Zambia

Decimation and Resurrection in the Land of Drums and Dance
BY DALE SHORT 
PHOTOS COURTESY OF ROB MCDONALD AND STEWART HILL


Zambia? That’s somewhere in Africa, isn’t it?
If you’re older than 50, you have a reasonable excuse for not knowing much about the nation of Zambia. A chunky, U-shaped mass of land slightly larger than the state of Texas and exactly centered in the southern half of the African continent, the country went by a different name in your 1960s geography textbooks: the British federation of Northern Rhodesia.

But Zambia by any other name would be just as beautiful, with its nine different vegetation zones, endless varieties of wildlife, and the mile-wide Victoria Falls—named for the British queen, by explorer David Livingstone of “Dr. Livingstone, I presume?” fame. Filling the sky with its giant rainbow of spray, Victoria Falls is one of the most photographed of African landscapes. The local tribes know the waterfall by a Bantu phrase that translates as “the smoke that thunders.”

But the people of Zambia are all too familiar with a different, and more recent, kind of manmade smoke and thunder: deadly riots and attempted political coups that savaged the nation during the 20th century, pitting rich against poor and poor against poorer, across countrysides where ruined antebellum-style mansions from the British Colonial era loom above the undergrowth like abandoned movie sets.

Today the country has a stable, democratically elected government and a growing tourism trade. But Zambia now faces a new kind of threat to its future, a threat that is silent and sometimes invisible: a rampaging epidemic of HIV/AIDS.

The numbers alone are staggering: Driven by the epidemic, Zambia’s death rate has catapulted to the fifth highest in the world. Of the country’s roughly 10 million people, two million—one in five—are estimated to be HIV-positive. In Zambia’s urban capital city, Lusaka, the infection rate is one in four. As many as 40 percent of women with HIV will transmit the disease to their babies, whose life spans are then reduced to a year or two.

The number of indirect victims is skyrocketing, as well. An estimated 630,000 Zambian children have already lost one, or both, of their parents to AIDS. And in an incredibly young country—half the population is age 15 or below—the next generation is rapidly becoming the next crisis, with tens of thousands of adolescents already carrying the virus themselves and passing it on to others.

But there’s hope on the horizon. An ambitious and unprecedented health initiative, led by the UAB Center for Infectious Disease Research in Zambia (CIDRZ) in partnership with the country’s Ministry of Health, is fighting AIDS on a number of fronts—from a public-information campaign that encourages testing and treatment to support for government clinics that dispense lifesaving anti-retroviral drugs free of charge, as well as a network of support groups that help HIV sufferers cope with the emotional devastation and the cultural stigma of contracting the illness.

Deadly Silence

Stigma has been perhaps among the major reasons the AIDS epidemic spiraled out of control after Zambia’s first diagnoses were made in 1984. Part of the problem is simple human nature—as evidenced by America’s reluctance to acknowledge its own AIDS crisis in the beginning, even as the death toll mounted, and the panic that ensued when the public believed (wrongly, as it turned out) that the disease could be spread by casual, everyday contact.

But two other factors exacerbated the situation in Zambia, says Isaac Zulu, M.D., a physician consultant for CIDRZ, a graduate of the UAB School of Public Health, and a Zambian native who watched with growing dread as the epidemic worsened: the country’s traditional belief system and political pressures.

“A large segment of the general population refused to believe that the disease really existed, even though there was some response from the government as early as 1986, establishing a program to protect the safety of blood transfusions. The sense of denial, sadly, continued throughout most of the 1990s. There was a silence so intense that it seemed almost like an official policy.”

 

Many Zambians don’t believe that accidents and illnesses are random life crises. Rather, they insist that such tragedies happen as judgment on individuals who either have done something wrong or have been bewitched by a supernatural spell. As a result, it’s not uncommon for wives who are diagnosed with HIV to be beaten and thrown out of their homes by their husbands—even though the husband is often the source of the transmission, because even married men frequently have multiple sexual partners. There’s also a superstition that a man with HIV can be cured by having sex with a young woman who’s a virgin.

Add to all of this the fact that the AIDS epidemic came at a time when foreign tourism was playing an increasing role in Zambia’s economy. Not surprisingly, political leaders were reluctant to acknowledge the full extent of the problem for fear of discouraging tourists.

