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The Blood in the Freezer Botswana Leads in HIV Treatment

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The Blood in the Freezer Botswana Leads in HIV Treatment HARVARD T.H. CHAN SCHOOL OF PUBLIC HEALTH AIDS INITIATIVE spotlight spring 2016 Botswana Leads in HIV Treatment Billions of dollars are spent every year on HIV/AIDS treatment programs. But how well are they working? In the African country of Botswana, where 25% of adults (aged 16-49) are HIV positive, the answer is extremely well. In a recent paper in The Lancet HIV, researchers showed that Botswana is close to reaching the ambitious UNAIDS 90-90-90 goals. Photo by Dominic Chavez In 2014, UNAIDS proposed new testing and treatment targets directed towards ending the AIDS epidemic: by the year 2020, 90% The Blood in the Freezer of all HIV-infected people would know their HIV status; 90% of those diagnosed with HIV would One tiny vial of blood contains a re- at the BHP headquarters in Gaborone, be on antiretroviral therapy (ART); markable amount of genetic informa- Botswana. Most are blood samples and 90% of those on ART would tion about both the person from whom collected from tens of thousands of have a suppressed viral load (very it was drawn and infectious agents like patients who have participated in BHP low levels of HIV in their blood). A HIV circulating at the time of the needle clinical trials over the past 20 years. growing body of research shows prick. Because HIV mutates so quickly, Besides blood samples, the biorepository that providing ART to people living having access to lots of samples to study also includes specimens of hair, tissue, with HIV, besides being good for is a valuable resource. “It’s a diamond for breast milk, and other bodily secretions. their own health, lessens their science,” said Sikhulile Moyo, Labora- tory Manager at the Botswana Harvard The samples were collected for one chance of transmitting HIV to reason: to end the HIV/AIDS epidemic. others. AIDS Institute Partnership (BHP). He was referring to the blood samples Botswana has one of the highest rates Researchers Surprised banked in the BHP freezers. “Specimens of HIV in the world with about 25% would be a more accurate term,” he cor- of adults infected. When the BHP The data for the paper was taken rected, “biological samples freely given was established in 1996, hospitals from the Botswana Combination to be processed for diagnosis or disease were overcrowded with very sick Prevention Project (BCPP), an monitoring.” AIDS patients. There was no available on-going clinical trial designed treatment. Death, often agonizing, was to measure how well a package Over 1.5 million specimens are stored the expected outcome. (continues on page 2) (continues on page 3) Botswana Leads in HIV Treatment (continued from page 1) come close to Botswana’s coverage. Why has a middle-income African nation with a high HIV prevalence been able to create a more successful HIV treatment program than richer Western countries? “Remember that the set-up of the Botswana national health system is that 95% of all people are within five- kilometer access of a healthcare facility,” said Dr. Tendani Gaolathe, BCPP Project Director and first author on The Lancet HIV paper. “In Botswana, there’s been dedicated governmental action at the highest level to take responsibility for the epidemic. Healthcare, including antiretroviral treatment, is free for all citizens in the country,” said Essex. “The government From left: Lyorlumun Uhaa, UNICEF; Michel Sidibé, UNAIDS; Max Essex, Harvard AIDS Initiative; Pride Chigwedere, UNAIDS, at a meeting for African Leaders in Addis Ababa. Photo by Aida Muluneh has also sought international cooperation with us and others to of HIV prevention measures receiving ART who had a verifiable viral get the latest advice and the best reduces the rate of new infections. load test, 2517 (96%) had a suppressed understanding of what can be done.” Researchers at the Harvard AIDS HIV viral load. Initiative (HAI) and their colleagues Attainable & Meaningful For a national HIV treatment program at the Botswana Harvard AIDS to achieve viral suppression in 96% When the UNAIDS 90-90-90 targets Institute Partnership (BHP) are of patients on ARVs is considered were first announced, many in the responsible for the design exceptional. The high rate was a international community questioned and evaluation of the project. surprise, even to the researchers. whether they were achievable, Adults aged 16 especially by 2020 in resource- strapped countries with a high burden to 64 were re- This is significant work as it provides cruited from a of HIV. The findings from Botswana random sample further evidence that UNAIDS 90-90-90 indicate that the targets are attainable. of 20% of house- treatment targets are both realistic and “This is significant work as it provides holds in each