SPOTLIGHT

Volume 5 Issue 1 / Summer 2007 Focus: How the BHP Came to Be aybe it all started with Deeda Fast forward to June 1996. Maurice Tem- Consultant Physician, heading one of the M Blair, an early (and constant) sup- pelsman, now Chair of the HAI’s Interna- Medical Units at Princess Marina Hospital porter of the Harvard AIDS In- tional Advisory Council, was hosting a din- in Gaborone. As Essex remembers, Dr. stitute. She introduced Max Essex, Chair of ner at Washington’s celebrated Cosmos Joseph Makhema had already retired for HAI, to Maurice Tempelsman in the 1980s. Club. The dinner was in honor of President the night when he was roused by the Pres- Because of his business and personal in- Ketumile Masire of . Knowing of ident’s knock. Still wearing his bathrobe, terests in , Mr. Tempelsman’s knowl- the growing AIDS crisis in Botswana, Mr. Dr. Makhema joined the two men for a edge and contacts were essential in helping Tempelsman invited Max Essex to the din- discussion about the growing AIDS crisis. establish HAI’s research and prevention col- ner and introduced him to President Masire. At the end of the conversation, it was de- laborations in . Studies with a cohort The two spoke briefly. The President asked cided that Essex would travel to Botswana of commercial sex workers yielded the iden- Dr. Essex if he could meet with him the next as soon as his schedule allowed. tification of HIV-2 and evidence that it was morning. Essex, who had a class to teach at A few weeks later, in the summer of less virulent than HIV-1. Senegal has been Harvard the next day, said no, but that he 1996, Max Essex landed in Botswana for cited by the World Health Organization as could meet later that evening. the first time. He was met by Ria Madison, a major success story, having the lowest rate When the meal was over and the formal who worked for Maurice Tempelsman as of HIV/AIDS in sub-Saharan Africa. The goodbyes said, President Masire and Dr. Personnel Officer at Lazare Kaplan program continues to this day, under Dr. Essex went back to the President’s hotel Botswana, a polishing operation Phyllis Kanki, making it the longest suite. The President knocked on the door that employed several hundred people. prospective study of HIV in Africa. of his Personal Physician, who was also a Many of the employees were young women (continues on page 5)

The Players. Top row: Deeda Blair, Dr. Max Essex, Maurice Tempelsman, President Masire. Bottom row: Dr. Joseph Makhema, Ria Madison, Dr. Ibou Thior, President Mogae. VViieewwppooiinnttss An Interview with Dr. Max Essex demic in , we should do it The questions about how drug-resistant with the virus most representative of that variants develop and get transmitted among region, rather than accept what was done people to interfere with one program or an- for the West. other have not been addressed. If women We also made major progress in learning and infants are getting infected for the first how to prevent mother-to-child transmis- time with a drug-resistant variant, then the sion of HIV and we ran the first vaccine tri- standard chemoprophylaxis won’t work. We als in southern Africa. already know that if women and infants are getting chemoprophylaxis with one or two Spotlight: What else? drugs to block mother-to-infant transmis- sion, then the antiretroviral treatment that Essex: Building the Botswana-Harvard HIV they will need later may not work. Drug re- Reference Laboratory, the largest AIDS- sistance feeds off itself in different ways dedicated laboratory in Africa, was a major when you have a combination of chemo- accomplishment. prophylaxis and treatment going on in the Through the KITSO program, we same population at the same time.

