From the Director

"My 20 Years as HIV Center Director:
The Gratifying, the Challenging, and the Frustrating"

By Anke A. Ehrhardt, Ph.D.

Most Gratifying: The People

The most gratifying part has been the opportunity to work so closely and for so long with a group of such talented and dedicated people. People who work in HIV/AIDS tend to be passionate, incredibly hardworking, and deeply committed to making a difference. From the beginning, I personally have always felt that it was urgent to double and redouble my efforts to try to get ahead of the HIV/AIDS epidemic. This shared passion and commitment has been one of the most gratifying experiences and continues to help to keep me going.

An early HIV Center investigators' meeting

As HIV Center Director, I have been deeply impressed by, and enormously grateful for, the skills, dedication, vision, and just plain hard work of our more than 100 research investigators and collaborators, administrators, and staff. I would like to particularly single out the following dedicated supporters and collaborators:

• Ellen Stover of NIMH deserves the major credit for the government's NIMH response to HIV/AIDS Initiatives.

• Rafael Tavares was one of the founders of the HIV Center and started with us as a gifted community leader heading the first Community Core. He tragically died in 1988 but will never be forgotten. (For more about Rafael, and other's we've lost over the past 20 years, click here.)

• Zena Stein has been a partner, mentor, friend and a fellow combatant, particularly in the area of gender and women's methods, the female condom, and the microbicide. One of the most gratifying aspects of the last 20 years has been my collaboration with Zena.

• The Program and Administrative team has been very stable, and I would like to single out three people in particular. Pat Warne, who arrived 18 years ago, has been critical to program development and grant initiatives. Masud Rahman, who started almost 20 years ago, is the Administrative Director and a wizard in financial and personnel matters. And Barbara Muller is semi-retired but has stayed as a valued member of the administrative team, as she has been for the last 20 years. I could not imagine my directorship of the HIV Center without Barbara, Pat and Masud. This administrative team is well oiled and tested!

A meeting of the first Community Core

A highly committed group of outstanding researchers has also been essential to the success of the various Cores which have provided crucial support for the Center's work. At the beginning, the Center established a Medical Core, a Neurology Core and a Community Core, reflecting our close collaborations with our biomedical colleagues on the one hand and the community at large on the other. Statistics and Epidemiology were strong from the start. Jacob Cohen was succeeded by Bruce Levin, who has spearheaded the Statistics, Epidemiology and Data Management (SED) Core for the last ten years. The Psychiatric Core, the Development Core and of course the Psychosexual Core -- directed by Dr. Heino Meyer-Bahlburg -- represented our unique emphasis on human sexuality and measurement. The Ethics and Policy Core was initiated by Ron Bayer and is now led by Bob Klitzman.

After the first five years of the Center's duration, we wanted to add a greater strength in psychosocial and qualitative methodology. I reached out to Susan Tross to join us and bring with her Joanne Mantell, Bruce Rapkin, Blanca Ortiz-Torres and Karen Wyche. They founded the Psychosocial Qualitative Core 15 years ago, which has become critical in integrating qualitative and sociological methodology. The current Interdisciplinary Methods Core (IRMC) has merged the Psychosexual and Psychosocial Cores. The IRMC's leadership by Heino, Susan and Jennifer Hirsch, a prominent anthropologist, represents the integrations of different methodological approaches.

Overall the most gratifying part of the work has been for me the shared passion, the commitment and hard work that I have had the privilege of sharing with the many people who have been part of the HIV Center's work. I feel that we have fought many battles together over the last 20 years and that we all hope and continue to be engaged in making a difference in the global HIV/AIDS epidemic.

Most Challenging: The Gender Lens and Multidisciplinary Perspectives

The team for Project FIO,
a gender-specific intervention for women

Over the last 20 years, there have also been challenges, two of which I would like to highlight: keeping the "gender lens" in focus and promoting work that is truly multidisciplinary.

HIV Center researchers and the Center leadership have remained on the forefront of defining the agenda of gender-specific prevention for women and their male partners. This was not only because Zena and I were the only two women who were directors of one of the three NIMH Centers in 1987 but also because we both have had a history of conducting research on gender in our previous careers. Over a decade ago, we defined the agenda for women as part of the NIMH Consensus Conference on HIV prevention, arguing that women's risk is embedded in their relationships with men.

Early on, we sounded the alarm that the male condom was not under women's control and that we were urgently in need of other methods. Zena and I branded the term "virucide" which became "microbicide." We began talking about a "virucide" as a women's method before anybody wanted to hear about alternatives to the male condom, in 1988. We have also conducted studies and published on the link between women's risk behavior and their reproductive health and their desire to becoming pregnant or not. And we argued that ultimately it was important to include heterosexual men and new approaches to masculinity in order to make a difference in women's risk for HIV.