But both the societal and political denials finally began to give way under the sheer volume of deaths, Zulu recalls: “When it got to the point where almost every family had lost someone, people started to realize that the silence was not helpful. By 1998, the local press started writing about the problem and calling on the government to do more work. That helped a lot with attitudes, and we saw more and more people coming forward for testing services. The stigma hasn’t all gone away, but fortunately we’ve seen a lot of change.”

Uphill Battles

The nerve center of UAB’s CIDRZ is a guarded clinic compound in a part of the capital known as the Kanyama district. The surrounding homes are mostly ramshackle and the people impoverished. Pit latrines serve as sewers, and during heavy tropical rains the flooding can start an outbreak of cholera. On a typical day, dozens of AIDS patients pass through the clinic’s front gate for testing and treatment. Most of them arrive on foot, others on bicycles. Patients who are too sick to walk are often brought by their families in wheelbarrows.

Clinic workers reported an increase in traffic after word began to spread in the community about recovering HIV patients who had previously been given up for dead. The improvements in their conditions were so dramatic that some residents attributed the change to witchcraft. But the true cause was new anti-retroviral drugs, given for free to patients who can’t even afford the government-subsidized cost of about $8 a month.

“Here, it’s the system that tends to fail, not the patient. So we continue to help strengthen that system, and it’s clearly getting better.”

“The stigma surrounding AIDS is a problem anywhere,” says Jeffrey Stringer, M.D., a UAB obstetrician/gynecologist, who directs the CIDRZ clinic along with his wife, Elizabeth Stringer, M.D., also a UAB ob/gyn physician. “In the U.S., we finally saw the tide start to turn for that stigma when we developed treatments that converted HIV from a death sentence to a chronic disease that has to be managed very carefully. And we’re starting to see that tide turn here in Zambia, where people are increasingly willing to come out and be tested.”

It’s been a hard-won victory, particularly in a country where women are “sometimes viewed as second-class citizens,” Elizabeth Stringer says. “They have to get permission from their husbands about so many things, such as pregnancy testing. All of that contributes to the stigma.”

Another complicating factor is the U.S. government’s current restrictions on recommending condom usage to Zambians. The President’s Emergency Plan for AIDS Relief (PEPFAR) program, launched in 2003, has provided an unprecedented amount of money, drugs, personnel, and equipment to fight HIV/AIDS in African, Asian, and Caribbean countries, but it is not provided without conditions. For example, “we are allowed to use U.S. funding to promote condoms only in ‘high-risk’ groups,” Jeffrey Stringer says. “But in a place where one in five people is infected . . . one in four, in cities . . . everybody who’s sexually active is, in a sense, at ‘high risk.’ So we have to work out ways for the funding for some of those messages to come from private sources.”

Traveling back and forth between Zambia and the United States has been a culture shock in other ways as well, the Stringers say. “It’s one of the most beautiful places you can imagine,” according to Elizabeth, “but the poverty is so overwhelming that it’s indescribable. There are wonderful rolling hills with little villages nestled in them. At first glance they look quaint and charming, but when you look closer you realize how desperately impoverished they are.

“But there are so many things to love about Zambia. Mainly, the people. For one thing, they’re so loving toward children . . . always picking them up, hugging them. Attitudes like that are a real plus.”

T-Cells Rising

As the Zambian AIDS project continues to grow, the Stringers find themselves spending more time with administrative tasks than clinical ones. The operation has outgrown its original health services building (funded by a grant from the University of Alabama Health Services Foundation), adding offices in three adjoining houses. From that base of operations, their team of some 30 Americans and 370 Zambian employees provides support services throughout a system of 24 district health clinics.

In addition to a shortage of traditional office space, the project has to overcome an ongoing “brain drain” of local medical professionals to train in HIV/AIDS care. “Because the country is so poor and health-care providers are so underpaid,” says Jeffrey, “they lose a great number of doctors to other countries—mainly the United States, the United Kingdom, and Australia.

“Our ultimate goal is to turn the program over to the Zambian government, who would coordinate, run, and fund it. All of these factors are ongoing challenges.”

