A very South African Thanksgiving

It has been over two months since I last posted. In that time…

• I attended the Opening and Scientific Symposium for the launch of the KwaZulu Natal Research Institute for Tuberculosis and HIV (K-RITH), a groundbreaking collaboration between the Howard Hughes Medical Institute (HHMI) and University of KwaZulu Natal, which is housed in a world-class laboratory facility at the UKZN Medial School campus. As a Caprisa fellow, I am lucky enough to sit in the K-RITH building! The energy and scientific rigor presented at the K-RITH symposium was inspiring, with a wide range of presentations, including Bruce Walker, Eric Goosby, Tony Fauci, and Nobel Prize laureate Peter Agre.
• President Obama was re-elected (!!), which allows the global health community to sigh a breath of relief and get back to work. Center for Global Development has mapped the top five global health items that should be on the President’s agenda over the next four years.
• Proposition 37 was defeated in California by 53.1% to 46.9%. The ballot measure, which was bankrolled by $47 million in campaign contributions from biotech companies such as Monsanto, would have made California the first state to require labels on foods containing genetically modified organisms. This disappointing result marks a major setback for the food movement.
• The Phase III trial of the RTS,S malaria vaccine showed only 31% efficacy in children, disappointing results after the Phase II trial results showed higher efficacy.
• UNAIDS released its Global Epidemic Annual Report, which details an increase in the number of people worldwide on antiretroviral therapy and a decrease in new infections. However, the pace of ART scale-up does not match the decrease in HIV incidence, with 2.5 million people becoming newly infected last year, while only 1.4 million received treatment for the first time.
• Hurricane Sandy devastated the Eastern seaboard.

On a personal level…

• I applied to graduate school (!!)
• I signed up for my first marathon (!!)
• I planned my boyfriend’s trip to South Africa and have watched the countdown go from 97 to 33 days (!!)

Today is Thanksgiving, a uniquely American holiday. I am living thousands of miles away from my family and the traditions of Thanksgiving that I grew up with and endlessly adore.

It’s funny how Americans living abroad instinctively seek each other out in late November–they crave the company of other Americans, the taste of Turkey and mashed potatoes, sounds of football on TV and in the backyard. But the values of Thanksgiving are universal–being thankful for family, friends and health. Family, friends and health relate to each other in such important and interconnected ways, and nowhere is that more clear than in Durban, South Africa.

Take TB for example, which correlates highly with HIV infection. South Africa has a 70% HIV/TB co-infection rate. Both TB and HIV are closely related to your social network: how many sexual partners you have, whether you are using a condom, being faithful, what type of work environment you’re exposed to, and the list continues. Your health and well-being is then again intricately related to your friends and family and the support they provide you in your care and treatment. Whether you are willing to disclose your HIV status to your partner is a powerful indicator for your treatment success or failure and loss-to-follow-up. Friends, family, and health (and in the South African context, community as well) reinforce each other in positive and negative ways through a powerful feedback mechanism. Any response to TB or HIV must consider the social and behavioral factors** that drive the epidemic.

Tonight I will feast on local sweet potatoes and butternut squash (yes, there will be Turkey, but I am a vegetarian) in a truly South African Thanksgiving. When I look around the table, I will see my South African family, made up of beautiful faces I have come to love. We will carve new Thanksgiving memories and traditions that will live on in the Durban soil.

**For post food-coma reading, check out the Center for Global Development’s publication by Saugato Datta and Sendhil Mullainathan on the ways that behavioral economics can and should be used to inform better policy design.

Study: Take TB drugs to the patient

Last week I discussed South Africa’s exponential growth in TB incidence over the past two decades and hypothesized, with support from the literature mind you, that HIV is the confounding factor that has thrown South Africa so radically off-track.

Veloshnee Govender has a different, though not mutually exclusive, explanation. The UCT health economist identifies weaknesses in South Africa’s public health care system as a reason for the rise in TB incidence. A study** in South Africa that looked at barriers patients face in taking their TB treatment consistently identified taking treatment at a clinic as the key variable. According to The Guardian article on Govender’s presentation at the Strategies to Overcome Poverty & Inequalities conference,

Taking treatment at a clinic was the key variable that determined whether someone missed their daily dose. Patients who missed treatment at clinics said the reasons they did so included the cost of transport, their distance from facilities and the conflict between taking medication and meeting work and other domestic responsibilities.

These findings call for more research and pilot projects focused on patient-centered and community-based TB treatment delivery: to measure adherence, health outcomes, costs and cost-effectiveness. Perhaps the model of TB treatment delivery can and should move closer to diabetes and HIV/AIDS treatment delivery?

**The study is currently under review for publication.

The elusive quest for an AIDS vaccine

The elusive quest for an AIDS vaccine is the topic of a four-day conference hosted by the Global HIV Vaccine Enterprise that begins today in Boston. The annual conference comes at a very exciting time in the HIV prevention landscape, and makes the conversation all the more interesting.

