro works with the other scientists to conceptualize the questions they need to ask, writes the protocol for studies, and makes sure the findings are reported in the international medical literature.
A primary focus of the organiza-tion's research is on sexual transmission of HIV.
"In Asia, the majority of HIV transmission is through heterosexual sex, largely driven by the female sex trade," Mastro explained. "Prostitution is illegal but common, and many men avail themselves of the services and then bring the disease home to their wives." The Chiang Rai Health Club in the northern region is one major site for conducting this research, which has included a long-term project following the progress of 500 female sex workers.
By understanding who is infected, how they became infected, risk factors, the course of infection and the social history of transmission, the team has built a body of knowledge that provides a scientific basis for the development of intervention programs by the Ministry of Public Health.
"This infectious virus is being spread through human behavior. It's tragic to see the suffering and mortality when you know AIDS is relatively easy to avoid. You are also witness to the inequalities of a society where poor young girls have to go to work in a brothel rather than going to high school, and where women with modest sex profiles become infected because of their husbands' risky behaviors."
One study Mastro is particularly proud of dealt with mother-to-child transmission of HIV. Each year, 20,000 HIV-infected women give birth in Thailand, and there is nearly a one in three chance their babies will contract the disease.
In a two-year trial in Bangkok, HIV-infected women were administered a short course of the drug AZT. The study showed that the treatment, dubbed the "Bangkok regimen," reduces the incidence of the infants contracting HIV by half.
"As soon as we were able to prove the regimen had a positive effect, the Thai Ministry of Public Health made AZT available for all HIV-infected pregnant women in the country," Mastro explained.
Now the partnership is evaluating the implementation. "It's working," he said. "Thailand has a well-organized healthcare system. This was probably the nicest complete study cycle we've done. We know we are preventing a couple thousand babies from contracting AIDS each year."
Another high-risk population is injecting drug users (IDUs) -- about 40 to 50 percent of IDUs in Bangkok are infected. Mastro and his team's studies of IDUs have identified different strains of the virus prevalent in Thailand and led to the first HIV vaccine efficacy trial in the developing world.
Mastro spends nearly 50 percent of his time in efforts related to getting
research findings published, and is senior author on many papers that have been
published in leading journals and presented at significant gatherings such as
the Geneva World AIDS Conference.
The job is satisfying, Mastro says, because he can watch the blossoming of the Thai scientists the collaboration is training, and because "our work makes things happen."
Life in Thailand is full for Mastro and his family. The varied and exciting cuisine is a pleasure. Dad coaches the kids' soccer and basketball teams on Saturdays. Travel, especially throughout southeast Asia, is a favorite pastime -- to ancient Khmer ruins, trekking in Nepal, exploring Bali, Singapore, Vietnam, Cambodia, Laos -- "although the kids have gone on so many elephant rides, those aren't really exotic any more."
Next month, Mastro will move on to a new position with CDC's division of HIV/AIDS prevention, as chief of the HIV Vaccine Unit, based in Atlanta. He will coordinate and oversee the CDC's HIV vaccine development and evaluation operations worldwide.
"It's exciting," Mastro said. "I will be able to stay involved in the vaccine trial in Thailand and I'll also get into new initiatives in other areas.
"For many parts of the world, a vaccine holds the greatest promise for stopping the epidemic."
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