What keeps the team motivated through their daily struggles, the Stringers say, are the medical success stories—which are plentiful. The number of support groups for patients is growing, and data for a recent six-month period show a substantial increase in the average patient’s T-cell count, which is evidence that they’re complying with treatment instructions and taking their medicines as prescribed.

“There’s an 11-year-old girl coming to our clinic right now whose parents both died of HIV,” Elizabeth says. “When we first saw her, she had huge ulcers on her skin, an inch deep. We thought she’d certainly die. But she’s improved to the point where she’s able to walk to the clinic and get her own medicine. It’s just incredible what these drugs can do.”

An older patient, a man who was one of the first in line to receive the free anti-retroviral drugs, weighed less than 80 pounds and was in critical condition when he began treatment. He began improving in a week or two, and has since doubled his weight.

“There’s a misperception that patients who are illiterate and medically unsophisticated can’t be trusted to take their drugs correctly,” adds Jeffrey. “But we’re finding that someone who’s poor and uneducated is about as likely to take their medicine on schedule as, say, a bank executive in the United States, if the health-care system can communicate the importance of the medication schedule.

“The larger problem here, especially in the more remote areas, is getting the drugs in the first place. If you’re receiving care back home at UAB, you’re never in a position where your medicines aren’t available. But here it’s very common for pharmacies to just run out. Shipments are often delayed during the rainy season, when so many roads are impassable. Or, you might go to a pharmacy and find that their fax machine has been out of order for months.

“Here, it’s the system that tends to fail, not the patient. So we continue to help strengthen that system, and it’s clearly getting better.”

Something else that’s improving is public awareness of HIV. Modern communication methods—from billboards to public-service TV announcements to a popular soap opera whose characters deal with HIV—are helping get the word out about the procedures for testing and treatment. And some old-fashioned outreach efforts are generating that crucial word of mouth, as well.

Street-Dance Salvation

In a scene that’s starting to play out in villages across the country, a circle of traditional native drummers and dancers gathers in a farmer’s market on the outskirts of Lusaka, bare-skinned except for their flashing grass skirts and bright-colored masks and anklets. To a casual passerby, the spectacle might easily seem to be a performance from a festival of centuries past, except for two prominent anachronisms: the group’s minivan parked nearby, and a promoter shouting into a battery-operated bullhorn, helping to draw a crowd.

As the bystanders increase and the dance progresses, its narrative suddenly takes a ribald, present-day turn. The star of the show jumps into the center of the action—the audience realizes it’s a man dressed in women’s clothing and, after initial confusion, they respond with laughter, catcalls, and applause. Before long, some of them join the dance themselves. Soon, the dance company gives way to a brief dramatic scene, a married couple having a dispute over whether they should be tested for HIV.

The performers are members of the Chipata Jungle Theatre, and their eye-catching burlesque is only the window dressing for a very serious message: Get tested and treated for HIV/AIDS, and use condoms to prevent the condition from spreading. In one shantytown, an audience of some 800 people recently gathered for the show. As each performance concludes, a community activist takes the megaphone and tells the crowd about clinic locations where the tests are performed.

The most common question: How much does it cost? The answer: Free. (To say that Zambia’s health-care resources are limited is an understatement. Even medicines to treat the side effects of AIDS, such as pneumonia, are too expensive for most people. A full course of anti-retroviral drugs for one AIDS sufferer runs about $5,000 per year, which means that the full cost of treating one million Zambians with AIDS, some $2 billion a year, would be more than half of the country’s gross domestic product.)

But not everyone in the audience is appreciative of the health message being delivered. From the edge of the crowd, a man shouts angrily that condoms are a sin, and people should practice abstinence instead. It’s a contentious point in a country where the most dominant of the Christian denominations is Catholicism, which preaches against contraception methods the church considers unnatural. The activist replies that abstinence is good, but that people who don’t abstain should use condoms for safety.

Though proven methods for prevention and treatment are being made accessible around the country, the religious controversy is not the only stumbling block to making those methods work. Patient compliance is another. As an old proverb puts it, “The devil is in the details.”

Studying the Strategies

Making those details work to the patient’s benefit was the mission last summer of UAB medical student Rob McDonald. Most days, McDonald and his team members ventured far into the countryside, to one of the dozen district clinics involved in the PEPFAR program.

