AAMC Reporter: May 2005

U.S. Medical Schools Help Combat AIDS in Africa

For four years, Paul Zeitz, D.O., lived in Zambia, treating a population ravaged by HIV and AIDS. He worked with the United Nations Special Program on AIDS (UNAIDS), the U.S. Agency for International Development, and the Zambian government to bring necessary treatment to dying patients.

The virus was so widespread that six of Zeitz's Zambian colleagues were also infected and died during his tenure. His frustration and the death of his coworkers stemmed from the prevalence of HIV/AIDS and the lack of resources to combat its spread.

"It's frustrating as a professional to know that there are drugs readily available in Europe or America, and we had no access to those medications," said Zeitz, co-founder and executive director of the Global AIDS Alliance, a non-partisan coalition that supports campaigns to fight the spread of the disease.

"We have to close the gap between what's possible with medical treatment in Africa and what's happening."

Globally, more than 60 percent of individuals who are HIV-infected — 25.4 million people — live in sub-Saharan Africa, home to only 10 percent of the world's population, according to UNAIDS statistics. Last year, an additional 3.1 million people became infected. Women were infected more than men by a three-to-one margin, increasing the need for treatments to reduce mother-to-child transmissions.

In the proposed 2006 federal budget, President Bush requested $21 billion for domestic and global HIV/AIDS initiatives, increasing the 2005 allocation by 7 percent. This amount represents less than 1 percent of the federal budget. Some $3 billion would fund global initiatives, including the President's Emergency Plan for AIDS Relief Global HIV/AIDS Initiative at the State Department and the Global Fund to Fight AIDS, Tuberculosis and Malaria.

Botswana-Baylor Children's Clinical Center for Excellence

But the funding is insufficient to counter the spread of HIV in Africa or to bolster research that could lead to discovery of new medications or a vaccine, according to Preston Marx, Ph.D., professor of tropical medicine at Tulane University School of Public Health and Tropical Medicine. For nearly two decades, Marx has worked in Africa against HIV. Scientists there struggle to find usable lab space and sometimes work without electricity, hindering their ability to contribute to AIDS research, he said.

Many U.S. medical institutions, including Baylor College of Medicine, Harvard University School of Public Health, and Dartmouth Medical School, have created programs in Africa to supplement the work subsidized by the federal government. The initiatives focus on the most severely affected countries such as Botswana, Zambia, and Tanzania.

Baylor-Botswana Care Center

Baylor launched its Botswana-Baylor Children's Clinical Center for Excellence in 2003. Operations are based in a 14,000 square foot facility used for patient care, training, and education. Located in Gaborone, Botswana's capital, the facility provides up-to-date care and antiretroviral treatment to more than 1,200 HIV-infected infants and children as well as 200 families. According to Mark Kline, M.D., director of the Baylor International Pediatric AIDS Initiative, Baylor focuses on children because their medical needs are overlooked.

"The government and president of Botswana are committed to fighting AIDS, but there is very little pediatric expertise there," Kline said. "Children are also given little priority because they have no job, they don't pay taxes and they don't vote."

By treating children, Baylor physicians help infected adults, Kline said, because a sick child is likely attached to at least one HIV-positive parent. Caring for one child could result in an entire family receiving medications they need to remain healthy. Since the antiretroviral program began, the annual AIDS death rate in the region where Baylor operates has dropped from 15 percent of infected individuals to less than 1 percent.

Educational training for youths is also vital to Baylor's program. A community education program offers psychosocial support while providing facts about sex, marriage, family relationships, and jobs. The goal is to help individuals make the right choices to stem the tide of HIV infections in Africa, Kline said.

Medical personnel from Botswana and the United States who work with HIV-infected individuals in Africa receive training through Baylor's program. Typically, African physicians visit Baylor's Texas campus through the Fogarty Center to acquire clinical experience with antiretroviral medications. Pediatric residents occasionally complete elective rotations in Botswana, giving them the experience of working with a larger group of infected children than they would encounter in the United States.

Research is paramount to conquering HIV and AIDS, and Baylor's program engages in investigations. But it is not the initiative's main goal, Kline said.

