The Botswana Harvard Partnership Turns 20: Q&A with Dr. Joseph Makhema

Dr. Joseph Makhema

The Botswana Harvard AIDS Institute Partnership (BHP) was established 20 years ago to help combat HIV/AIDS at the epicenter of the epidemic. At the time, about 37% of pregnant women in Botswana were infected with HIV. Dr. Joseph Makhema was a young physician working what seemed like unending hours at the public hospital in Gaborone, where effective treatment was not yet available. Today, Dr. Makhema is the CEO of the Institute he played an important role in establishing. Martha Henry, Executive Director of HAI, spoke with him about the BHP’s history and future.

Martha Henry: When an agreement was signed between Harvard University and Botswana’s Ministry of Health to create the Botswana Harvard AIDS Institute in 1996, how bad was the AIDS epidemic in Botswana?

Dr. Joseph Makhema: At that time, I was in the department of medicine at Princess Marina Hospital, which was being overwhelmed by AIDS patients. All we could do was treat the opportunistic infections: pneumonias, meningitis, recurrent episodes of diarrheal illnesses. Some people were emaciated. The ward occupancy ran beyond capacity, with beds all over the place. Mortality was high.

In medicine, you are taught to save lives. When you feel unable to do so, it has an impact on morale.

As the epidemic unfolded, there was an increasing sense of anxiety as to what the future held for the country. Within families, multiple funerals would occur on the same day with multiple relatives to bury. There was poor productivity within the workforce. The social fabric was stretched to the limit. I suppose that’s when you delve into your spirituality to help you through.

How did you become involved with the BHP?

I had a role being the president’s physician. I got to first meet Max [Essex] in Washington when he met with President Masire. Max had seen some of the data coming out of Botswana in terms of the high HIV prevalence and expressed his wish to set up a collaborative effort within Botswana.

Prof. Max Essex and Dr. Joseph Makhema
Prof. Max Essex and Dr. Joseph Makhema

I briefed the Ministry of Health officials when I returned. After initial contact, Max was keen on pushing things along. He wanted to start a study to determine the HIV clade or subtype that was circulating in Botswana. Since I working at Princess Marina, I facilitated the drawing of samples for that analysis.

Before we knew it, a memorandum of agreement was signed by the Ministry of Health and the Harvard AIDS Institute to establish the institution we now know as BHP. I formally joined BHP in 2003, as a Co-Director, then subsequently took over as Project Director when Ibou Thior, the first BHP Project director, left in 2006.

What was the BHP’s role in helping to shape the Masa program?

Masa, the national antiretroviral program for HIV treatment in Botswana, was rolled out in 2002. (Masa means new dawn in Setswana, Botswana’s spoken language.)

The BHP worked hand in glove with Masa, whether it was for clinical skills to treat and monitor patients with HIV, laboratory testing, or pharmacy issues relating to antiretrovirals and their side effects.

Through Hermann Bussmann and Bill Wester, the BHP contributed to the setting up of the Infectious Disease Care Clinic (IDCC) and were the first physicians running the clinic. The Princess Marina IDCC was the first to be established in Botswana and was established concurrently with the BHP’s clinical research infrastructure to conduct the Tshepo Study, a foundational clinical trial that looked at different antiretroviral treatment options, their efficacy, and drug resistance among Botswana AIDS patients.

Drs. William Wester and Hermann Bussmann
Drs. William Wester and Hermann Bussmann

What is KITSO and why was it necessary?

KITSO is an acronym for Knowledge, Innovation and Training Shall Overcome HIV.

It was important to ensure that we had adequately trained health care personnel in the country. To do so, we set up a robust training program for HIV/AIDS nurses, physicians, laboratory technicians, and general staff. KITSO was established in 2001 and was initially funded by Merck Pharmaceuticals and the Bill & Melinda Gates Foundation through the African Comprehensive HIV/AIDS Partnerships.

At BHP, we provided the first cohort of trainers who assisted in rolling out the program. They conducted core competency trainings required of all healthcare practitioners who would be involved in management of HIV patients, ensuring standardization of knowledge and application of protocols to manage patients in Botswana.

As the needs for decentralization of HIV treatment services arose, it was also necessary for training to become decentralized. The Master Trainer Program was subsequently developed to compliment KITSO and provide on-site training, support, and mentorship for clinics where HIV care was provided.