“Basically, it’s about saving a continent.”

—Michael Saag, who contributed to an exhibit about UAB’s programs in Zambia as part of the Birmingham McWane Science Center’s Inside Africa exhibit, which runs through May 7.

“Our job was to collect information on missed clinic visits, by talking to teams of home-based caregivers who go to see patients who have missed appointments,” says McDonald. The reasons for missed appointments go into a database, and the information helps the decision-makers at CIDRZ spot trends and problem areas in the caregiving system. A sample finding: Many patients who miss appointments also give false home addresses to the clinic. Apparently they’re worried that strangers coming to their homes to deliver follow-up care might cause their neighbors to gossip.

McDonald and his colleagues also tracked patients who might have been given a drug called single-dose NVP in recent years. “Single-dose NVP has been the standard of care in much of the developing world for preventing mother-to-child HIV transmission during pregnancy,” he says, “and a research question of great practical significance right now is whether women who have taken that drug in the past will respond differently than non-NVP patients to the highly active anti-retroviral therapy for treating their long-term HIV.” Since far more women than men have come to clinics for testing and treatment thus far, such paperwork is no small task. In his first 11 weeks on the job, McDonald’s team reviewed more than 20,000 patient charts.

“So Many Funerals”

When McDonald first traveled to Zambia in 1997, it was for on-the-job training in administration at a research clinic after completing UAB’s MPH-MBA program, a hybrid degree in business and public health. He had no way of knowing the experience would change the course of his life.

“At the time, I couldn’t have cared less about HIV. I was just there to gain career experience. But I came away caring more about HIV than just about anything else. While I was working in Lusaka, seeing so many friends and co-workers die from the disease had a big impact on me.” He also began dating a young Zambian woman named Maggie who worked at the clinic, and as they grew closer, McDonald says, “I began to see, through her eyes, the true extent of the HIV epidemic here. So many funerals, so many lost young people.” This past October, Rob and Maggie celebrated their fifth wedding anniversary.

“I found a wife, a vision, a mission, and a focus for my life, all in the same place,” says McDonald. “I started medical school a year ago and became involved with local, national, and international community-based HIV organizations. I want to do whatever I can to improve the lives of people affected by HIV.”

Though he’s seen stories of hope in Zambia that amount to what he calls “the Lazarus effect, of people at death’s door responding to the anti-retroviral drugs and re-entering their previous lives again,” he’s also learned that the big picture is far more complicated than testing and treatment alone: “I realize I need to expand my focus to include public-health issues like clean water and transportation, and to address other diseases like tuberculosis and malaria that are important in areas where HIV hits the hardest. So I want to train in internal medicine, followed by learning more about infectious diseases. One day I’d like to practice medicine in Lusaka, providing care to the people who need it most, and also maintain ties to UAB, helping promote the transfer of technologies between the two places.

“And it’s not just a transfer of ‘rich country’ to ‘poor country,’” he notes. “It’s a two-way street. I think what we’re doing in Zambia with community sensitization and mobile voluntary counseling and testing centers could be implemented in Birmingham and elsewhere.”

Sequels of Success

Another member of the UAB project who’s finding the treatment data from Zambia to be cause for excitement is Michael Saag, M.D., director of the UAB Center for AIDS Research and of UAB’s 1917 Clinic for HIV/AIDS patients. Though most of Saag’s work with CIDRZ—such as designing Zambian treatment protocols for the anti-retroviral drugs—has been done at a distance, he visited last year to see the results firsthand. He and his teenage son Harry shot hours of video and created a short documentary titled The Plague That Thunders, which screened at Birmingham’s Sidewalk Moving Picture Festival in September 2005.

“We’ve now treated some 20,000 individuals,” Saag says. “And as far as we can tell, the outcomes—particularly the reduction in mortality—are remarkably similar, if not identical, to the results we’ve gotten in the U.S. The one area where we see some differences is in the range of available drugs, which isn’t as extensive in Zambia as here.”