The development a vaccine, while progressing, remains in the very distant future, for reasons that only a real scientist can articulate. There are some exciting and game-changing tools such as microbicides and other forms of pre-exposure prophylaxis on the horizon with the potential to dramatically alter the shape of the epidemic and change the gendered power dynamics that fuel the epidemic.

If you take a cold hard look at the statistics, the fact remains that despite enormous progress, for every person who is initiated onto lifesaving ART, two more people are infected with HIV. While countries like South Africa are making huge strides in bringing new people onto treatment, they still are struggling to keep pace with the rate of new infections and are missing a large portion of people in need of treatment. According to the World Health Statistics 2012 report, South Africa is reaching just 55% of people with advanced HIV infection with ART. This leads people to the conclusion that it will not be possible to treat our way out of the epidemic and makes the elusive quest for an AIDS vaccine all the more critical; until recently, many argued that a vaccine was the only tool that will ever “end AIDS”.

Myron Cohen threw a wrench into that line of reasoning this past year when he published findings from the HPTN052 study, which showed that treating people with HIV with ART reduces their sexual transmission of HIV by 96 percent. Is it possible, then, that we could treat our way out of the epidemic? Cohen’s findings lend additional weight to ongoing modeling studies examining how “test and treat”—immediately putting an HIV-infected individual on treatment, despite their eligibility (measured by CD4 count)—would alter the course of the epidemic. The reasoning? As more and more people are put on medication, the epidemic theoretically should fizzle out.

In a 2009 commentary in The Lancet, Geoffrey Garnett responded to the first notable modeling study that looked at the impact of test and treat on the epidemic. He addresses the multi-faceted questions related to treating our way out of the HIV pandemic: could we, would we, should we?:

When early treatment is considered as a prevention tool, success will require substantial resources and depend on a remarkable degree of acceptance and cooperation across populations. If we could eliminate HIV this way would we, given the will needed, and should we, given the conflict between utilitarianism and individualism inherent in this strategy? 

Pilot programs are now emerging, including one in San Francisco, under the assumption that this approach works. NPR’s Shots Blog wrote a great feature piece examining some of the controversy surrounding the “test and treat” approach, including the possibility of drug resistance development and high associated costs.

Cohen’s findings do not obviate the need for a vaccine. Rather, they complicate (in a good way!) the puzzle of options available to policymakers, ministries of health, donors and other key stakeholders involved in the global AIDS response. The question remains, how do we balance the resources devoted to the elusive quest for a vaccine, when worldwide, people are still living with HIV, and in need of treatment. These questions must be answered, but who has the authority to answer them?

To stayed up-to-date on the latest happenings of the conference, check out their website, and use the conference hashtag, #AIDSVax2012 on Twitter.

Washington Post talks about TB in India, but not in South Africa

The Washington Post’s Simon Denyer wrote a very important article about India’s great effort to treat and control tuberculosis, in the face of a growing threat of drug-resistant strains of the disease. The article was paired with a graph of TB incidence over the past 20 years. India, which is highlighted on the graph, has clearly done quite well against major odds–poverty, inequality, poor infrastructure. It has decreased TB incidence by 14% over 20 years, mandated case notifications and for all of this deserves praise, case studies and much more.

The article mistakenly fails to mention the outlier in the graph–South Africa’s TB incidence has increased by over 200% over the same 20 year period, while all other countries in the graph, including the “global trend line”, have decreased.

The confounding factor is HIV. While South Africa’s TB control program benefited from the introduction of directly observed treatment short course (DOTS) in the 1990s, the same way India’s did, South Africa’s growing HIV epidemic muted these gains and led to a sharp rise in TB case notifications. South Africa now faces a 70% HIV/TB co-infection rate (Karim et al. 2009) and TB is the leading cause of death among people living with AIDS.

This graph highlights the need to address TB and HIV concurrently and with an integrated response. Check out the recently released National Strategic Plan on HIV, STIs and TB for 2012 – 2016 to learn a bit more about how South Africa is addressing its HIV and TB epidemics.

Same gate, new country

After traversing four European cities in 13 days, I have arrived and settled into my new home in Durban. While I have traveled to Durban numerous times before, the visible and abject poverty never fails to unsettle me each time I return. The side of the highway from the airport is littered with tin-roof shacks that house entire families. And as I pull up to 8 Musgrave Avenue—my current spacious apartment—and make my way through two sets of wrought-iron security gates, I am painfully aware of my privilege. I have a sneaking suspicion that this feeling won’t go away anytime soon.

I first arrived at this same gate just over six years ago to volunteer at the Sinikithemba AIDS Clinic of McCord Hospital. That summer, I lost my heart and soul to the spirit of South Africa. I witnessed true strength and courage in the face of enormous challenges: devoted health workers motivated by their faith and commitment to caring for others; children orphaned by AIDS and infected through vertical transmission of HIV; patients, who in the face of great stigma, never give up the will to live; and communities of “Gogos”, the Zulu word for grandmother, caring for young children. Most importantly, I witnessed the transformation that successful HIV prevention and life-saving drugs make possible.

