"In med school, I found the bulk of the patients I encountered suffered from infectious diseases that were largely preventable," Aina says. "Before long, I realized I would be much more useful for the country if I worked on infectious disease prevention. After a clinical internship, I worked briefly in primary health care, when I came to appreciate the magnitude of the HIV/AIDS problem in the country."
Aina is one of the first postdoctoral fellows in the School's AIDS Prevention Initiative in Nigeria (APIN), which began in 2000 with a $25 million grant from the Bill and Melinda Gates Foundation, the largest in the School's history. APIN is modeled on the School's 17-year effort in Senegal, which has helped keep that nations HIV infection rate among the lowest in Africa. Its training program, in which fellows like Aina earn advanced degrees at the School, is designed to produce the next generation of leaders in fighting Nigeria's AIDS epidemic. In its three years, APIN has also launched dozens of projects to prevent HIV infection in high-risk populations, prevent mother-to-child transmission of the virus, promote AIDS awareness, and monitor HIV and other sexually transmitted infections.
A guiding principle of the initiative is to mobilize and strengthen local resources, expertise, and infrastructure, so Harvard faculty and staff work closely with Nigerian institutions including government, universities, and community organizations. APIN has offices in Boston and the Nigerian cities of Ibadan and Abuja. "All our programs are basically run by Nigerians, and we collaborate and provide training and research support where necessary," says APIN Director Phyllis Kanki, a professor in the School's Department of Immunology and Infectious Diseases. It will be crucial for their efforts in three target states to spread to neighboring areas, she adds, because the Gates grant, while generous, cannot pay for prevention projects throughout all the country's 36 states.
Nigeria's transition in 1999 from military dictatorship to democracy drove the country's first serious attempts to control the HIV epidemic. "When we started there in 2000, the country had really made some strides," Kanki says. President [Olusegun] Obasanjo created a presidential commission and a national action committee on AIDS." Along with the federal health ministry, the action committee advises APIN on where its resources can best be targeted. Nationwide, the infection rate is around 6 percent--lower than many African countries, but already at what epidemiologists believe is a critical threshold. In some countries, when HIV gained a foothold in about 5 percent of the population, rates quickly ballooned to nearly 40 percent. With 120 million people in Nigeria--Africa's most populous country with about 20 percent of sub-Saharan Africans--"not to intervene there would be a catastrophe for the continent," adds Kanki.
Three of Nigeria's 36 states--Lagos, Oyo, and Plateau--host APIN's first projects. Their selection was guided by geopolitical diversity and the location of medical schools and hospitals there. "Partnering with other academic institutions not only helps build research bases and infrastructure for sustained efforts, but also takes advantage of Harvard's ability to provide training to health and laboratory professionals," Kanki says. This year the initiative will move into two more states, including Borno in the north. "We need to have multiple intervention strategies depending on the population and the epidemiology of a particular region," Kanki notes.
APIN administers three of the eight centers the government has set up to prevent mother-to-infant transmission. Mothers are given the drug nevirapine at delivery, then provided with infant formula so they can avoid transmission through breast milk. The program began in 2002, but to date only the APIN-supported sites are fully functional.
Another crucial goal is to control the spread of HIV into the general population from "bridge populations"--such as uniformed servicemen, university students, and truck drivers, whose mobility and lifestyle put them at high risk. Interventions are often targeted at venues where the virus is likely to be transmitted sexually from person to person but where, with will and luck, life-saving information and condoms might be passed along instead. In the former capital of Lagos, for example, are vast "motor parks" where people--in one park, five million of them--live in shacks next to their cars and where merchants and service providers set up stands. There, with funding from APIN, a non-governmental organization called STOPAIDS has set up shop to provide counseling, condoms, and referrals for treatment of sexually transmitted diseases.
Complementing this community outreach work is APIN's laboratory work, led by people like clinical microbiologist Jean-Louis Sankale. A native of Senegal, Sankale trained in virology at the School. As a senior research scientist with APIN, he shuttles between Boston and Nigeria, where he oversees two modern HIV testing and research laboratories that he helped design and build at the universities of Jos and Ibadan, and runs training sessions in collaboration with the Nigerian health ministry.
The Jos laboratory, built from scratch and housed in a once-abandoned campus building, opened to great fanfare in December 2002. With equipment to quickly and accurately test patients' viral load and CD4 cell counts--including a $30,000 flow cytometer donated by the cell phone company MTN Nigeria Ltd.--these facilities represent a major step up in Nigeria's HIV lab capabilities. These tests are considered crucial for determining when to start antiretroviral (ARV) treatment and to monitor treatment effects. Yet many treatment centers in Nigeria do not have the necessary equipment, and those that do typically charge high fees that most patients cannot afford, says Sankale. The new CyFlow machines reduce the cost of a CD4 test from $25 to $2, and will benefit not only ARV treatment but also mother-to-infant prevention and surveillance projects to assess HIV levels in subpopulations in Plateau State.
"A good thing about Nigeria is there are a lot of highly trained people in the medical sciences, so it's very easy to introduce new techniques to lab workers, with only some specific training needed," says Sankale.
For Aina, the Nigerian physician, "The work I am doing now is extremely exciting. It's a big relief to be back home and able to apply the valuable tools and innovative strategies I acquired at Harvard in combating the epidemic in my own country. Nothing gives satisfaction like being able to positively impact your own peoples' lives directly." His team is conducting community-based research into the biological, behavioral, and sociocultural factors associated with HIV infection among various subpopulations.
To illustrate the rewards of his work, Aina offers an anecdote: "A few days ago, I had a long talk with the wife of an HIV-positive man. He had been aware of his seropositivity for four years but never informed his wife for fear of stigmatization and even a divorce. During that time, he and his wife had a daughter, now two years old. After counseling him and explaining the benefits of his wife knowing her status, he agreed to inform her, and we offered her voluntary counseling and testing. She came out negative, and we are counseling her and her husband on ways of keeping their marriage and her staying negative."
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