AIDS research must link to Local policy

[Guest guest]

[Editors comment: The following review of South African HIV research policy

resonates well with the current situation of HIV research in India. One of the

serious drawbacks of National AIDS Control Program (NACP) is lack of a cohesive

HIV research policy to guide the National program. Though, ICMR has constituted

National AIDS research Institute (NARI), NARI failed to overcome the

bureaucratic slumber, typical of any government- research department.

Indian social and health science academic has particularly failed to provide

policy oriented research leadership to guide National HIV program. Professors

Salim Abdool Karim and Quarraisha Abdool Karim `s summary of observations on HIV

research in Africa, a) Dependence on international finance has skewed the

agenda of South Africa's HIV scientists, Stagnant government funding for HIV

research must increase substantially and c) The country must connect its AIDS

research with its prevention and treatment programmes, reads almost like an

observation on HIV research in India as well. Anybody in NACO listening?]

______________________________

AIDS research must link to Local policy

HIV research in South Africa is world class. To halt the country's epidemic,

scientists need to shift focus from global problems to priorities at home, say

Salim Abdool Karim and Quarraisha Abdool Karim.

NATURE Vol 463 11 February 2010 OPINION 2010 Macmillan Publishers Limited. All

rights reserved

SUMMARY

& #9679; Dependence on international finance has skewed the agenda of South

Africa's HIV scientists

& #9679; Stagnant government funding for HIV research must increase substantially

& #9679; The country must connect its AIDS research with its prevention and

treatment programmes

Despite being Africa's scientific powerhouse, 16 years on from the end of

apartheid South Africa has failed to make the most of its well-established

clinical and research infrastructure and its rich tradition of scientific

excellence in curbing the HIV epidemic. More than one in ten South Africans are

infected; 17% of all people living with HIV are in South Africa, even though it

has only 0.7% of the world's population; and the rates at which people are

catching the virus and dying from AIDS are unacceptably high (see graph,

overleaf). Mandela's call at the 13th international AIDS conference in

Durban, South Africa, a decade ago to " mobilize all of our resources and

alliances … until this war is won " has too often fallen on deaf ears.

The problem is not a lack of science. South African scientists have had leading

roles in research on the prevention of HIV transmission from mother to child,

violence against women, the role of human leukocyte antigen, the treatment of

tuberculosis-HIV co-infection, viral genetic diversity and the treatment of

HIV-infected infants.

South African researchers are also active participants in numerous international

multi-centre clinical and laboratory studies on vaccines, microbicides,

mother-to-child transmission and pre-exposure prophylaxis. What's missing is an

effective conduit between the country's AIDS research and its prevention and

treatment policies and programmes.

One of the main stumbling blocks to achieving this is the lack of local research

finance and the increasing reliance on foreign finance, particularly funding

geared towards providing sites and specimens for international AIDS studies. The

dependence on international finance has shifted the focus of South Africa's

scientists from local to global priorities.

For example, important research is being done in South Africa on developing HIV

vaccines, yet little attention is being paid to devising approaches to reduce

the high rates of infection among young women, the main driver of the HIV

epidemic in the country.

The disconnect between public-health policy and research is rooted in the

country's recent history. When HIV emerged in apartheid South Africa in 1982,

medical research in the country was focused on diseases of affluence rather than

poverty; there was negligible emphasis on public health. Until 1990, indigenous

research provided scant data to guide efforts to prevent HIV on the ground and

either inadvertently or deliberately portrayed HIV as a disease confined to gay

men, black people or foreigners working in the mines.

The first post-apartheid government prioritized AIDS in its Reconstruction and

Development Programme, but it gave little political support to evidence-based

interventions. The support for unorthodox AIDS denialist theories from

then-President Thabo Mbeki and his health minister Manto Tshabalala-Msimang,

along with their persistent attacks on science, put the government at odds with

scientists, AIDS activists and the general public. By 2000 this schism had grown

so deep that it was very difficult for scientists to influence the government's

AIDS-control efforts. The distrust and antipathy simmered right up until last

year's change in government and the appointment of a new health minister.

Meanwhile, domestic financing of AIDS research has stagnated at a

disproportionately low level given the scale of the problem. At the time of the

country's first democratic elections in 1994, when 7.6% of pregnant women had

HIV, government funding for AIDS research amounted to around 2.1 million rands

(US$300,000). A decade later, when HIV prevalence in pregnant women had

increased nearly fourfold to 29.5%, AIDS research funding had grown only two and

a half times, excluding funds raised through a newly created South African AIDS

Vaccine Initiative (SAAVI) public– private partnership. Thanks to contributions

from international agencies, overall support for AIDS research grew 200-fold

during this period to an estimated $62.5 million.

The end of isolation

While South Africa's AIDS strategy spent 20 years in disarray, the country's

research community started to flourish. The transition to democracy ended

decades-long academic isolation from the global scientific community.

