Quarraisha Abdool Karim, PhD, is an infectious diseases epidemiologist whose research involves understanding the evolving HIV epidemic in South Africa; factors influencing acquisition of HIV infection in adolescent girls; and sustainable strategies to introduce antiretroviral medicines in resource-constrained settings. She is an associate professor of Clinical Epidemiology at Columbia University’s Mailman School of Public Health and is an associate professor in Public Health and Family Medicine at the Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, South Africa.
This week, Dr. Francis Collins, director of the U.S. National Institutes of Health (NIH), and Dr. Eric Goosby, U.S. Global AIDS Coordinator, are set to travel with Dr. Karim to the sites of the CAPRISA microbicide trials. Dr. Karim talked with John Donnelly about the trials, what she hopes Collins and Goosby will see during the visit, and the startling high rates of HIV incidence among adolescent girls. This is the second in a “Research Frontlines” series focusing on the HIV epidemic.
Dr. Collins and Dr. Goosby are scheduled to travel with you on Wednesday to Durban (South Africa) to see the CAPRISA trials. What do you hope they will learn from the trip?
One thing is that although we have treatment access and it has made a huge difference to people’s lives, we need to scale up treatment and get to higher coverage levels. Then we will see a higher impact on mortality and transmission. We see the individual impact, but we don’t see the impact overall. There are a couple of reasons for that. One is the intertwining of the TB-HIV epidemics. It took a while to figure out the best way to introduce antiretroviral (ARV) medicines with TB drugs. Second, to achieve an impact in the rural settings, more people need to access treatment and new technologies, which take a long time to get to communities. In our rural settings in KwaZulu-Natal, we have one of the highest HIV prevalence in the world.
So we want to show them how a nurse-driven model can overcome the barrier of not having enough medical clinicians. And it will be important to flag for them the young people under the age of 20 who acquire HIV in their adolescence when they have very little guidance in how to manage their relationships.
Tell me more about the HIV incidence rates among teenagers.
In the (CAPRISA) microbicides trial that we completed in the Durban and in the rural setting of Vulindlela, we were able to demonstrate incredibly high incidence rates among women. We are familiar that women face a greater HIV risk, but despite high prevalence in the country, and more so in KwaZulu-Natal, what we are seeing is high, high incidence rates, driven by the age-sex difference with many women acquiring HIV almost around sexual debut, at 14 or 15 years. By the age of 20, one in three women is already infected with HIV. By the time they are 25, it’s one in two. You cannot sustain this kind of onslaught on our communities.
We need a very focused approach that alters acquisition rates in teenage girls. If we don’t do that, we will never turn this epidemic around. CAPRISA was set up with a lot of investment from NIH, particularly the National Institute of Allergy and Infectious Diseases (NIAID) and the Fogarty Center. Fogarty helped set up the capacity to respond to the epidemic. So I hope Dr. Collins takes away the importance of adolescent girls in the epidemic. It’s going to require boldness, some out of the box thinking about removing barriers that restrict our work with adolescents.
What are the research constraints with adolescent girls?
We face ethical and legal constraints. If you speak to people doing AIDS research in South Africa, you’ll find we have 60 percent of new HIV infections in young people. We have a whole lot of research documents that guide how we do research. But we are doing that with people 18 years and above. As soon as you want to go below 18, you face a complex set of procedures. You need parental consent and assent from a child depending on his or her age. But what is typical of rural areas, you have female-headed households, and the mother often is living in a close-by town and is not at home. Or you have parents who have died from AIDS, and the child is part of a child-headed household. Or there are a range of other scenarios. There are concerns about doing research with under 18 year olds who are sexually active when the law says having sex with someone under 18 years old is criminal. But when you look at HIV data, it is taking place. It’s important, for instance, to know if you want to make microbicides available to adolescent girls. The inability to negotiate safer sex is more pronounced with lower legal status.
So what happens is we do a lot of microbicide trials, but we do not have the understanding of the impact, safety or efficacy in women under 18. This is further risk to this group and we need to concentrate our efforts to protect them.
So what are the best types of prevention programs that should be used to stop HIV transmission among the youth?
It’s not going to be rocket science to figure out what will turn the tide on this epidemic. What will turn the tide is to focus intensive programs on people from under the age of 20. We should circumcise young men in school before they are infected. We have evidence from the Tenofovir gel in the microbicides work, if we make it available to young girls, that with targeted circumcision, that gives us a glimmer of hope, and gives the girls the ability to survive their teens, and negotiate an HIV-free status into their 20s.
Can new HIV technology make a difference in protecting women from infection?
Right now, in terms of the options available, the only option for women who are unable to practice safe sex or insist their partner use a condom, is nothing. Microbicides is still a concept. I do think that prophylaxis use of ARVs opens the door for women to use to prevent infection. I don’t believe technologies on their own can change women’s lives. HIV risk in women is a complex set of factors that is interrelated and rooted in gender power imbalances. Technology at least gives women a little bit of space to protect themselves from getting infected.
Right now, we have an HIV epidemic decimating the female population in many communities in South Africa. The technology will help stop that decimation. That will be an important role in prophylaxis use of ARV, either as a choice of oral or topical formulations. With either, we have proof of concept, and we are moving on getting them available easily to women. That will make a difference in terms of the HIV threat.