Six years later, significant strides have been made to decrease the rate of new infections and increase access to care and treatment in South Africa. This progress was made painstakingly clear in US Secretary of State Hillary Clinton’s visit to South Africa earlier this month, part of an eight-nation African visit. On her trip she discussed the PEPFAR transition, what Reuters described as “symbolic of Pretoria’s shift from being a pariah to a global player in fighting the disease.” Secretary Clinton commended President Zuma and Minister Motsoaledi for putting the policies and systems in place to get 1.7 million people on treatment.

Despite signs of progress, it’s important to not lose sight of the enduring unemployment, poverty, crime and TB, among many other factors, which compound South Africa’s HIV epidemic and hinder prevention, treatment and care efforts. These ongoing socioeconomic challenges are a critical component to South Africa’s holistic and comprehensive AIDS response.

As I arrive on the same steps as I did six years ago (and many times since then), I am keenly aware that I have returned to a very different country—economically, politically, socially and epidemiologically.

 

Introducing Global Health Beat

This morning I am flying to Durban, South Africa (well, by way of Europe, for 2 weeks!), to begin a 9-month Fulbright grant in Public Health. I will be conducting independent research on the costs, benefits and impacts of HIV treatment models in South Africa.

Some food for thought

South Africa’s complex history of apartheid has shaped a landscape of enduring socioeconomic inequality and a legacy of apartheid that will live on for decades. Nevertheless, South Africa has moved forward to create a unified, democratic, “rainbow nation.” South Africa is warm, vibrant and sophisticated, I place I will feel privileged to call home. Travel the beautiful Durban beaches, Cape Town rocky coastline and Drakensburg Mountains; read about the prolific South African-based scientific research being conducted.

Despite this extraordinary progress, HIV threatens the social fabric of the country, as well as its economic and political viability. South Africans have responded to this challenge and demonstrated their will to tackle the epidemic. AIDS activists, including members of Treatment Action Campaign and others, successfully lobbied for publicly provided AIDS treatment in the early 2000s and continue to campaign for HIV education and treatment literacy to reduce AIDS stigma. They have also played a vital role in challenging the system of HIV treatment delivery.

However, 12 years after the historic Durban AIDS conference and on the heels of the first conference to return to the United States in 22 years, and we still have not turned the tide on the epidemic. South Africa is currently burdened with the most number of people in the world living with HIV and is continually challenged to meet an incredibly high demand for treatment—both for individuals and public health (more on that later). Rhetoric is not the answer.

To add fuel to the fire, PEPFAR has recently begun transitioning from financial to technical support to South Africa. In an era of constrained resources and fiscal austerity, research on ways to optimize public health dollars spent and find additional system-wide efficiencies is particularly timely.

My research

For too long, South Africa’s health policy was not adequately aligned with the health workforce and infrastructure landscape—doctors are largely concentrated in the urban hospitals and in the private sector and are in short supply in rural, disadvantaged communities where nurses run most clinics. Until 2010, initiation and management of HIV treatment, which is called antiretroviral therapy (ART), was limited to doctors practicing at accredited sites. Although publicly provided ART is free, infrastructural and resource constraints imposed substantial indirect costs on patients, including transportation costs and lost income from missed days of work. Large public hospitals accrued long waiting lists for ART and patients got sick and died waiting for treatment.

Recognizing the lingering effects of apartheid, pilot projects emerged across the country to “decentralize” HIV services to primary heath clinics through nurse-provided treatment. The results were impressive. In a study of one program in Lusikisiki township in the Eastern Cape province, TAC and Médecins Sans Frontières (MSF) showed that for every health outcome—ART adherence, viral load, mortality, loss-to-follow-up—patients managed by nurses performed as well or better than patients managed by physicians. In light of the encouraging results from these pilot sites, South African national policy is catching up. This small body of research led to policy guidance in April 2010 recommending that nurses provide comprehensive HIV/AIDS services at the primary health clinic level.

Over two years have passed since this landmark policy change, and I want to understand the costs, benefits and impacts on the health care system, individuals and communities. My research will be based at CAPRISA (Centre for the AIDS Programme of Research in South Africa), a preeminent research institute, performing rigorous studies that are guiding the development of progressive interventions and policy. Quarraisha Abdool Karim, an absolute rock star in the global health field who co-directs CAPRISA with her husband Salim, will mentor me.

I hope to use this blog as a platform to discuss global health policy and research in South Africa and beyond as well as my experience as a Fulbright student. It will be most successful if it is interactive, so please leave comments or email me if you have suggestions (Jamie.alex.cohen@gmail.com).

Thanks for reading!