Photograph by R. Feldman trained more than 5000 clinical AIDS Spotlight: How long do you think the col- workers, including doctors, nurses, mid- Drs. Max Essex and Joe Makhema laboration between HAI and Botswana wives, counselors, pharmacists and lab will continue? workers. Approximately 80-90% of all Dr. Max Essex is Chair of the Harvard School healthcare workers who serve AIDS patients Essex: I think it will continue for a long, of Public Health AIDS Initiative (HAI), the in Botswana have received KITSO training. Lasker Professor of Health Sciences, and Chair long time. I hope it will continue for an- of the Botswana–Harvard Partnership for other 20 years at least because many of the HIV Research and Education (BHP). As the “Botswana is an example of what problems we are now addressing need great attention. Harvard has experts in different BHP celebrates its 10th anniversary, Martha hopefully will occur in much of Henry, Editor of Spotlight, asked Dr. Essex to aspects of these problems. We are commit- reflect on past accomplishments and future the rest of Africa.” ted to helping the situation in Botswana. goals of the BHP. - Dr. Max Essex Botswana is an example of what hope- fully will occur in much of the rest of Africa. It’s the first place where a large program was Spotlight: What major accomplishments launched to cover most of the affected pop- were achieved during the first ten years of Spotlight: What are the future goals of the ulation of a country, and in some ways an the Botswana-Harvard Partnership? Botswana-Harvard Partnership? easier case because of its good government and economic resources, but it’s clearly an Essex: We treated the first AIDS patients Essex: We need to develop better prevention example of what has to happen in the rest of with antiretroviral drugs (ARVs) in approaches for adults at risk of HIV infec- Africa to control HIV/AIDS. Botswana. Bill Wester and Hermann Buss- tion. We need to do more with vaccines, mi- mann, who work at the BHP, were the first crobicides and other biological approaches to prevention. physicians to administer ARVs through the SPOTLIGHT is published by the government health system. The Minister of We need to determine whether the es- Harvard School of Public Health AIDS Initiative Health at the time, Joy Phumaphi, wanted tablished drug regimens will work as well in 651 Huntington Avenue, 6th Floor Boston, MA 02115 USA to demonstrate that lives could be saved the medium and long term in Botswana, es- Phone: 617-432-4400 pecially if drug-resistant HIV variants begin Fax: 617-432-4545 through three-drug combinations. This led Email: [email protected] to a government program that is by far the circulating in the population. Web: aids.harvard.edu largest in Africa, setting the example that a Chair: Max Essex Botswana’s situation is unique. Nowhere Executive Director: Richard Marlink country can treat a lot of their AIDS pa- else in the world has a significant fraction of tients if they really want to. PUBLICATIONS STAFF the population been involved in both ARV Editor: Martha Henry In our research work we showed that the treatment for AIDS and chemoprophylaxis Print Designer: Kim Morrisseau Contributors: Michelle Schaan, Lendsey Melton, virus in Botswana and southern Africa is to prevent transmission of HIV/AIDS from Patricia Burns, Bukamu Hulela, Ameliah Sanders, different. This taught us that when making mothers to infants. This affects the kinetics Christine Bussmann, Erika Fardig, Michael Roy a vaccine or designing drugs for the epi- of transmission.

2 How the BHP Came to Be (continued from front page) whose small hands enabled them to do the After hours of discussions, planning and Makhema, who was present at that first precise work of cutting and polishing dia- negotiations, the idea of a collaboration be- meeting between President Masire and Dr. monds. Later, young women as a group tween HAI and the Republic of Botswana Essex, is the current Project Director of the were found to have one of the highest inci- became a reality. In October of 1996, an of- BHP. One of his long-term goals is to see dences of HIV/AIDS in Botswana. ficial agreement was signed. more African senior scientists employed by the BHP. After hours of discussions, planning and negotiations, the idea of a col- Botswana elected a new president in laboration between HAI and the Republic of Botswana became a reality. 1998, His Excellency Festus Mogae, who continues his government’s tradition of strong leadership and support in the fight On that first trip, Essex made presenta- Dr. Ibou Thior, a researcher who had against AIDS. President Masire is now chair tions about his research and met with gov- played an important role in HAI’s work in of the National BHP Advisory Committee. ernment officials to discuss potential areas Senegal, was appointed as the first Project As President Mogae said at the time of of collaboration. Blood samples from HIV- Director. Ria Madison formally became the BHP’s 10th anniversary, “Through positive individuals were collected for Essex the Project Administrator, the first official close collaboration with the BHP clini- to bring back to Boston. employee of the Botswana-Harvard AIDS cians, the first public ARV therapy clinic When the samples were analyzed back in Institute Partnership for HIV Research was piloted in 2001. This pilot provided the lab, researchers discovered that the virus and Education (BHP). Doctors, nurses, many valuable lessons and later grew into in Botswana was different from the virus lab researchers and pharmacists soon Masa, the first public and nationwide ARV found in the U.S. and Western Europe. “As joined the project. therapy program in the region. It is en- soon as we knew that the rates of HIV in- Fast forward ten years to the present. couraging to know that as a result of this fection were high and that the virus was dif- Today the BHP employs 204 people, of program, many people who were on their ferent, which we didn’t know until then,” whom 163 are Batswana. HAI was renamed deathbeds are back on their feet and are said Essex, “we decided that it was important in 2004 and is now the Harvard School of productively engaged and providing for to set up a program and have a lab.” Public Health AIDS Initiative. Dr. Joseph themselves and their families.”

