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Temporary Miracle

The Temporary Miracle Page 2

ARVs are potent drugs, and the patient's health must be followed closely for dangerous side effects. "If they don't die of the disease, they might die of these drugs," says Taha Taha, a Bloomberg School professor of Epidemiology who has led a major HIV research program in Blantyre, Malawi, since 1992. "These drugs, you can't use them like 10 tablets of chloroquine for malaria. We can't use these drugs indiscriminately. These drugs require discipline."

Patients must take anywhere from one to three pills twice a day. In the first few weeks of ARV therapy, they often feel worse before getting better. Their blood must be tested regularly to monitor their immunity and the effectiveness of the drugs. "A CD4 test costs at least $15. Even if you use only one of these a year, we're still talking about more than what the ministry of health can afford," he says. In Malawi, only about 2,000 people are on ARV treatment despite an adult HIV prevalence rate of 16 percent, says Taha, MBBS, PhD '92, MPH.

A paucity of trained health workers also hinders attempts to administer nationwide programs. In many African countries, the ranks of physicians, nurses, laboratory technologists and other health workers have been ravaged by the AIDS epidemic and further thinned by the "brain drain" to the West. Malawi, for example, has just 250 physicians to serve 12 million people.

Like many others in Africa, Yosam Katongole isn't threatened just by the virus that causes AIDS. With his first month's supply of ARVs, he will also receive a large cardboard box. Inside are a jerry can and a filter for treating water to avoid diarrheal diseases and two mosquito nets to fight off malaria. These and other health threats like acute respiratory infections vie for attention and resources in Africa. "For ministries of health, these are competing priorities," says Taha. "Should they make all resources available to HIV and not cover immunizations? What about the people who come to the hospital with injuries? Shouldn't they be operated on? There are other health problems too: safe water, nutritional supplementation and sanitation. Governments have got very finite resources to cover them."

The difficulties convince Taha that simple, sustainable ways of preventing HIV transmission are essential. In Malawi, Taha and colleagues still encourage men to use condoms but they also study the effectiveness of methods such as vaginal microbicides and the use of antiseptic wipes by men before and after sex.

For most HIV researchers, ARVs are clearly not the solution to the AIDS epidemic. "It's just simple arithmetic. You look at the people infected now and project forward 10 years," says Ron Gray, MBBS, MSc, the William G. Robertson Professor of Reproductive Epidemiology. "If we cannot prevent new infections, the mortality consequences and the treatment load are going to be devastating." In Rakai, for example, 510 people are currently being given ARVs. And every year, researchers expect that number to increase by 10 percent. Rakai researchers believe that sometime in the next year or so they will no longer be able to enroll new people in the ARV program. "We are going to face the ethical dilemma of turning people away," says Gray resignedly. PEPFAR's recent approval of the use of less expensive generic drugs means more people can be enrolled in ARV programs. (Previously, only approved, brand-name drugs were funded by PEPFAR.) But even with the growing use of generics, demand will far outstrip supply.

ARVs have another downside: More drugs do not necessarily translate to less disease. Researchers worry that the mere availability of ARVs will alter people's behavior. The change in attitudes in developed countries following the widespread availability of ARVs is not encouraging. "It was a naive assumption that having access to treatment would mean that HIV's spread would decrease," says Chris Beyrer, associate professor of Epidemiology and director of the Johns Hopkins Fogarty AIDS International Training and Research Program. "In fact, there is some evidence that the opposite has happened. The next generation of people come along and don't see a lot of death. Some at risk for infection may not think there's much to worry about."

Beyrer, MD, MPH '90, puts the conundrum in dueling sociological terms. "Treatment optimism" (when the introduction of a viable therapy reduces your concern and caution) can trump the "funeral effect" (once you've gone to 10 funerals linked to a certain behavior, you change your behavior).

The likelihood of treatment optimism makes Maria Wawer, professor of Population and Family Health Sciences, uneasy about ARVs' effects in Rakai. In a 2005 study, Wawer and her colleagues warned that current behavioral trends indicate that rates of HIV may soon be increasing. "The improvements seen up to now in Uganda's HIV epidemic may not be sustainable without major new prevention efforts. We should not be complacent. It's not as if the HIV story is over," cautions Wawer, MD, MHSc.

"We are truly at a crossroads," says Serwadda, a key player in Uganda's fight against AIDS since the early 1980s. Serwadda sees ARV therapy as either presenting a great opportunity to reduce HIV or leading to a complacency that masks the epidemic's true nature and allows it to become much worse. "If we can invest in prevention, then we have a chance that we may actually reduce both incidence of the disease and make a dent in the epidemic," he says. "I really don't think we have invested in ARV education in Africa the way we should have, and there isn't a good companion program at the moment in monitoring resistance. That is the capacity we're starting in Rakai."

As Steven J. Reynolds, MD, MPH '02, scientific director of NIAID's International Center of Excellence in Research based in Rakai, puts it, "ARVs are one component, but they are not going to miraculously eliminate the epidemic. Our efforts still need to focus on prevention as well."

ARVs are an expensive way of buying time, keeping people alive while research in Rakai and elsewhere continues. As Wawer says, research is the only way to track the epidemic, identify risk factors in HIV acquisition and transmission, find weaknesses in the virus and ways to strengthen the human immunological defenses against it and test promising prevention and treatment methods.

For Yosam Katongole, prevention research offers hope for his five children, but not for him. He says he talks openly with them about HIV. "I don't hide anything. I tell them everything about HIV. I tell them they can only prevent HIV if they use condoms or if they go for HIV testing before getting married," he says, pulling at the grass in front of him. "I don't know how I got HIV. I didn't have so many sexual partners."

He suffers a brief coughing fit, turning his head to the side and muffling it with his left hand. Then he talks more about his plans for his kids, his hope that they will not join the 940,000 Ugandan children orphaned by the AIDS epidemic. "I've bought land for my children. I've built a house for my children. I'm trying to educate them as long as I'm still living," he says.

Before rising to make his long journey home, Katongole ponders his situation a few moments more. Then he confesses, "I need prayers from so many people."

Not all the prayers for Yosam Katongole are answered.

A few weeks after commencing antiretroviral therapy, he suffers bouts of severe diarrhea and is admitted to a Rakai hospital. His health improves briefly, but he dies on February 17.

Postscript: On April 24, Yosam Katongole's wife Jovurete Mpirirwe gave birth to a baby boy. Both mother and child are in good health. (Following local custom, he will be named by the father's relatives.) Mpirirwe continues her ARV therapy. The Rakai program will test the child for HIV when he is four to six weeks old.

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