Irving Hoffman is a professor in the Division of Infectious Diseases, the International Director of UNC Project-Malawi, and Director of International Operations for the Institute for Global Health and Infectious Diseases (IGHID). With more than 32 years of service to UNC’s global health community, Hoffman has worked in over 19 countries, providing technical assistance and leadership that has grown and stabilized UNC’s global presence in infectious diseases.
Hoffman’s legacy is particularly marked by the co-founding of UNC Project Malawi, the Institute’s flagship site, with Dr. Myron (Mike) Cohen. What started with a modest HIV and STI research agenda is now an internationally recognized, academically diverse center of excellence. Hoffman has worked tirelessly to ensure Malawians who seek specialty training in clinical medicine and public health can receive the training and leadership skills they need to work in Malawi’s academic or public settings.
How did you come to UNC?
“I graduated from the Duke Physician Assistant Program and UNC’s Master of Public Health Program. One of my first jobs was working as the clinical coordinator at the Durham Health Department, from 1983-1992, where I was in charge of the STI Clinic, and where we developed an HIV program at the beginning of the epidemic. In 1989, I met Mike Cohen and Fred Sparling, who at the time was chief of the division of infectious diseases, when we had an outbreak of resistant gonorrhea in Durham.
“In 1990, I read about a global health project in sexually transmitted diseases that Mike was starting with the USAID funded AIDS Control and Prevention Project (AIDSCAP). At the time, the thinking was that if the traditional sexually transmitted diseases could be controlled, HIV could also be controlled. Mike formed a consortium with the University of Washington, the University of Antwerp, and FHI 360 (formerly Family Health International) to reduce the rate of sexually transmitted HIV infection in developing countries. He hired two research coordinators to manage these activities at UNC, and I wanted to join this work. I had no research experience, but I was an STI clinical expert. I had lots of personal global experience, I had confidence, and mostly, I was unafraid to go anywhere and do anything.
“Every month for a year, I would call Mike or visit him, and say: ‘You need to hire me.’ And he would say: ‘Well, I’m not going to hire you. You have no research experience and we don’t have a position.’ But when one of the investigators left before the project was completed, Mike said: ‘Here’s your chance. You can go to Malawi on a contract, and if it works out, we’ll consider hiring you.’ From there, I immediately took a leave of absence from the Durham Health Department and went to Malawi for six months. With two Malawian nurses, I enrolled and followed over 800 STI symptomatic men and women in an STI etiology prevalence study. When we finished, I brought back the data and the results of that study which formed the basis of the first STI syndromic guidelines for Malawi. I guess I did a good job because in 1992, I became an assistant professor of medicine at UNC.”
What attracted you to this work and where did you travel?
“In the mid-seventies I had already traveled a lot in Africa, Mexico and the Caribbean. I lived for a year on an agricultural estate in Dominica, (ironically where I developed my love for medicine). Another year, I backpacked from South Africa through Botswana, Northern Rhodesia (now Zimbabwe), Zambia, Tanzania and Kenya. Global health was right for me. There was a great need, and I really liked and respected the people.
“Under that first AIDSCAP grant, I traveled about 70% of my time to Mexico, Jamaica, Haiti, Nigeria, South Africa, Malawi, Egypt, India, Nepal, Bangladesh, Indonesia, Philippines, China, Russia and Kyrgyzstan.
“I also did domestic work with Bill Miller in Eastern North Carolina, looking at chlamydia screening guidelines, and then at Fort Bragg, with Arlene Seña and Bill, looking at gonorrhea and other STIs among active-duty military.”
What are some pivotal events in your career, and in the history of the Institute?
“In 1996, when Mike and I received a small grant from the World Health Organization to study HIV in semen in Malawi, I moved to Blantyre with my wife Sarah Craige, and our two children, to conduct the trial. This was the first scientific research project in Malawi (or anywhere in Africa) that required men to donate semen, and the Blantyre hospital committee, despite having IRB approval in Malawi and at UNC, wouldn’t allow men to masturbate in their hospital. But Dr. Peter Kazembe at Kamuzu Central Hospital (KCH) in Lilongwe, who was one of the first two pediatricians in Malawi, and also head of the Malawi IRB, told us we could conduct the trial at KCH. So we packed up and moved everything to Lilongwe, which would eventually become the site for UNC Project Malawi.
