Projet San Francisco

I’ve recently realized that even though I’ve been writing on a regular basis, I haven’t really explained Projet San Francisco (PSF) or the work that I do on a daily basis. I’ll start today with the project, which is easiest to explain by breaking it into three parts.

The first aspect of the project is couples’ voluntary counseling and testing (CVCT). PSF operates three centers throughout Kigali that provide services to married and cohabiting couples. The centers are open three days per week for couples to come to receive information, testing and counseling for HIV and syphilis. The project promotes these services in a number of ways. Sometimes radio announcements and billboards are used, but our predominant means of promotion involves recruiting community leaders (such as ministers, civic leaders, public officials, teachers and others) to publicize our services within the community and distribute information and invitations to couples interested in our services. I’ve already described what happens at CVCT in a posting on 13 September 2007, so I won’t repeat myself, but I will mention that lately we’ve been seeing approximately one hundred couples each week.

The second aspect of the project – observational studies – stems from CVCT. Of the couples who are tested at CVCT, couples who are discordant, meaning one partner is HIV-positive and one is HIV-negative, and who meet certain eligibility criteria are invited to join our study of heterosexual transmission of HIV, which we refer to as the HT study. This is an observational study to understand the behavioral, virologic, immunologic and immunogenetic correlates of HIV transmission, so these couples come to our main site every one to three months for follow-up and testing. We also have an observational study of a cohort of 85 long-term nonprogressors, many of whom have been HIV-positive for twenty years. These women are studied to identify why they remain healthy despite HIV infection and to analyze host and receiver genetics related to the progression of HIV. They come to the clinic every three months. All observational study participants receive some benefits for their time and effort. At each visit they are reimbursed for their transportation cost and are given lunch. They are also welcome to receive reproductive health care from PSF and are given mutuelle cards so that they are able to obtain free health care at their local clinic. Currently we have approximately 900 individuals in these observational studies, the largest cohort of discordant couples in the world (the second largest is our project’s cohort in Zambia), and we see forty to fifty individuals at the clinic each morning.

The third aspect consists of more specialized research, currently focusing vaccine feasibility studies and clinical trials. Participants in these studies are usually recruited from the HT study. Some recent and ongoing studies include a clinical trial to evaluate whether HIV-transmission could be reduced by suppressive treatment of genital herpes with acyclovir, the establishment of reference ranges for lab results to identify adverse events in a trial, studies of disease progression in newly-infected individuals and follow up of long term nonprogressors (a different study from the one I mentioned above). We were prepared to begin a clinical trial of an HIV vaccine this month, but with the disappointing results from the Merck trial, it’s been postponed.

I’ll try to write soon about my role within all of this, but let me know if you have any questions so far. Below is a picture of one of the project buildings and the road on which most of our offices are located.

Halloween in Kigali

Even though no one in Rwanda celebrates Halloween, last night one of my friends and I borrowed Rwandan Defense Forces uniforms and joined everyone else for a costume party.

Vaccine research nightmare

I mentioned a few weeks ago that an HIV-vaccine trial by Merck had been canceled, but now more details are coming out about the results of the trial, and it really doesn't look good. It seems the vaccine actually put people at greater risk of getting HIV rather than decreasing their risk. The results from the trials in North America won't be available for a couple more weeks, but if they show the same results, this has several serious implications: (1) the most obvious implication is that now all the people who participated in the trial and received the vaccine are now at greater risk of getting HIV, (2) when another vaccine is ready to be tested, it will be much harder to recruit participants to be in the trial, (3) this may be the end of the road for a number of other vaccine candidates because many of the vaccines that are in advanced stages of research have the same basic mechanism as the Merck vaccine, and (4) we most likely will not be going through with our vaccine trial here at PSF. Here's the article from the Washington Post.

Warning is sent to AIDS vaccine volunteers
by: Craig Timberg

South African AIDS researchers have begun warning hundreds of volunteers that a highly touted experimental vaccine they received in recent months might make them more, not less, likely to contract HIV in the midst of one of the world's most rampant epidemics.

