Viewpoints: Max Essex

Max Essex photo by dave Cliff

Dr. Max Essex is Chair of the Harvard School of Public Health AIDS Initiative (HAI), the Lasker Professor of Health Sciences, and Chair of the Botswana-Harvard Partnership for HIV Research and Education (BHP). As the BHP celebrates its 10th anniversary, Martha Henry, Editor of Spotlight, asked Dr. Essex to reflect on past accomplishments and future goals of the BHP.

Spotlight: What major accomplishments were achieved during the first ten years of the Botswana-Harvard Partnership?

Essex: We treated the first AIDS patients with antiretroviral drugs (ARVs) in Botswana. Bill Wester and Hermann Bussmann, who work at the BHP, were the first physicians to administer ARVs through the government health system. The Minister of Health at the time, Joy Phumaphi, wanted to demonstrate that lives could be saved through three-drug combinations. This led to a government program that is by far the largest in Africa, setting the example that a country can treat a lot of their AIDS patients if they really want to.

In our research work we showed that the virus in Botswana and southern Africa is different. This taught us that when making a vaccine or designing drugs for the epidemic in southern Africa, we should do it with the virus most representative of that region, rather than accept what was done for the West.

We also made major progress in learning how to prevent mother-to-child transmission of HIV and we ran the first vaccine trials in southern Africa.

Spotlight: What else?

Essex: Building the Botswana-Harvard HIV Reference Laboratory, the largest AIDS-dedicated laboratory in Africa, was a major accomplishment.

Through the KITSO program, we trained more than 5000 clinical AIDS workers, including doctors, nurses, midwives, counselors, pharmacists and lab workers. Approximately 80-90% of all healthcare workers who serve AIDS patients in Botswana have received KITSO training.

Spotlight: What are the future goals of the Botswana-Harvard Partnership?

Essex: We need to develop better prevention approaches for adults at risk of HIV infection. We need to do more with vaccines, microbicides and other biological approaches to prevention.
We need to determine whether the established drug regimens will work as well in the medium and long term in Botswana, especially if drug-resistant HIV variants begin circulating in the population.
Botswana’s situation is unique. Nowhere else in the world has a significant fraction of the population been involved in both ARV treatment for AIDS and chemoprophylaxis to prevent transmission of HIV/AIDS from mothers to infants. This affects the kinetics of transmission.
The questions about how drug-resistant variants develop and get transmitted among people to interfere with one program or another have not been addressed. If women and infants are getting infected for the first time with a drug-resistant variant, then the standard chemoprophylaxis won’t work. We already know that if women and infants are getting chemoprophylaxis with one or two drugs to block mother-to-infant transmission, then the antiretroviral treatment that they will need later may not work. Drug resistance feeds off itself in different ways when you have a combination of chemoprophylaxis and treatment going on in the same population at the same time.

Spotlight: How long do you think the collaboration between HAI and Botswana will continue?

Essex: I think it will continue for a long, long time. I hope it will continue for another 20 years at least because many of the problems we are now addressing need great attention. Harvard has experts in different aspects of these problems. We are committed to helping the situation in Botswana.

Botswana is an example of what hopefully will occur in much of the rest of Africa. It’s the first place where a large program was launched to cover most of the affected population of a country, and in some ways an easier case because of its good government and economic resources, but it’s clearly an example of what has to happen in the rest of Africa to control HIV/AIDS.

Title image: Max Essex photo by dave Cliff