Our work is hardly done

Bill Snyder
Published: July, 2006

In late 2001, a team of U.S. and Zambian investigators launched an ambitious program to prevent HIV-positive women from infecting their babies.

Within two years, HIV counseling and testing was being provided in public delivery clinics throughout the Zambian capital, Lusaka.

Thousands of HIV-infected pregnant women were given tablets of nevirapine, a drug that can dramatically reduce mother-to-child transmission of the virus when taken by the woman during delivery, and when given soon after birth to the baby.

Yet when the researchers examined the results of their labors, they had an unfortunate surprise: only 30 percent of the women had actually taken their pills.

A gravel maker and his wife use hammers to crush stone near Lusaka, the Zambian capital.
Photo courtesy of Sten Vermund, M.D., Ph.D.
“We were horrified,” says Sten Vermund, M.D., Ph.D., who now directs the Institute for Global Health at Vanderbilt University School of Medicine. “It’s not so easy to implement this in some of the world’s poorest countries, even with the advantage of free drugs and relatively simple interventions.”

At the time, Vermund was chair of Epidemiology and director of the John J. Sparkman Center for International Public Health Education at the University of Alabama at Birmingham (UAB).

A former chief of the AIDS Vaccine Trials and Epidemiology Branch at the National Institute of Allergy and Infectious Diseases, he had studied the spread and treatment of HIV and other sexually transmitted diseases (STDs) all over the world.

In 2000, Vermund and fellow UAB faculty member Jeffrey Stringer, M.D., helped found—with UAB support—the Centre for Infectious Disease Research in Zambia (CIDRZ) to facilitate AIDS research in collaboration with Zambian public health officials led by Moses Sinkala, M.D.

The effort was supported by a training grant from the Fogarty International Center of the National Institutes of Health and by research funding from the Elizabeth Glaser Pediatric AIDS Foundation.

CIDRZ also had recently received a $4 million grant from the Bill & Melinda Gates Foundation to set up a paperless reference system in the clinics. “It was fundamentally an effort to jump from the 19th Century to the 21st Century—just skip the 20th Century,” Vermund explains.

Yet technology was not enough. When the researchers examined what had gone wrong, they found gaps at every step along the “prevention cascade.”

In some cases, pregnant women weren’t offered nevirapine during their clinic visit. Or they forgot to take the drug when they went into labor. Or they gave their pill to a sick relative.

By attending to each step, the researchers have managed to increase nevirapine coverage to 60 percent. “Still, 40 percent of women are falling through the cracks,” Vermund says. “So our work is hardly done.”

With support from several U.S. and international aid agencies, and especially the $20 million in grants received in 2004 from the President’s Emergency Plan for AIDS Relief (PEPFAR), the Zambian program has been able to dramatically extend its reach.

Stringer and Isaac Zulu, M.D., of the University Teaching Hospital in Lusaka, are the co-principal investigators for the grants.

“PEPFAR has transformed our operation in Zambia,” Vermund says. “We have got over 17,000 persons on ART (anti-retroviral therapy) in the past two years, and we have over 30,000 people in care. That was done because we got the money.”

In 2006 Vermund turned his attention to Mozambique which, like its South African neighbors, has a numbingly high rate of AIDS.

The Vanderbilt-led effort, which has just garnered a PEPFAR grant, will initiate ART and HIV care in six small towns in rural Zambezia Province. Team members in 2006 included:

Maria de Fatima Lima, Ph.D., Dean, and Christine Minja-Trupin, Ph.D., School of Graduate Studies and Research, Meharry Medical College, Nashville;

J. Gary Linn, Ph.D., professor of Nursing in the Center for Health Research, Tennessee State University, Nashville;

Paula Schuman, M.D., MPH, director of the HIV/AIDS Center at Virginia Commonwealth University, Richmond;

Mauro Schechter, M.D., Ph.D., professor and director of AIDS Programs at the Universidade Federal do Rio de Janeiro; and Adele Schwartz Benzaken, M.D., of the Alfredo da Matta Foundation in Manaus, Brazil.

Brazil shares Mozambique’s national language—Portuguese.

The program won’t just be about AIDS. “You cannot provide HIV care without broad-based upgrading of the primary health system,” Vermund says. “HIV care settings with excellent laboratories don’t make sense if the adjacent clinic is bereft of water, sanitation, electricity…

“So we’re going be in there with HIV and TB (tuberculosis) and STDs and primary health care and vaccinations and upgrading of maternity services and chronic care services for kids.”

PEPFAR won’t pay for that kind of infrastructure development. Nor does it cover research to determine the most cost-effective way to provide AIDS care and treatment.

According to a recent Government Accountability Office report, its emphasis on abstinence-until-marriage programs has made it difficult for countries to “respond to local needs, local epidemiology and distinctive social and cultural patterns.” An Institute of Medicine evaluation of the program’s effectiveness is underway.

Still, Vermund argues, “it’s the best thing the Bush administration has done… It’s remarkable how well it’s working.”

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