The move stems from the discovery last month that an AIDS vaccine developed by Merck & Co. might have led to more infections than it averted among study subjects in the United States and other countries. Among those who received at least two doses of the vaccine, 19 contracted HIV compared with 11 of those given placebos.

Researchers shut down the trial on the grounds that the vaccine was proving ineffective, but the surge in infection among vaccinated volunteers prompted intense scientific debate and anxiety among researchers. The failure of the Merck vaccine is the latest in a series of disappointing results for research projects aimed at curbing AIDS.

"This is my worst nightmare," said Glenda Gray, the lead South Africa investigator for the vaccine study. "I haven't slept for days. I have a headache. I'm ready to resign from trials for the rest of my life."

Researchers in Soweto, Cape Town, Durban and two other sites began contacting South Africa's 801 trial participants on Tuesday, mainly by cellphone text message. The goal is to tell each one individually whether they had received a placebo or the vaccine, a process called "unblinding" the trial. Researchers are telling the roughly half who received the vaccine that it might have increased their risk of contracting HIV.

"It's quite shocking," said Nelly Nonoise, 26, who had received three injections of the vaccine in her left shoulder.

She added, "I probably wouldn't have joined the study knowing there's a risk."

Another participant, Nonhlanhla Nqakala, 22, said she thought the text message urging her to visit the vaccine test site meant she had tested positive for HIV. Her brother and a close friend had the disease and died, she said.

Nqakala said she was relieved when a doctor explained that she was not infected, but the news of a possible problem with the vaccine -- she had received three doses, not placebos -- left her distressed. "I thought the trial would help us find a cure for HIV," she said.

Merck developed the vaccine in conjunction with the U.S. National Institutes of Health, and until September's announcement, researchers worldwide considered it the most promising candidate yet in a multibillion-dollar quest for an AIDS vaccine dating to the 1980s.

Scientists crafted the vaccine by genetically altering a common virus to include elements of HIV. They hoped that it would trigger an immune response that would make recipients less likely to contract HIV, or at least delay the onset of full-blown AIDS.

The vaccine could not have caused infection, researchers say, but it could have caused immunological changes that made it easier for the virus to take hold during a later exposure.

The Merck vaccine trials took place in 15 cities in the United States, including Boston, Los Angeles and New York, and three in Canada. There were also sites in Peru, Brazil, Australia, Haiti, the Dominican Republic and Jamaica. Those trials began in December 2004 and included 3,000 participants, mostly gay men.

In South Africa -- where an estimated 5.5 million people are infected with HIV, more than in any other country -- the study used the same vaccine but was administered separately. The trial here started later, with the first injections this year, and had its own ethics oversight board. Most of the subjects were heterosexual.

The ethics oversight board in the United States, which monitored the trial everywhere but in South Africa, has not decided whether to tell participants if they received the placebo or the vaccine, said Mark Feinberg, vice president for medical affairs and policy for Merck.

Continuing research could be compromised, he said, if participants were told immediately whether they received the placebo or the vaccine. Vaccine researchers are scheduled to meet in Seattle on Nov. 7.

"Given the complexity of the issue, we feel the best conclusions will be reached when all the data are analyzed in their entirety," Feinberg said from Atlanta, where he was traveling.

He added that individual participants who want to know whether they received the vaccine will be told. Researchers also are counseling all study participants that the vaccine may have increased HIV risk for those who received it.

Other AIDS studies also have had unexpected results. Trials of two vaginal microbicide gels to prevent HIV led to more infections among those using the products instead of placebos. A massive study in Zimbabwe of the ability of HIV counseling and testing to prevent the spread of the epidemic found more infections among those with expanded access to testing.