News & Events

Educating Southern African Politicians networked with scientists and Parliamentarians about clinicians. Members of Parliament, influen- tial leaders, and high-ranking government HIV/AIDS officials were provided with the knowledge The Conference on AIDS Action and and tools necessary to support and imple- Botswana: Lessons in Capacity Building ment successful national HIV/AIDS re- and Importance of Research took place in search programs. The conference detailed Gaborone, Botswana in late January. the latest HIV/AIDS research results and Under the auspices of The Southern emphasized the need for countries to par- African Development Community Parlia- ticipate in local HIV/AIDS research for their own benefit. mentary Forum (SADC) and the Botswana- velopment and implementation of pro- Harvard Partnership, in collaboration with grams for HIV/AIDS. Sessions covered the Delegates appreciated the opportunity the National Assembly of Botswana, the benefits and challenges of research per- provided by the Botswana-Harvard HIV conference was attended by delegates from formed in southern Africa, the ability of re- Reference Laboratory to share experiences, the 14 SADC countries. search to build scientific and medical ca- expertise, and best practices within south- The conference focused on basic scien- pacity, and suggestions of how to better ern Africa. The Bill and Melinda Gates tific information on HIV/AIDS with a view coordinate responses for combating Foundation provided major funding for towards facilitating policy formulation, de- HIV/AIDS in SADC countries. the conference.

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SPOTLIGHT

periences and suggestions for improvements. for suggestions and periences Lisa Flannery inspects a sedated lion on an excursion in the Kalahari Desert. Kalahari the in excursion an on lion sedated a inspects Flannery Lisa

ing in Gaborone will benefit from their ex- their from benefit will Gaborone in ing

Botswana. The next group of students arriv- students of group next The Botswana.

vard’s first undergraduate program in program undergraduate first vard’s

experimental subjects themselves in Har- in themselves subjects experimental

Lisa, Jamie and Amy were, in many ways, many in were, Amy and Jamie Lisa,

huge lion,” said Jamie. said lion,” huge

was sedated, so we have pictures with this with pictures have we so sedated, was

“They let us get out of the truck when he when truck the of out get us let “They

keep him from being shot by local farmers. local by shot being from him keep

workers darting a male lion to collar him to him collar to lion male a darting workers

in the bush they came across conservation across came they bush the in

as a high point of their semester. On a drive a On semester. their of point high a as

Khutse Game Reserve in the Kalahari desert Kalahari the in Reserve Game Khutse

All three students mention a trip to trip a mention students three All

Okavanga Delta. Delta. Okavanga

trips to Jwaneng Diamond Mine and the and Mine Diamond Jwaneng to trips

in the Harvard Class of 2005, arranged field arranged 2005, of Class Harvard the in

Hulela, a native of Botswana and graduate and Botswana of native a Hulela,

batse. The Program Coordinator, Bukamu Coordinator, Program The batse.

selves in Harvard’s first undergraduate program in Botswana. in program undergraduate first Harvard’s in selves nership in Mochudi, Molepolole, and Lo- and Molepolole, Mochudi, in nership

sociated with the Botswana-Harvard Part- Botswana-Harvard the with sociated Lisa, Jamie and Amy were, in many ways, experimental subjects them- subjects experimental ways, many in were, Amy and Jamie Lisa,

The three students also visited clinics as- clinics visited also students three The

rural lab expansion initiative. initiative. expansion lab rural came here. My U.B. friends were excited to excited were friends U.B. My here. came everyone I pass by.” pass I everyone

to work with the Clinton Foundation on a on Foundation Clinton the with work to said Amy, “but it was still a surprise when I when surprise a still was it “but Amy, said street and greeting ‘Dumela!’ to almost to ‘Dumela!’ greeting and street