achievable. further evidence that UNAIDS 90-90-90 of 30 Botswana treatment targets are both realistic and villages.Partici- Michel Sidibé, UNAIDS Executive Director achievable,” said UNAIDS Executive pants answered Director Michel Sidibé. questionnaires and were tested for HIV. “I thought it would be very good, by The data collected from the BCPP is which I would have said 90% or so. I “The targets are definitely more than among the most complete population- was surprised that it was as high as bureaucratic goal posts,” said Essex. level estimates of HIV available for 96%,” said Max Essex, Senior Principal “It’s clear that rates of new infections southern Africa, the epicenter of the Investigator of the BCPP and Chair of will go down dramatically as a result of AIDS epidemic. both HAI and BHP. reaching these goals.” Of the 12,610 participants surveyed, Why Botswana? 3596 (29%) were infected with HIV. Of those individuals, 2995 (83%) already According to a recent analysis of HIV The BCPP is funded by the President’s knew their HIV status. Among those treatment programs, no country has Emergency Plan for AIDS Relief who knew their status, 2617 (87%) were yet met the overall UNAIDS goals. Very (PEPFAR), through the Centers for receiving ART. Of the 2609 individuals few countries, including the U.S., have Disease Control and Prevention. 2 The Blood in the Freezer (continued from page 1) In 2002, Botswana’s Ministry of Health storing over a million samples becomes with a temperature monitoring system launched a national antiretroviral an issue. The BHP currently houses 70 connected to the internet, a mobile program to provide free AIDS drugs freezers at headquarters. The majority phone network, and a security company. to eligible citizens. The BHP played an of samples are kept in big freezers at important advisory role in planning, close to -80°C, but viable cells used for Freezers are expected to last ten years implementing, and monitoring the immunological studies are stored in or longer, but disasters happen. If a program. BHP clinical trials evaluated liquid nitrogen tanks at -140°C. freezer breaks down in the middle of the different drug regimens. Samples in night, Moyo is awakened by a text and the freezers come from those trials and Each big freezer costs about $25,000, a phone call. If he’s not available, the others that followed. Today, with proper weighs 805 pounds, and can hold 24 security company works its way down a treatment, people living with HIV can steel racks of 2000 separate vials for a list of key staff contacts, with Dr. Joseph expect to live a nearly normal life. total of 48,000 samples. Each sample Makhema, CEO of the BHP, last on the is bar-coded with a unique identifier. list. Whoever responds must quickly “What we have in the freezers is a his- Descriptive information such as date and move samples to a reserve freezer the tory of the AIDS epidemic in Bo- time of collection, study identifier, and BHP is required to have available at all tswana,” said Moyo. There are blood specimen type is stored in an electronic times. When the power fails, a back-up samples from across the spectrum of inventory system that links to non- generator keeps the freezers cold. the epidemic: from studies in the 1990s confidential demographics such as the before the national program, to studies age and sex of the participant. Samples Shared Access of treatment-naïve patients beginning are anonymized, meaning personal drug regimens in the 2000s, to current information such as name and address The stored samples are useful not only for studies of sero-converters—people re- has been removed. the BHP, but for the global HIV/AIDS cently infected with HIV. research community. When a study Because the samples are irreplaceable, participant signs a consent form allowing Freezers efforts are taken to ensure their safety the use of his or her sample for a specific Though each sample is small in size, and integrity. The freezers are equipped research study, the participant has the BHP lab technicians store cell samples in liquid nitrogen tanks at -140°C. Photo by Dominic Chavez 3 option to sign a second consent form that Britain, the U.S. and Canada. others to help us chew the pie.” allows the unused portion of the sample “BHP acts as the custodian,” said “The samples are valuable because they to be used for future HIV research. Moyo. “This resource is open to other represent a unique population of HIV- scientists as long as their research has infected people at different stages of In addition to BHP scientists and been approved.” Though scientists the epidemic,” said Max Essex, Chair students, researchers from other have a reputation for being highly of the Harvard AIDS Initiative and the countries can request samples for their competitive, AIDS researchers have a Botswana Harvard Partnership. “These HIV studies.
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