Seroconversions

At work today, we had our third seroconversion in two weeks, meaning that, in only fourteen days, three of our study participants who were initially HIV-negative have been infected with the virus. That’s three more individuals added to the forty million already living with HIV/AIDS. Three more who will ultimately die from a disease that has been around for twenty years and yet we still can’t find a way to prevent or cure it. These three individuals weren’t infected because they were part of a classic ‘high risk’ group such as sex workers or injecting drug users. And they weren’t uneducated about HIV; on the contrary, they received counseling and education from the project at least once every three months. Their only downfall was being married to or cohabiting with someone who was HIV-positive. So if these individuals weren’t participating in ‘high risk’ behavior and they weren’t unaware of the disease, how much, then, are our prevention strategies really doing? In the world of HIV, we continue to preach the ABCs, but are those interventions really appropriate for the largest risk group in the world? Abstinence promotion isn’t exactly an appropriate intervention when you’re working with married and cohabiting couples. Being faithful is a suitable message, but it does nothing for discordant couples where one partner is already HIV-positive. Condom use is the only other strategy, and while it has been proven effective, it isn’t always an option. What about those with religious beliefs which prohibit contraceptive use? Or those in relationships with partners who refuse to use them? Or those who want to have children? Maybe the ABCs are the best option we have right now, but if the best we have doesn’t work for the largest risk group in the world, then what do we really have?

Floods in my living room

Today I came home from work to find that I couldn’t even walk inside without getting my feet wet and my entire living room was flooded. I guess that’s what happens when it storms all afternoon and your house is on a hill at the bottom of a steep driveway. So instead of relaxing and enjoying my evening, I moved furniture and then started cleaning, mopping up as much water as possible with towels and then wringing them out into the trashcan.

R&R

This Saturday, a friend and I took a day of R&R at the Hotel Serena in Kigali. Even though we were only a few blocks from my house, it felt like we were a world away on vacation. We began the day with the hotel’s breakfast buffet, which was exactly what I’d been missing – crepes, eggs, sausage, fresh bread, tomatoes, bacon, potatoes, fruit, real juice, coffee. It was perfect, especially sitting on the porch overlooking the garden and the pool. After breakfast, we moved down to a couple lounge chairs by the pool. The next few hours were spent laying in the sun, drinking Fanta and watching the past two weeks' episodes of Grey’s Anatomy (it only takes a couple days to download an episode on iTunes!). Eventually we decided to go for a swim, which was nice, even if the paint from the bottom of the pool did dye our feet bright blue. The best part of the day, though, was probably the shower I took after swimming. I’m sure it probably sounds strange to be so excited over a shower, but if you’d been using the shower at my house for the past six weeks, you’d be thrilled to have both hot water and water pressure too. After a late lunch and some more lounging by the pool (and maybe another shower, if I dare admit it), we went to Bourbon Café, a new, very-western coffee shop, complete with comfortable couches and wireless internet. Not a bad vacation considering I never left town!

To an English friend in Africa

I may not be English, but an English friend who works with me here in Kigali forwarded this to me, and I thought I would share it:

Be grateful for freedom
To see other dreams.
Bless your loneliness as much as you drank
Of your former companionships.
All that you are experiencing now
Will become moods of future joys
So bless it all.
Do not think your ways superior
To another's
Do not venture to judge
But see things with fresh and open eyes
Do not condemn
But praise what you can
And when you can't be silent.

Time is now a gift for you
A gift of freedom
To think and remember and understand
The ever perplexing past
And to re-create yourself anew
In order to transform time.

Live while you are alive.
Learn the ways of silence and wisdom
Learn to act, learn a new speech
Learn to be what you are in the seed of your spirit
Learn to free yourself from all things that have moulded you
And which limit your secret and undiscovered road.

Remember that all things which happen
To you are raw materials
Endlessly fertile

Endlessly yielding of thoughts that could change
Your life and go on doing for ever.

Never forget to pray and be thankful
For all the things good or bad on the rich road;
For everything is changeable
So long as you live while you are alive.

Fear not, but be full of light and love;
Fear not but be alert and receptive;
Fear not but act decisively when you should;
Fear not, but know when to stop;
Fear not for you are loved by me;
Fear not, for death is not the real terror,
But life - magically - is.

Be joyful in your silence
Be strong in your patience
Do not try to wrestle with the universe
But be sometimes like water or air
Sometimes like fire

Live slowly, think slowly, for time is a mystery.
Never forget that love
Requires that you be
The greatest person you are capable of being,
Self-generating and strong and gentle -
Your own hero and star.