Amy will remain in Gaborone this summer this Gaborone in remain will Amy Botswana are incredibly nice and friendly,” and nice incredibly are Botswana culture. I will really miss walking down the down walking miss really will I culture.

research, policy, healthcare, or advocacy.” or healthcare, policy, research, “I have always heard that people from people that heard always have “I teach me about their traditional foods and foods traditional their about me teach

(continued from page 3) page from (continued Semester Abroad: First Harvard Undergraduates in Botswana in Undergraduates Harvard First Abroad: Semester What’s New: Semester Abroad: First Harvard Undergraduates in Botswana This spring, three adventurous young women were the first Harvard undergradu- ates to study abroad in Botswana. The three biology majors lived on the campus of the University of Botswana and took classes there. The greater part of their education took place at the Botswana-Harvard Refer- ence Laboratory. To learn standard HIV diagnostic tech- niques, the students spent the first weeks of the semester rotating through the basic lab- oratories—the CD4 cell count lab, the viral load lab, the serology lab and the PCR lab. For the rest of the term, the students worked on independent research projects. Jamie Greenwald is a junior from St. Louis. Though—or perhaps because—her father is a physician, she grew up thinking BHP Viral Load Lab. From left: Monica Phiri, Amy Wu, Jamie Greenwald, Lisa Flannery, she would be anything but a doctor. She Fredah Mulenga. Kneeling: Pong Phillimon Sebogodi. changed her mind in her sophomore year at Harvard and switched to pre-med. and getting the chance to see how it works the summer of 2006 she returned to Beijing from the inside was one I could not pass up.” to work as an intern in the HIV/AIDS Di- Jamie’s research project evaluated a sero- vision of the China Center for Disease Con- logic diagnostic test to distinguish between Her work in the lab concerned HIV in- trol. After her research experience in China early and chronic of HIV. A relat- fection of the central nervous system. She and involvement with the Harvard AIDS ed test was developed using HIV-1 subtype was interested in HIV/AIDS-related de- Coalition, she wanted to visit a place where B populations in the U.S. She is trying to mentia rates amongst viral subtypes. For HIV has a major impact on the population develop a test for subtype C, the HIV sub- subtype B, the predominant subtype found and see firsthand what was happening. type in Botswana. Jamie also played soccer in the U.S., rates are known to be high, but “This research abroad program to Botswana with the University of Botswana girls’ team. less is known about subtype C, found in Botswana and most of southern Africa. She was the opportunity I had been waiting for,” wants to know if a possible difference in said Amy. “I thought it might be a little out rates is influenced by the difficulty in diag- She began an HIV immunology project of my comfort zone, but I wanted nosing dementia in the presence of more to see whether certain genes related to im- pressing opportunistic with sub- mune responsiveness are associated with to experience something completely type C, or if it is based in the virus’s inabil- viral suppression in AIDS patients on drug different from how and where I ity to actually infect/affect the cells of the therapy. She is studying samples from pa- had been living.” central nervous system. tients in a large treatment trial that involves four different drug combinations. She ana- - Lisa Flannery “After spending time in Botswana,” said Lisa, “I feel like I will be more willing to re- lyzes samples from patients who have failed turn to Africa later in my life. It has opened their first line of drug therapy, as well as pa- tients who were the best responders, having When asked why she was studying in up new possibilities for me when I think successfully suppressed their viral load for at Botswana, Lisa Flannery, a junior from Ster- about living and working abroad and has least two years after HAART (Highly Active ling, Massachusetts, replied, “I thought it served as a gateway to taking chances that I Antiretroviral Therapy) initiation. might be a little out of my comfort zone, but wouldn’t have even considered before.” This I wanted to experience something complete- summer, Lisa will continue her research at “My experience in Botswana has only ly different from how and where I had been the BHP on the molecular aspects of cell strengthened my plans to work in interna- living. I also think that it is a phenomenal tropism with the hopes of developing a sen- tional health and medicine in the future,” environment in which to study the ior thesis project. said Amy. “Coming here has made me real- HIV/AIDS epidemic. It is a country that has Though born in Beijing, sophomore ize just how many ways are possible to con- dealt remarkably well with the current issues Amy Wu grew up in Corvallis, Oregon. In tribute to this field, whether through basic (continues on back page) 3 Research & Intervention Programs