“This study, showing that treating urethritis in HIV-infected men dramatically reduced the HIV viral load in semen, was reported during a plenary session at the 1996 International AIDS meeting in Vancouver, and subsequently published in the Lancet. For me, this was UNC’s first global health study that was broadly recognized by other global health investigators. After the trial, I advocated for permanent staff in Malawi. I convinced Mike that we needed to finance a lab technician and an HIV nurse/counselor, and we needed a brick-and-mortar presence. Malawi continued to be the place that had the most glaring public health problems, needed the most resources, and had the most welcoming collaborators. With this permanent presence, we established the STI clinic at KCH. In 1999, Malawi became part of the HIV Prevention Trials Network (HPTN), the beginning of the NIH’s global research. In 2003, we built the Tidziwe Center, our academic site to conduct HIV trials, for patient care and training.
“It was this first study of HIV in semen, and Mike’s vision, that led to the concept for HPTN 052, which took over 10 years to prepare and implement. But it led to the 2011 discovery that antiretroviral therapy prevented HIV transmission, a real game changer in global HIV prevention, which until that time focused more on behavior change. I traveled frequently in preparation and implementation for 052. During this time I bought several round-the-world airline tickets so that I could travel and develop the main 052 study sites in Brazil, Zimbabwe, Malawi, India, Thailand, and South Africa.
“There have been several other important studies conducted in Malawi. We were one of just a few sites that conducted the first malaria vaccine (RTSS) trial for young children, that had a significant but waning effect on malaria incidence over three years. Other sites were in Ghana and Kenya. Subsequently, we were part of the WHO funded team that evaluated the roll out of the vaccine in rural Malawi, where this immunization led to a 10% reduction in overall mortality, in children under the age of five. The Breastfeeding, Antiretrovirals, and Nutrition (BAN) study, funded by the CDC and led by the late Charlie van der Horst, successfully showed methods to reduce post-partem mother to child transmission of HIV. Recently, Mina Hosseinipour led the HPTN study (084) that showed Cabotegravir, an injectable antiretroviral given every two months for pre-exposure prophylaxis, prevented at risk women from getting HIV.
“Today, among others, we have research, training and clinical activities underway in pediatrics, internal medicine, hematology, STI, HIV, sickle cell disease, mental health, cancer, OB/GYN, GI, reproductive health, surgery, urology, pathology anethesiology and radiology. Most recently, UNC intervention cardiologists visited Malawi to screen patients and provide training, exploring the possibility of providing the first onsite cardiology intervention in the entire country.
How was the Institute formed?
“It was our work in the early 1990s that provided the foundation for the UNC Institute for Global Health and Infectious Diseases (IGHID) that everyone knows today. But it wasn’t until 2007 that UNC set a priority to become recognized as a global university. It was during this time that our portfolio and global infrastructure, and developing global sites, became formally identified as IGHID. But the strength of the Institute has always been our faculty and investigators, who have been very successful in being awarded individual grants, who have focused on their passions and built relationships in country. Our success is the result of years of building relationships and growing infrastructure around the world.”
Why do you think your work has been so successful?
“It has been about taking opportunities, and building on them, and as Mike told me long ago, perseverance is often more important than brains. I think this was already part of my personality. So basically, you get up every day and address the problems and the opportunities and try to move the needle forward. I have never been afraid to act. I have been successful because I’ve kept my head down, worked hard, and not been distracted by external forces or opinions I can’t control.”
Looking back, what would you say has been your greatest accomplishment?
“Today, UNC Project Malawi is led and operated almost entirely by Malawians, and we continue to invest in educational opportunities for future Malawian leaders. The Project has developed into a trusted local institution, woven into the research and training fabric of Malawi. Getting to that point was a decades-long commitment, and I am very happy with the results.”
What have you enjoyed the most?
“Want me to be honest? I like the adventure and the risk of global work. I like to be surprised with a problem and figure a way out. I like the action. I love African and Caribbean and Asian cultures, and the life-long friendships I have made in the places I have worked. And each time I return to Malawi, I am often greeted with a “welcome home,” which says it all because as long as I can remember, I have loved being part of a team. The Institute and all of its global sites are successful because teamwork is at the heart of our culture.”
Do you have a life motto?
“Treat everyone with respect.”
The Institute for Global Health & Infectious Diseases (IGHID) attracts people who are driven to make big change. From principal investigators and grant managers to regulatory specialists and study coordinators, everyone has an important role to play in what we do around the world. We are pleased to highlight the work of the people who proudly serve IGHID.