Love demands the best in us
To always and in time overcome the worst
And lowest in our souls.
Love the world wisely.

It is love alone that is the greatest weapon
And the deepest and hardest secret.

So fear not, my friend.
The darkness is gentler than you think.
Be grateful for the manifold
Dreams of creation
And the many ways of unnumbered peoples.

Be grateful for life as you live it.
And may a wonderful light
Always guide you on the unfolding road.

(Ben Okri, March 1991)

World clock

A professor from Emory recently sent an email with a link to a website that I saw a long time ago but had forgotten about. It's called the World Clock and counts disease incidence, population factors and other statistics. I thought some of ya'll might find it interesting: http://www.poodwaddle.com/worldclock.swf.

Billboards

In the time that I’ve spent driving in Kigali and around Rwanda, there are a couple things that have truly surprised me. One of the most amazing is that the vast majority of billboards are devoted to HIV/AIDS. I’m yet to figure out what exactly they say, but throughout the country, billboards are covered with red ribbons and mention of ‘SIDA’.

Trusses and siding

Perhaps it means I’ve spent too much time around construction in the U.S., but I feel the need to take pictures of construction sites here in Rwanda. The most recent one I’ve seen was in a village near Nyungwe Forest this weekend. I have to admit, I was impressed by the truss system and the siding on this building.

Nyungwe Forest National Park

Since Friday was a national holiday, six of us decided to take a weekend trip to Nyungwe Forest National Park, an incredible rainforest in the southwest corner of Rwanda.

Early on Friday morning, we bought tickets and boarded a minibus at the bus station in Kigali. The bus was meant to hold twenty people (four in each row), but the three of us in the backseat bought an extra ticket so we could have a little extra space on the five hour trip. It turned out to be the best decision of the day; we still didn’t have a lot of room and the ride still wasn’t very comfortable, but I can’t imagine making the five-hour trip with four of us packed into the seat.

When we arrived in Nyungwe, we unpacked and had lunch at the guesthouse, and then went trekking for a colony of colobus monkeys. As soon as we started out on our trip, it started pouring rain, so within a few minutes we were soaked, but we continued anyway. We first had to hike through a tea plantation to get to the area where the colony of monkeys lives. As we hiked, the rain just kept pouring harder and harder. Eventually we stopped to wait for it to let up a bit.The rain never really let up so we continued into the forest. As the rain continued to pour, I was convinced that we wouldn’t see any of the monkeys. Finally, however, we spotted three sitting in a tree. We walked a little farther to try to get a better look, and saw a couple more. Even farther down the trail, we arrived at a point where we could see six or eight. We stopped to watch them for a few minutes, and the rain stopped. They were difficult to spot, but if you look closely, you should be able to see two of the black and white monkeys in this picture. One is near the top, just to the left of the center, and the other is more hidden at the bottom just to the right of the center.With the rain gone, the clouds also started to clear and we had a beautiful view into the distance. Just past the trees, we could see Lake Kivu and, beyond that, the hills of the Democratic Republic of Congo.
Finally, cold and wet, we returned to the guesthouse. One of the men took our shoes to be washed and dried while we ate dinner. Afterwards, we gathered around a fire in a small, covered area. While we were there, the man returned with our shoes, which had been washed, but not dried, so they were dripping wet, inside and out. We spent the next two or three hours roasting our shoes over the fire.

The next morning, we again got up early to hike to a waterfall in the forest. This time, the weather was perfect. It was sunny, warm and breezy as we again hiked through the tea plantation toward the forest.

Then we entered the forest and started the real hike. As we hiked, our guide showed us several trees and fruits and explained which ones were used to make clothing, which were used to start fires before matches were available, which the gorillas and chimpanzees ate, which the diviners in the village used to make candles to read the future, etc.
After a couple hours, we made it to the waterfall. We climbed to a rock just at the bottom of the falls and were surrounded by a beautiful scene. The forest rose up all around us, and in front of us was a huge, powerful waterfall. None of my pictures do it justice.