South African scientists rapidly established themselves as able to compete and

collaborate with others across the world. The effect has been most evident in

the dramatic increase in international funding for AIDS research. The step-up in

international support has been dramatic: in 1990 the country was receiving

negligible research funding from the US

National Institutes of Health (NIH); by 2000 it was the largest recipient of NIH

funds outside the United States. Several others made large contributions to AIDS

research in South Africa. For example, in 1997 the Wellcome Trust provided a £5

million (US$8 million) grant to create a rural research centre on reproductive

health; in 2000 the Doris Duke Charitable Foundation provided $5 million for an

AIDS research institute; and the Medical Institute recently

announced an unprecedented contribution of $60 million towards the creation of

an institute investigating tuberculosis and HIV.

The growth in international funding during the first post-apartheid decade

triggered a rapid expansion in AIDS research, training and physical

infrastructure. This has had lasting benefits, for example leading to the

establishment of 10 large, independent AIDS research centres, which together

account for close to 90% of the expenditure on AIDS research in the country.

This level of financial autonomy has had three obvious benefits for the

country's research community.

First, it has reduced dependence on the government, enabling scientists to

challenge politicians on their AIDS denialism without fear of losing research

funds.

Second, it has raised the quality of local research to international standards.

Third, it has enabled South Africa to build research capacity, for example

through the Columbia University–Southern Africa Fogarty AIDS International

Training and Research Program.

Over 15 years, this programme has provided training for 310 young scientists,

including 125 who obtained masters or doctoral degrees in the United States and

are now involved in almost every major AIDS research project in South Africa.

Importantly, all of but two of the students who studied in the United States

returned to South Africa, an illustration of how international funding for AIDS

science has provided shelter from a potential `brain drain'.

The flip side to the foreign-funding boom is the shift from local to global

priorities. This affects the country's efforts to deal with the epidemic. For

instance, there has been little research on why the substantial increase in

condom distribution in the country, rising from 8 million in 1994 to an

estimated 376 million in 2006, has had little effect on reducing HIV

transmission, especially in high-risk sex between adult men and teenage girls.

Four steps

A new approach is needed for South African AIDS scientists to contribute

actively to stopping the spread of HIV. There are four key steps. First,

scientists and policy-makers must commit jointly to an evidence-based approach

to the country's AIDS response, including the development of a common

understanding of the main drivers and risk factors for HIV transmission at a

local and national level. Data need to be collated and synthesized so that

researchers and policy-makers can agree on priorities.

Second, regular interaction must occur between scientists, policy-makers and the

leaders of public-health programmes to ensure that AIDS policy takes account of

the latest science.

A suitable forum for this is the recently revived South African National AIDS

Council, set up to advise the government on HIV and AIDS policy and help oversee

the national response to the epidemic.

Third, a national AIDS research agenda needs to be developed on the basis of

detailed knowledge of the country's epidemic and the priorities for action. It

needs to take a long-term view — AIDS is likely to be around for decades to come

— and should strike a balance between implementing and evaluating known

effective public-health strategies and new technologies and approaches to

prevention and treatment.

Government backing will be essential and scientific excellence must remain the

benchmark.

South African researchers will have to redirect some of their effort away from

internationally contracted studies towards implementing this national agenda. A

good example of a country that has developed an effective national AIDS agenda

is Botswana. Driven by policy-makers at the highest level of government, it has

created several public–private partnerships with the likes of Merck and the

Gates Foundation and drawn up a clear set of priorities and targets for

prevention and treatment.

Finally, government funding must increase substantially. Today, less than 5% of

South Africa's AIDS research funding comes from the government's three major

funding sources — the Medical Research Council, SAAVI and the newly established

South African HIV/AIDS Research and Innovation Platform. This has to change. But

even if the government increases its budget several-fold, international finance

will still be required. Initiatives like the NIH's Comprehensive International

Program of Research on AIDS, which until recently supported important globally

relevant research that responded to local priorities in poorer countries, need

to be revived to support research on policy and programme implementation.

The change in government leadership in 2009 has created hope that the country

will beat the HIV epidemic. Doing this by tailoring research to local needs

does not mean that South African science needs to relinquish its important role

in the global effort against HIV. Local solutions are likely to be globally

applicable and will have a marked influence on the global burden of disease. The

country has the scientific capacity, the top-class laboratories and a new-found

commitment by policy-makers, scientists and health-service leaders to work

together to finally take up the challenge that Mandela proposed a decade ago. We

cannot afford to fail.

Salim S. Abdool Karim and Quarraisha Abdool Karim are at the Centre for the AIDS

Programme of Research in South Africa, University of KwaZulu-Natal, Congella

4013, South Africa, and at the Department of Epidemiology, Columbia University,

New York 10032, USA. e-mail: caprisa@...

Further reading accompanies this article online at go.nature.com/Kr4kkj.

See Editorial, page 709 , News Feature, page 726 and Correspondence, page 729.

http://www.nature.com/nature/journal/v463/n7282/pdf/463733a.pdf