Production of an HIV Center video

To this end, I worked with Theresa Exner, Susie Hoffman, and others to carefully develop and test a gender-specific intervention for women, Project FIO, which is currently one of the 18 projects chosen from 222 to be disseminated by the CDC as part of the DEBI program. Gender was also a major theme of a series of videos that the HIV Center sponsored and has distributed around the world. These videos were based on the unique model of collaboration of the Media Group, the community, and researchers.

I have found it challenging to keep the focus on the gender lens against the overwhelming gender inequities around the world and the many obstacles we have encountered in developing an effective microbicide and in making the female condom available and accessible. It remains critical that gender empowerment be rooted in the realities of women's lives, from their economic situations to religious constraints, to the vulnerability of mothers, grandmothers and providers.

The second challenge I would like to highlight has been the fostering of multidisciplinary collaboration among investigators from numerous disciplines. This process began with my Co-Director Zena Stein, a medical doctor and epidemiologist – and has flourished into a dynamic partnership among researchers in psychology, psychiatry, neuroscience, social work, sociology, anthropology, infectious diseases, public health and many other fields. Particularly at our weekly Cross-Core meetings, we have all been challenged to think outside of the bounds of our disciplines to try to respond to an epidemic that knows no borders or boundaries. We have also constantly "pushed the envelope" in ensuring the inclusion and prioritization of research involving women, who now represent more than half of the world's population of people living with HIV.

Team working with the homeless mentally ill

The multidisciplinary perspective has helped us to respond to the epidemic from many angles and directions. Thus, in addition to gender, a developmental perspective on children and adolescents has run through our multidisciplinary work like a red line, notably including the work of Claude Ann Mellins and Joyce Hunter. We are also focused on risk within the context of same-sex behaviors, particularly with different populations of gay men. Alex Carballo-Dieguez, Bob Remien, Richard Parker, and others have conducted 20 years of research on risk behavior for both HIV-negative and HIV-positive gay populations. Likewise, mental illness and mental health have been central to all of our research. Ezra Susser and his team conducted a number of studies, together with Alan Berkman, on the homeless and mentally ill. Fran Cournos was an early pioneer in the area of mental illness and HIV and is now part of our Center with a major training program. Milton Wainberg has expanded this line of work to Brazil.

At the same time, we have also engaged in the work of training and mentoring the next generation of researchers, including many postdoctoral fellows and other trainees. The NIMH Fellowship training program has been in existence since 1989, initially directed by Zena Stein and Bob Kertzner, and for the past 8 years by me with Bob and then, since 2003, with Theo Sandfort. Our most recent training effort is the MAC AIDS Fund Leadership Initiative, which selects community leaders from South Africa who are recruited for one year of mentorship with two months in New York City. This is a collaboration with Tom Coates from UCLA who has been a long time friend of the HIV Center and to me personally.

Most Frustrating: The "Same Old Stuff"

The most frustrating dimension of the past 20 years has been witnessing some of the same mistakes being made repeatedly, and the same unresolved problems recurring over and over again. You might want to think of this as the SOS Script, ("the Same Old Stuff") script. Of course, we have made a lot of progress in prevention and care of HIV. However, we have not been able to stop the global spread of the virus. The strategies applied in different regions of the world often come up against the same prejudices and the same myths, and therefore progress is often too slow and the spread of HIV is not effectively halted in time. Stigma and discrimination are still consistent roadblocks to progress, just as they were in the 1980s and 1990s. Drug use and sex work, major contributors to the epidemic, remain criminalized and thus forced underground. Needle exchange programs are still controversial in some quarters despite clear evidence that they work. One of the most frustrating parts of the "SOS Script" for me as a sexuality researcher is that we cannot talk frankly and appropriately about sexual behavior, especially to young people because it might "give them the idea" to become sexual.

HIV Center investigators and staff in 2007

Ultimately, the most frustrating experience for me over the last 20 years has been that the HIV epidemic has continuously spread around the world and that we are still caught in public health approaches that are largely ideological rather than evidence-based. So far, the world community has been unable to join forces and develop a cooperative and comprehensive strategic plan that would ensure progress and access to the best prevention practices and treatment roll-out for all. As frustrating as this cycle can be, these realities -- as well as other, still-emerging problems -- must not deter us from trying to make progress but rather provide us with the determination to persevere.