Using Nevirapine More Effectively A study published in the January 11th issue during labor is frequently all that is accessi- of The New England Journal of Medicine ble to pregnant women in resource-limited found that for mothers given a single dose of settings where more expensive treatments nevirapine during labor to reduce the chance multi-drug treatments are not available. of HIV transmission to their children, wait- The team of researchers led by Shahin ing six months after birth before taking a Lockman, Assistant Professor in the nevirapine-based antiretroviral treatment Department of Immunology and Infectious dramatically reduced their chances of devel- Diseases at Harvard School of Public Health oping resistance to nevirapine. and at Brigham and Women’s Hospital, and The use of single-dose nevirapine has Max Essex, Chair of the Harvard AIDS successfully reduced mother-to-infant trans- Initiative, followed 218 HIV-infected Photograph by Graham Ramsay mission of HIV, but with a significant draw- women who received a single dose of nevi- Drs. Max Essex and Shahin Lockman back. Research has shown that 20 to 69 per- rapine during labor, as well as a short treat- cent of women who take a single dose of ment of anti-retroviral drugs during preg- who waited, just 12 percent had the treat- nevirapine during labor subsequently devel- nancy. Sixty women started a nevirapine- ment fail. op resistance to the drug—a situation that based treatment within six months of giving Dr. Lockman speculated the better results may undermine the patients’ ability to birth, while the remaining 158 women were because the amount of nevirapine- respond later to nevirapine-containing anti- started on the drugs six months afterward. resistant HIV in the body decreases as time retroviral therapy. And nevirapine, or a The outcomes were dramatically differ- passes from the single-dose exposure to nevi- closely related drug that shares the same ent. Of those women taking the drugs rapine during labor. The findings will affect resistance, is used for almost all AIDS treat- soon after giving birth, 41 percent experi- treatment approaches during pregnancy for ment in Africa. A single dose of nevirapine enced treatment failure. Of those women millions of HIV-infected mothers.

KITSO Update

In 2001 the Government of Botswana, in professionals to implement Botswana’s quickly to new research information and an initiative unprecedented in Africa, ambitious goals in a sustainable, standard- changing national public health guidelines. announced that it would provide antiretro- ized national ARV treatment program. The central course in KITSO’s training viral (ARV) therapy free of charge to all In 2002 the first four ARV treatment program is AIDS Clinical Care qualifying patients. At that time, few sites were opened. Today 32 main treat- Fundamentals, which includes lectures, physicians in Botswana had experience pre- ment sites are operating throughout the case study discussions, practice exercises for scribing ARV drugs. country. From its inception, KITSO-BHP pediatric ARV dosing, question and answer That same year the Botswana Ministry has carefully incorporated monitoring and sessions, and a final exam. Other courses of Health, in collaboration with the evaluation methods to assess the quality include Medication Adherence Botswana-Harvard AIDS Institute and integrity of the program’s structure, Counseling, and Advanced HIV/AIDS Partnership, established the KITSO AIDS content and implementation. This commit- Care and Treatment. Training Program. KITSO was developed ment to constant evaluation has helped to KITSO’s training of over 5,000 health to train doctors, nurses and other health create a program that is capable of adapting professionals has supported Botswana’s national program, which now provides How You Can Help... ARV therapy to over 80,000 patients and serves as a model for HIV/AIDS care and treatment throughout Africa. The research, training and education To make your online donation to KITSO-BHP’s training efforts are made efforts of the Harvard School of HAI, please visit the Giving Page of possible through the support of the African Public Health AIDS Initiative depend Harvard School of Public Health at Comprehensive HIV/AIDS Partnerships upon your support. Your contribu- http://www.hsph.harvard.edu/give/ (ACHAP), a collaboration between the tion will make a difference. Government of Botswana, the Bill and Contributions are tax deductible. Melinda Gates Foundation, and The Merck Company Foundation/Merck & Co., Inc.

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