Finally, we hiked back out of the forest to the guesthouse. Some of the group had planned to stay another night, but three of us caught a bus back to Kigali so we could work today. I can’t decide whether the ride back was better or worse than the ride there. We were on a larger bus than before, which was much, much more comfortable, but it also drove much, much faster than the minibus, which made some of the mountain curves a little terrifying. But we made it back to Kigali, safe and sound, in just over four hours.

A national holiday?

Even though less than ten percent of the population is Muslim, Eid al Fitr, which marks the end of Ramadan, is a national holiday in Rwanda. However, the date of the holiday apparently depends on an interpretation of the moon, so it cannot be set ahead of time. Instead, an approximate date is set and an announcement is made on the radio on the morning of the holiday. So we knew the holiday would be either Friday or Saturday (making the holiday from work either Friday or Monday), but we had to wait for a radio announcement to find out which it would be. Now, the thing to note is that (1) I don’t have a radio, and (2), even if I did, the announcement would be made in Kinyarwanda. Thankfully, our medical director offered to send text messages to all of the expats when the announcement was made, and the announcement was made early, so on Thursday night we found out that Friday would be a holiday. Even though we had scheduled approximately forty clinic visits and planned a full day at the counseling and testing centers, there would be no work. Instead we would post a notice on the gate at each site and take a vacation.

In and around Kibuye

On Sunday afternoon, we decided to explore town and drive up in to the hills just behind Kibuye.

Again, the views were incredible.
As we drove, all cares and concerns seemed far, far away, at least until we ran into a group of Congolese refugees and were reminded of the harsher realities that coexist with the beauty of this place. Three young girls were making their way up the road to a refugee camp on top of the mountain. They had at least fourteen more kilometers to walk before they made it there.
Although we decided it would be best not to visit the camp, we did drive close enough to see it.
After our drive, we went to the market in town. Almost as soon as we arrived, though, it started pouring rain, and we had to split up and seek refuge under the awnings of the storefronts.
Waiting under the awnings for the rain to stop turned out to be a surprisingly fun, especially since almost everyone wanted their picture taken.

Kibuye genocide memorial

On Sunday morning we went to the genocide memorial church in Kibuye.
During the genocide, four thousand people sought refuge in this church. A mobbed attacked, throwing grenades through the stained glass windows and then using machetes to kill anyone who survived the explosions. Within three hours, all four thousand were killed. For a long while, the church remained deserted and scarred, but over time, it has been restored. The stained glass windows have been replaced, as have the carvings on the walls and the altar.
Outside there is a memorial to those who were killed and a mass grave for many of the bodies.
We arrived at the very end of Sunday morning worship. We were greeted by a huge crowd of children as the melody of final hymn from the service drifted outside. While we played and laughed with the children, the service ended and an enormous crowd exited the church. Many from the crowd greeted us and I was amazed at their hospitality. I found it truly amazing that there was such vibrancy and life at this place where such a horrific event had taken place. Yet the church was filled and the children welcomed us with huge smiles.

Weekend in Kibuye

This weekend, seven of us went to Kibuye, a town on the coast of Lake Kivu, a volcanic lake in western Rwanda on the border with the Democratic Republic of Congo (DRC). Kibuye is only about two and a half or three hours from Kigali, and the drive through the moutainous country was much better than I expected. The roads here are surprisingly good (thanks to the Chinese) and the scenery is gorgeous.We stayed at the Hotel Centre Bethanie, a Presbyterian retreat and hotel on a small penninsula on the lake. The entire scene was beautiful, especially the view from our rooms.

After we arrived on Saturday, we had lunch and then decided to take a boat ride on a wooden double-decker with lots of character.

We took the boat out to two islands in the lake. Once we were on the water, the view back toward Rwanda was incredible and across the lake we could barely see the DRC.The first island we visited, named 'Napoleon,' was uninhabited except for a few cattle and about a million bats. The second island was called Peace Island and had a small beach area where we hung out and swam for a while. I had no idea the lake would be so beautiful and so relaxing. It was a perfect vacation from work and from Kigali.