"African children are not dying because of a lack of access to research," he said. "They're dying due to a lack of access to care and treatment."

Harvard AIDS Initiative

Research is the primary focus of another Botswana program maintained by the Harvard University School of Public Health AIDS Initiative. The local governments work closely with Harvard, but Botswana officials control operations because they want primary responsibility for improving the lives of infected citizens, according to Richard Marlink, M.D., executive director of the Harvard AIDS Initiative. Harvard has similar programs in other African countries.

Established in 1996, Harvard's program provides grant funding and resources for epidemiologic and lab research, including mother-to-child transmission and genomic analysis of HIV-1C, a viral sub-type common in southern Africa. Researchers are conducting the first Food and Drug Administration-approved HIV vaccine study in Africa for a medication that will be tested in the United States and Botswana, Marlink said.

"Two U.S. sites and our center in Botswana will test the vaccine simultaneously," Marlink said. "There's no political concern that anyone is being used as guinea pigs because this is a true collaboration."

Research project funding comes from several sources, including the World Bank, the National Institutes of Health and the Bill and Melinda Gates Foundation. Money from the organizations also supports Harvard's other African HIV/AIDS programs.

Health professionals in Harvard's program must have the skills to implement research findings successfully. The KITSO AIDS Training Program, named after the Setswana word for "knowledge," gives Botswana health professionals the multi-disciplinary training they need to treat HIV-infected patients including standardized clinical knowledge and hands-on practice. While some Harvard faculty members are teachers, KITSO is rapidly moving toward a training program that includes only indigenous professionals.

Although Harvard's program welcomes its medical students and residents, as well as those from other institutions, only individuals willing to make a long-term commitment to an existing project have an opportunity to work in the Botswana facilities. Otherwise, they could not make significant contributions to ongoing research efforts, Marlink said.

So far, local response to Harvard's program has been positive as researchers and health professionals treat an ever-growing number of infected people. By making an HIV test mandatory for all individuals who come to Harvard's Botswana facilities, the program took the first step toward successful treatment and prevention of the disease, Marlink said.

Treating Children in Dar Es Salaam

Some international AIDS programs, rather than focusing solely on HIV, branch out to research how it affects other health conditions. Dartmouth Medical School conducts its African HIV/AIDS work in Dar Es Salaam, Tanzania. The program, known as DARDAR, is a joint effort between Dartmouth and Muhimbili University College of Health Science in Dar Es Salaam. It concentrates on HIV-associated tuberculosis (TB) in sub-Saharan Africa. So far, a current TB vaccine study includes 4,000 individuals with tuberculosis, of whom 1,700 are HIV-positive.

Last year, the Foundation for the Treatment of Children with AIDS announced a $1.6 million grant for the Infectious Disease and International Health section at Dartmouth Medical School and Dartmouth-Hitchcock Medical Center. According to Ford von Reyn, M.D., chair of the infectious disease section and DARDAR principal investigator, the majority of the grant will pay for building, staffing and operating a clinic for HIV-positive children in Dar es Salaam.

"Programs to treat children are lagging behind those for adults," von Reyn said. "Drugs studied in adults are not often studied in children, and we know children must be treated differently. This grant helps us set up and expand treatment for children."

The clinic will help infected children and their mothers, von Reyn said. HIV-positive patients will have appointments every three months, and if they do not arrive within two weeks of the scheduled time, staffers will search for them.

In addition to being a research program, DARDAR allows medical students to come to Africa to participate in scientific investigations and receive hands-on experience with a large HIV-positive population. Participating in the program is an elective through Dartmouth Medical School, and von Reyn said working in Africa profoundly affects many students.

"One student said she changed her career plans after being in Africa," he said. "She realized that she wanted to dedicate part of her career to improving health in developing countries."

Fighting the African AIDS crisis is riddled with limited medical and human resources, but it is imperative that U.S. medical and public health schools stay active in the region, according to Zeitz of the Global AIDS Alliance. Their work provides innovation in confronting a disease that is strangling generations of Africans while improving access to care for individuals who might not otherwise receive help.

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