KITSO staff
The KITSO staff marks teaching over 8000 course units.

After 10 years, thousands of healthcare workers had been trained and management of KITSO was transitioned to the Ministry of Health. Without the skills and training that KITSO provided, the Masa rollout would never have been possible.

Will training remain an important part of the BHP’s mission?

We are committed to building scientific capacity for research activities, not only in clinical trials, but also in basic laboratory science.

The BHP became a limited liability corporation (LLC) in 2007. What are the advantages of being an LLC?

It was important for the BHP to become a local entity. We now have access to funding meant exclusively for sub-Saharan African institutions. We have built administrative capacity and have the ability to apply independently and manage our own grants.

A big percentage of the BHP’s operating costs is covered by grants from the U.S. National Institutes of Health (NIH) and the Centers for Disease Control (CDC). Will that change?

We are exploring new avenues to support the future work of the BHP beyond just the classical competitive grants from the NIH and CDC. We are now able to approach other sponsors, including the European Union through the European Development Capacity Training Programme, the Wellcome Trust, and the private sector.

We have developed a sustainability plan that centers on a new business model, which includes fee-for-service work based on competencies and skills we already have within the BHP. This revenue would be plowed back into the BHP to support the research agenda.

The BHP’s official name is the Botswana Harvard AIDS Institute. Will the BHP continue to focus primarily on HIV/AIDS research?

The whole dynamic of how we view HIV has changed. It has become more of a chronic disease. With access to antiretroviral treatment for HIV, we are seeing a healthier population, which unfortunately has transitioned to some of the lifestyle, non-communicable diseases such as high blood pressure, strokes, heart attacks, etc., The interface between infectious diseases and non-communicable diseases, including cancer, has become increasingly important. We must address this new challenge from a public health perspective.

We are also looking at the effects of exposure to antiretroviral drugs amongst HIV exposed-but-uninfected children, who may face other challenges such as low birth weight or neurocognitive impairment.

There are other emerging public health challenges—infections like Ebola and the Zika virus, as well as a range of non-communicable diseases. These are threats, but they also offer opportunities for widening the scope of the BHP agenda. We are looking at transforming the BHP into more of a public health institute that will address the changing epidemiology of diseases that affect and are becoming prevalent in Botswana and across the region.

How do you set your research agenda?

We are in partnership with the Ministry of Health. Their agenda and priorities are of utmost importance. We also look at regional challenges. Our research and programs have mainly focused on advancing public health within Botswana and the region. Often those are also needs of the global community, so our research has a global impact.

Dr. Makhema addresses the field team of an HIV prevention trial. Photo by Dominic Chavez
Dr. Makhema addresses the field team of an HIV prevention trial. Photo by Dominic Chavez

What are the biggest challenges facing the BHP in the next decade?

One of the biggest challenges is how BHP will adapt over time to new patterns of disease. As we move towards becoming a public health institute, it will be important to have an epidemiology unit within BHP to study disease trends and interventions required to address the diseases.

There is also the question of retention of our key personnel. As we have developed and evolved over the years, we have trained a cohort of researchers that have left BHP for other institutions to work in different public health programs. How then can we retain our core personnel to ensure that over time they are available to provide the backbone of the work that we do? That will be a big challenge in the next decade. The solution is to continue to strengthen the BHP to become a center of research excellence that shall attract and offer the best environment and reward for scientific achievement.

What makes you want to come to work in the morning?

The fact that the work that we do has a positive impact in changing people’s lives. Knowing that the children that I drive past as they walk to school in the morning may not have been infected with HIV because of our work. Or that the healthy looking, HIV-infected but AIDS-free individual in our society can fulfill his or her full potential and contribute to the socio-economic development of their families and the country. That motivates me.

Botswana Kids

What accomplishment are you most proud of at the BHP?

Without a doubt, it is prevention of mother-to-child transmission of HIV. Transmission has fallen all the way from 40%, so we hardly have an infant now who is infected. Being able to say we have almost attained our goal of an HIV-free generation, which I could never ever have dreamt of previously.

That has to be one of the greatest accomplishments of this institution. We have been at the forefront and led the world in the programs and research for prevention of mother-to-child transmission.

Title photo: Dr. Joseph Makhema, by Dominic Chavez