Trying to figure out a final cure: A conversation with Professor Max Essex of the Botswana-Havard partnership
Dr. Max Essex helped stop a plague. You can’t say that about many people, but you can say that about the Lasker Professor of Health Sciences at Harvard University. He has been involved with AIDS research since the beginning of the epidemic. He was one of the first researchers to hypothesize that a retrovirus was the cause of AIDS. His laboratory identified the envelope proteins of HIV commonly used for AIDS tests. He and his team conducted several breakthrough studies on the prevention of mother-to-child transmission of HIV. His current work focuses on the use of antiretroviral drugs to treat and prevent HIV in adults.
Dr. Max Essex is the Chair of the Harvard AIDS Initiative and also heads the Botswana-Harvard AIDS Institute Partnership (BHP). Here he is in conversation with renowned Kenyan columnist Wycliffe Muga:
First, congratulations on the recently celebrated 20th anniversary of the Botswana-Harvard Partnership. Then let me give you the bad news: I would guess that while about 95% of our readers within Africa will have some idea of Harvard University, hardly 5% of them will have heard of the Botswana Harvard Partnership. So maybe you could start telling us what the BHP is, and how it was first set up.
The Botswana Harvard Partnership, or BHP as it’s known, was set up in 1996 to address the problem posed by HIV in Botswana and southern Africa. At that time, Botswana had one of the most severe epidemics in the world. The HIV prevalence was over 25% in adults. The rate for pregnant women was as high as 37%. Botswana was also one of the best places to set up a research partnership because the highest levels of the government were very interested and sympathetic.
So if you were to name the founders of the BHP – apart from yourself, of course – who would you name prominently on this roll of honour, and what was their role in all this?
Well, I would say Maurice Tempelsman, who is Chair of the Harvard AIDS Institute’s Advisory Council and is very knowledgeable about Africa. He knew that we were interested in setting up a partnership in southern Africa. He suggested Botswana and introduced me to President Masire, who invited me to visit. This was all in 1996.
President Mogae, who succeeded President Masire in 1998, showed tremendous interest and leadership to move the government forward in relation to the problem of HIV/AIDS.
I would also say Joy Phumaphi, then Minister of Health, who was also very encouraging. She, along with President Mogae, helped convince the government to provide support to build the Botswana–Harvard HIV Reference Laboratory, so research and laboratory tests could be conducted in Gaborone.
Botswana was also one of the best places to set up a research partnership because the highest levels of the government were very interested and sympathetic
Of all the aims and objectives you all had when the BHP was started, which ones would you say have been substantially achieved? And which ones would you say have proved most resistant to your efforts to find solutions?
We have been able to completely characterize the epidemic within the country—who’s infected, how they’re getting infected, what’s most common for different size villages or regions of the country. We also characterized how the virus was different from viruses in other parts of Africa and other parts of the world.
With the rollout of Botswana’s national program to make treatment available throughout the country and such high acceptance of antiretroviral treatment (ART), we showed that transmission could be greatly reduced among adults. That made Botswana one of the top countries in the world in relation to achieving the UNAIDS 90-90-90 guidelines announced in late 2014. [By 2020, 90% of all people living with HIV will know their status; 90% of all people diagnosed with HIV will receive sustained antiretroviral therapy; and 90% of all people receiving antiretroviral therapy will achieve viral suppression.]
Another objective of the BHP was building capacity so that the physicians, nurses and research scientists in Botswana could take responsibility themselves for handling and controlling the epidemic. We have trained more than 100 people in a research capacity, as well as thousands, including nurses and physicians, in a clinical capacity to diagnose and treat HIV/AIDS. Of the over 300 people who now work at the Botswana Harvard Partnership, at least 95% of them are from Botswana or other African countries.
All journeys, however long, will have one or two high points which make it all worthwhile. What would you say was your high point in your work within the BHP?
The clear message that mother-to-child transmission of HIV can be prevented. That our strategies using antiretroviral drugs given to the mother could prevent mothers from infecting their infants, not only during pregnancy and the birth process, but also during breastfeeding. It meant that you didn’t have kids getting infected and dying in a year or two, or if they survived, having to be treated for the rest of their lives. The recognition that we could do that so successfully has to be considered a high point.
And your lowest point? Maybe the time when you more or less wondered if you might not have been better off doing something else instead of pouring all your efforts into the BHP?
I would say just the lowest point was the disappointment with the vaccines that we tested, and recognizing that they had negligible or no efficacy. Yet as vaccines were failing, drugs were becoming more effective than we imagined at the early stages.
We continued our work because we recognized that prevention of mother-to-child transmission was really beginning to work. We continued because we were effective in training AIDS experts within the country, and with the availability of more effective drugs, they were effective in saving the lives of HIV-infected people.
We have trained more than 100 people in a research capacity, as well as thousands, including nurses and physicians, in a clinical capacity to diagnose and treat HIV/AIDS
There has always been a mutual respect and feeling of cooperation. The Botswana Harvard Partnership is a true partnership. Botswana’s Ministry of Health and local medical experts define the big issues that confront the country. We work closely with them to devise strategies to help solve those problems in the long run. The knowledge gained through the BHP is relevant for the rest of sub-Saharan Africa, if not for the rest of the world.
Finally, what do you see ahead for the BHP over the next 20 years?
One of the greatest challenges will be to finally figure how to cure or completely eradicate the HIV virus from people living with HIV. It would be wonderful if we could do that. You would eliminate the chance that they could infect other people and you would save the money and the medical care needed to deliver drugs for the rest of their lives.
I think the places where that type of research can be done best are places like the Botswana Harvard Partnership, where there’s such a strong base of knowledge and a large population of people who have been successfully treated.
Professor Essex spoke to Wycliffe Muga who is a Kenyan writer and newspaper columnist