In January, the Botswana Harvard Partnership (BHP) celebrated its 20th anniversary. At the ceremony in Gaborone, Dr. Max Essex , Chair of both the BHP and the Harvard T.H. Chan School of Public Health AIDS Initiative, delivered these remarks:
Botswana and the Botswana Harvard Partnership have much to celebrate. Although AIDS in Africa was recognized as a major epidemic in east and central Africa in the early to mid 1980s, it was not yet a big deal in southern Africa. By the early to mid 1990s, however, UNAIDS and the World Health Organization prevalence estimates showed that southern Africa was much more impacted than all other regions of the world.
My colleagues and I at Harvard decided we should get involved to find out what was going on. We had experience in other parts of Africa and Asia, but those epidemics were modest in comparison to the situation in southern Africa. I had a discussion with Maurice Tempelsman, an old friend who had many friends in Africa and was the Chair of the Harvard AIDS Initiative’s International Advisory Council. He recommended Botswana. Soon I was invited to a state dinner in Washington in honor of President Masire. After being introduced to President Masire, he, in turn, introduced me to Dr. Joe Makhema.
Dr. Ric Marlink and I made our first visit to Botswana in August 1996. We obtained blood samples from donors with HIV/AIDS. A few months later, we signed a five-year Memorandum of Understanding with the Ministry of Health, officially establishing the Botswana Harvard Partnership. We are scheduled to have the fifth renewal and expansion of that agreement signed tomorrow.
Soon after, we analyzed the virus and showed that it was HIV-1C, quite different from other HIVs in east or west Africa, the U.S., Asia, or Europe. It was characterized by a very high rate of genetic variation.
BHP established a small lab in Gaborone and in 2001 a much larger lab, all made possible through huge contributions from the Ministry of Health, with help from the Gates Foundation, Merck, Bristol-Myers Squibb, and of course the U.S. National Institutes of Health.
By the late 1990s, Botswana was ground zero for HIV/AIDS. According to UNAIDS, more than one in three pregnant women and about one in ten infants were infected. Otherwise, the country was doing very well—a model of democracy, good economic development, high literacy and high childhood vaccination rates.
But one of the fastest growing sectors in the economy was the funeral industry. President Mogae, who followed President Masire in 1998, expressed great concern. For several years, he mentioned the emergency of HIV/AIDS in every speech he made.
From the early days, the BHP had four major goals. In my opinion, one of these was a failure, while the other three have been tremendous successes.
The failure was our early attempt to make a preventive vaccine. Of course, that has also been a failure for AIDS researchers throughout the world. On the bright side, we have several projects underway on the use of vaccine-type antibodies for advances in treatment or prevention. Much of the research was still useful scientific knowledge.
Our second major emphasis was the prevention of mother-to-child transmission of HIV. An unbelievable success. With chemoprophylaxis—providing antiretroviral drugs to pregnant HIV-infected women—only a tiny fraction of infants now get infected. And this while allowing for safe breastfeeding so that infants don’t develop other problems, like diarrhea or respiratory infections associated with formula feeding. The protocols developed at BHP soon became guidelines for the world.
Our third major emphasis was antiretroviral treatment. We conducted clinical trials with different drug combinations. Again, a resounding success. Botswana is clearly the leader in Africa, with the highest fraction of HIV-infected people getting the best drugs. One of the top two or three countries in the world. This went beyond our wildest expectations, as treatment also became prevention, perhaps even minimizing the need for a protective vaccine.
The breakthrough for this was the HPTN 052 study, done at the BHP and other sites that collaborated to show that adult heterosexual transmissions could be reduced by more than 95% with drugs. There is now a worldwide effort for implementation of “treatment as prevention” which includes the Botswana Combination Prevention Project, a collaboration between the U.S. Centers for Disease Control (CDC) and BHP.
Our final area for emphasis has been teaching and training. Again, a major success. For the long-term future, this may be the most important of all. Over the last 20 years, Harvard and BHP have spent more than 25 million dollars in laboratory and clinical research training for people from Botswana, including about 100 people in the early days of the Masa program for national antiretroviral treatment. The BHP was also responsible for the short-term training of thousands of physicians and nurses through KITSO, the Master Trainer program, and other quality control programs under Drs. Marlink and Gaolathe. BHP now has local leaders that are internationally recognized, like Drs. Gaolathe, Moyo, Gaseitsiwe, and Makhema. For these and other reasons, the future looks bright.
HIV/AIDS is no longer a death sentence. Treatment will continue to get better, and costs will continue to go down. But we must keep up the research—find a complete cure, universal prevention, rapid control of TB, reduction of cardiovascular diseases and various cancer outcomes. The list is long and daunting. But just think of all we’ve done in the last 20 years.
—Max Essex
Title Image: Dr. Max Essex stands in front of the construction site for the headquarters of the Botswana Harvard Partnership on the grounds of Princess Marina Hospital in Gaborone, Botswana, circa 2000.