Fighting AIDS now and in the future

In the heart of the South African AIDS epidemic, at a medical school named for the nation’s legendary anti-apartheid leader, a fight against a different sort of oppression is being waged.

Unlike apartheid, the oppression comes not from unjust laws and men wielding guns. Rather, it is the work of the HIV virus, which has devastated this nation of 44 million even as the country has stretched its newly democratic wings since apartheid’s end in 1994.

During a decade when its poorest citizens should have enjoyed newfound freedoms and economic opportunity, HIV and the AIDS it causes cast an increasingly lengthy shadow over South Africa.

Today, roughly one in five South Africans age 15 to 49 is thought to be infected with HIV. Among certain populations the infection rate is much higher, with 60 percent of pregnant women at antenatal clinics in some parts of the impoverished KwaZulu-Natal province testing positive for the virus. The disease killed 320,000 in 2005, and life expectancy was just 48 in 2004. Left in the disease’s wake are an estimated 1.2 million children who’ve lost one or both parents to AIDS.

In the fight against AIDS, Harvard Medical School’s Division of AIDS and the Partners AIDS Research Center — a cooperative effort of Harvard-affiliated Massachusetts General Hospital and Brigham and Women’s Hospital — have joined forces with the University of KwaZulu-Natal’s Nelson R. Mandela School of Medicine to fill critical voids in both knowledge and manpower that are hampering the search for new treatments and, ultimately, a vaccine.

The resulting program, called the HIV Pathogenesis Program (HPP), is based at a research building that opened in 2003 at Nelson R. Mandela School of Medicine in Durban. The building, called the Doris Duke Medical Research Institute, was constructed under the leadership of Harvard Professor of Medicine Bruce Walker in collaboration with faculty leaders at Nelson R. Mandela School of Medicine and with funding from the Doris Duke Charitable Foundation.

The work is just one example of an enormous and diverse body of global health research, education, and training across Harvard. Researchers toil away to understand everything from the genetic code of the malaria parasite to the impact of air quality on human health, instructors impart the latest in medical knowledge to top students, and colleagues at Harvard’s many affiliated institutions not only teach and conduct research of their own, they also put that knowledge into action to improve people’s lives — in Boston and around the globe.

Walker first became involved in South Africa in 1999, but it was the financial commitment from the Doris Duke Charitable Foundation that really allowed programs to expand. When the HIV Pathogenesis Program opened at the Nelson R. Mandela School of Medicine, it began to fill a glaring lack of AIDS-related research capacity in South Africa and became a training ground for African scientists interested in working on the epidemic.

The program is in the midst of several research studies that examine the disease’s long-term chronic phase, its short-lived acute phase right after infection, transmission from mother to child, and the role that other sexually transmitted diseases play in transmission of HIV.

HPP Lab Manager Karen Bishop said enrolling people for the acute study is particularly challenging, because researchers have to catch people in the disease’s early stage, sometimes even before the subjects know they’ve been infected. The shock of learning one is infected with HIV is sometimes too much for patients, and they are unwilling to enter the study. They often come around months later when they’ve adjusted to the news, but then it’s too late, Bishop said.

“It’s quite shocking, telling people they’re infected. It’s a lot to deal with. It takes time, but we don’t have time,” she added.

Associated programs have been started at area hospitals, including McCord Hospital and St. Mary’s Hospital, where programs examine how to treat patients the most cost-effectively and through which thousands have gained access to counseling and antiretroviral drug therapy.

Walker emphasized that though faculty at Harvard Medical School and its affiliated hospitals have played a guiding role in starting up the various programs, much of the work is being done by South African doctors, nurses, and scientists.

“We’ve had a big impact,” Walker said. “It’s our South African collaborators doing all the heavy lifting. … We did not go to South Africa to plant a Harvard plan; we want to build sustainable local programs with local leadership.”

Thumbi Ndung’u, an associate professor at Nelson R. Mandela School of Medicine, visiting associate professor at Harvard Medical School, and scientific director of HPP, is one of those providing African leadership in HPP’s work.

Ndung’u grew up in a coffee-growing region north of Nairobi, Kenya, and came to South Africa by way of Harvard, where he received a doctorate in 2001.

Ndung’u said the lab’s main research goal is to come up with a vaccine against HIV. A vaccine, he said, would do the most good for the most people, as the drugs used today to treat the disease face problems of toxicity, causing side effects and logistical problems that interfere with distribution. Ndung’u said he’s also committed to fostering the careers of a new generation of African scientists.

“I’m an African and I’d like to make an impact within the continent, whether playing a role stopping infectious diseases or helping increase capacity by training African scientists,” he said.

Helping increase the numbers of African scientists would ease what Ndung’u said is the lab’s biggest challenge: a manpower shortage. South Africa, like many other developing countries, does not have a strong research tradition, so skilled scientists and technicians are in short supply.

“We don’t have a long tradition of basic science research,” Ndung’u said. “Getting a critical mass of people who can get excited about the research has been a challenge.”

In February 2008, 18 people worked at the lab, according to Bishop, including two postdoctoral fellows, three doctoral students, and two master’s degree students. In addition to the research into HIV’s function, the lab also processes samples from the patients involved in its associated programs and clinical trials, providing measures of immune system function, such as CD4 counts and viral load measurements.

Ndung’u said the clinical side of the program, where patients are seen and treated at area hospitals, has been successful and gratifying.

“We see children who are HIV-infected and treat them. We see the results immediately,” Ndung’u said.

Ndung’u said he enjoys the collaboration with top researchers at Harvard and also values the ability to send promising students and young scientists to Boston for further training.

“We are building capacity, but it takes time,” Ndung’u said.