Aids and nutrition: a personal journey.

I am humbled to have received the John M. Kinney Award for Pediatric Nutrition. My involvement in investigating the nutritional aspects of growth failure and infection with the human immunodeficiency virus (HIV) began relatively recently, although I have been interested in investigating associations for as long as I can remember. I was not very interested in or fond of mathematics for most of my childhood and adolescence. However, my disposition changed in a matter of minutes one day when one of my biology professors in college handed me a book written by two eminent evolutionary biologists, George Oster and E. O. Wilson, detailing a mathematical treatment for the basis of the evolution of ants as colonial organisms. Looking through almost 400 pages of mathematical equations left me puzzled and lightheaded. Despite this minor problem, I was so dreadfully fascinated by the subject that I decided to commit myself to learning the skills necessary to unravel the mystery that lay between the pages. Eventually, I acquired those skills, finally submitting a thesis detailing my own mathematical models that was so theoretical that it could not be deciphered by the biology department and had to be submitted to the department of mathematics for review. So began my affair with working with numbers, an affair that would ultimately lead me to working professionally as a biostatistician. My interest in acquired immunodeficiency syndrome and nutrition developed a few years later, while studying epidemiology and biostatistics as a graduate student. Although I was already drawn to and fascinated throughout my graduate studies by the effectiveness and possibilities offered by the public health model toward controlling the pandemic, one experience in particular forged my decision to professionally pursue a career in international health and nutrition. During the summer of 1998, I traveled to Yerevan, the capital city of Armenia, to implement a study, as part of my graduate thesis, assessing the seroprevalence of HIV infection among commercial sex workers. In addition to determining the prevalence of infection, I was interested in investigating and characterizing the risk factors (behavioral, economic, and social) associated with infection status in this population. Through the course of the next 3 mo, I interviewed and tested more than 200 women in various clinics across the city. A large proportion of the women I interviewed also cared for their infants’ ailments, ailments that had developed in some cases as a consequence of maternal transmission. What followed was my first personal experience learning about the devastating consequences of this pandemic. While listening to each woman’s story, I was at once not only profoundly saddened and humbled but also deeply agitated by my own inability to offer some sort of amelioration. The precipitate of these experiences resulted, almost immediately, in a profound change; not only in my professional plans but also, more importantly, in my personal approach to thinking about the multidimensional problems of international health. Looking back, I realized that what each of those patients conveyed to me was in truth a new and different reason for why I must find a way to join others in the scientific community and learn about new avenues to finding answers and asking questions. In December 1999, deferring my plans to study medicine for at least another 18 mo, I accepted a junior faculty position as a biostatistician working with Dr. Richard Semba at the Center for Human Nutrition at the Johns Hopkins School of Medicine. Dr. Semba and his research group have been studying vitamin A deficiency and nutritional blindness among children in developing countries for the past 14 y. Vitamin A and the carotenoids had been shown to influence growth among preschool-age children.1 Further, maternal nutrition status during pregnancy in HIV-infected mothers was shown to contribute to growth failure among infants.2–4 Growth failure was shown to be a prognostic indicator of mortality during pediatric HIV infection.5 These studies provided indirect evidence associating infant vitamin A and carotenoid status with growth in the context of HIV infection and a possible link between infant nutrition status, growth failure, and infant mortality. As the next logical step, we investigated the relation between these three factors in a longitudinal study to confirm our suspicions. It was the results of that effort that ultimately led to the recognition by the John M. Kinney Award Committe.6 Although I am honored as the recipient of this award, it is clear that this work is truly a product of the collective efforts of our entire group. As a statistician, I have often been privileged with the task of investigating relationships and finding associations among variables and posed hypotheses subsequent to most of the arduous field work. I thank Dr. Semba for his leadership, collaboration, and insight in making this study possible.