Eduard Sanders: Reducing HIV
Men who have sex with men (MSM) are a stigmatised group in Africa, but a predominant actor in the transmission of HIV. Recognising this vulnerability and developing better prevention programmes targeted to this population will ultimately reduce the wider public health impact of HIV epidemic.
Q: Can you tell us a little bit about your research and where you are based?
Eduard Sanders: I have been working in Kiifi, in coastal Kenya, for the last 12 years. I am supported by the International AIDS Vaccine Initiative, to find people who are at a higher risk of HIV infection. We would like to test a HIV vaccine and of course, to contribute to developing that vaccine and testing its efficacy.
Quite unexpectedly, we stumbled onto a particularly high risk group - men who have sex with men [MSM] - which was a hidden population in Kenya some 10 years ago. It is not hidden anymore and has come forward, partially based on our research. One of the outcomes of that research include two new lines, and one new line is the importance of community engagement. Men who have sex with men are a very stigmatised group; various communities and stakeholders feel that this group should not be allowed to come to the fore. The other, more medically interesting aspect is that we learn so much from the acute HIV infections that this group has, when people unfortunately acquire HIV.
Q: Given the difficulties of working with this specific group, why is it so important to work with this population to control HIV?
ES: We and others now have documented that there is so much that is unknown, and that this group has been lagging behind in receiving HIV prevention information. Programmes have been targeted to mostly pregnant women and the general public, and key populations including female sex workers, drug users and truck drivers. But men who have sex with men specifically lack information to protect themselves and have a high instance of getting HIV and transmitting it. Information provision, HIV preventive measures and education linking people who test positive to trained health care workers is an enormously important programme that has emerged since we started working in Kenya.
Q: It sounds as though your research has also a broader impact. Could you tell us how your work has helped change public health policies in HIV affected countries?
ES: We have been fortunate to be at the beginning of the policy change. We were initially quite nervous about what we were documenting, but it turned out there was a renaissance in Africa of recognising this group. We started working with MSM in 2005, and shortly thereafter, various countries have documented similarly high prevalences; studies are now beginning to document the incidences that we already documented in 2007-2008.
The wider public health impact is that it impacts society: recognising the vulnerabilities in people and stigmatised populations who have not been engaged benefited from a substantial HIV prevention programme in Kenya. It impacts training, care and counselling, and all these things are beginning to be taken up by the Ministry of Health, which in Kenya is now quite successful in putting these key populations at the centre of the epidemic.
Q: What are the most important lines of research that have emerged in the last 5-10 years?
ES: From the research with MSM, we have learned that when MSM acquire HIV, they seek healthcare for symptoms. This is quite well known in the West but surprisingly, this not well documented in Africa, where an estimated hundred thousand populations get HIV each year. So healthcare seeking behaviour right at the time when you acquire HIV is an unknown area.
We learned that MSM went to pharmacies, to small private facilities for symptoms like fever, joint pain or fatigue, and that they are quite frequently treated for malaria. Our new line of research is on how we detect acute HIV infection, not only in MSM, but also in the wider population, as it is clear that people seek health care when they acquire HIV - but it is difficult to diagnose.
Q: Why is it particularly important to detect acute HIV?
ES: People are so infectious: right at the time you acquire HIV, your viral load shoots up and unfortunately, at that moment, your antibodies are not yet developed, so you cannot detect it with a rapid test. But if you do not learn your status (which is the case for the majority of MSM) and you continue the risk behaviour that you may have at that time, you will infect three or four other people in the next six months - these are estimates, but it indicates how an epidemic can spread.
Q: Why is this line of research important and why should we fund it?
ES: There is a budget in Kenya for about five hundred million dollars a year, very focused on treatment for people with prevalent HIV. For every two new cases that will be started on ART [antiretroviral therapy, now a standard treatment for HIV], three new cases actually acquire HIV. As HIV spreads so quickly right after the moment you acquire it, we need to develop algorithms, so that people can be evaluated with lab assays that cost more, but that detect acute HIV infection early.
Q: How does your line of research fit into translational medicine within the department?
ES: Most of my work is actually quite operational and I would think I am already on the translational side, because many questions arise when you identify patients with acute HIV infections. Are such patients willing to be linked to care, start ARTs, retain care and suppress their viral load? My public health questions are on the operational side; there is a basic science component to it that actually links quite nicely to the department but I am on the translational side already.