In fact, the HIV/AIDS successes are so dramatic that they’re creating another health care challenge. Ironically, common conditions such as tuberculosis, diarrheal illnesses, and malaria are on the increase because people with AIDS are living longer. Tuberculosis is a special focus, Saag says, because patients with drug-resistant TB—who would already be dead of AIDS without the breakthrough of anti-retroviral drugs—are surviving and spreading their tuberculosis to others.

Doing More with Less

Some difficult choices remain for the CIDRZ, in fine-tuning the standard treatment program for Zambian AIDS sufferers. For example, Saag says that the center is about to launch a new study that will determine the benefits of a diagnostic test of “viral load”—the amount of detectable HIV in the blood—that’s routinely used in the U.S.

“We’ve elected not to use that particular test in Zambia, so that we can use the resources we have available to treat more patients. But we don’t know if we’re doing some harm by not checking viral load and changing failing regimens before the patient’s virus becomes resistant to available drugs. So, we’re comparing groups with and without the viral load test, who receive the same standard of care otherwise, to see if the test makes a difference in either health outcomes or the number of drug-resistant infections.”

UAB professionals from other disciplines who have toured CIDRZ say that the efficient use of resources is one of the most impressive aspects of the project. “What I saw is a remarkable initiative to create a fairly sophisticated health-care infrastructure for HIV treatment on top of a developing primary-care system,” says Max Michael, M.D., dean of the UAB School of Public Health. “I think that’s a tribute to the extraordinary partnership between local health officials, UAB investigators, and the Zambian people—who are kind, gentle, hard-working, and very focused on trying to solve a complex problem with limited resources.

“By necessity they’ve had to be creative in overcoming problems with consistent communications, effective medical records, data handling, transporting pharmaceuticals, and many other factors. And what they’ve achieved in that regard is extremely impressive.”

UAB provost Eli Capilouto, D.M.D., Sc.D., agrees. “It’s very satisfying to know that this international project had its seeds in classrooms and seminar rooms here at UAB, where physicians and students from both countries worked side by side to forge new approaches for treatment and research. It’s just a beautiful manifestation of the kinds of partnerships that can arise through education, research, and a shared passion for saving lives and improving the quality of life.

“The clinics, hospitals, and hospices that we visited previously were once overflowing with people—every bed was filled, and there were even beds on the floor, so it was difficult to walk. But this time the aisles were clear, because thousands of patients who once were near death are now living fairly normal lives. Their courage, perseverance, and commitment are an inspiration to us and give real meaning to the word hope.”


“What they’ve achieved in a modest infrastructure, particularly with their use of electronic databases, is very impressive,” says Robert Rich, M.D., dean of the School of Medicine. “Trying to understand what’s going on with care and treatment would be impossible without access to computer records, and they’ve been very savvy in making it all work.

“Of course, there are huge mountains still to climb. But I came away from that trip thinking that if all the HIV efforts around the world were functioning as well as UAB’s, we’d be in a much different situation.”

For Saag, the results so far show that the Zambia project has the potential to impact the country on two crucial fronts: “Our hope is that, as we treat more and more patients and their viral loads drop, not only will we be keeping people with AIDS alive, but we’ll also be fighting the epidemic by reducing their likelihood of transmitting the disease to other people. In addition, by reducing the mortality rate among young people living with AIDS, the productivity of the society will increase.

“Basically, it’s about saving a continent,” Saag says. “That’s a lofty goal. But believe it or not, it’s achievable.”

Decimation and Resurrection in the Land of Drums and Dance
BY DALE SHORT 
PHOTOS COURTESY OF ROB MCDONALD AND STEWART HILL


Zambia? That’s somewhere in Africa, isn’t it?
If you’re older than 50, you have a reasonable excuse for not knowing much about the nation of Zambia. A chunky, U-shaped mass of land slightly larger than the state of Texas and exactly centered in the southern half of the African continent, the country went by a different name in your 1960s geography textbooks: the British federation of Northern Rhodesia.

But Zambia by any other name would be just as beautiful, with its nine different vegetation zones, endless varieties of wildlife, and the mile-wide Victoria Falls—named for the British queen, by explorer David Livingstone of “Dr. Livingstone, I presume?” fame. Filling the sky with its giant rainbow of spray, Victoria Falls is one of the most photographed of African landscapes. The local tribes know the waterfall by a Bantu phrase that translates as “the smoke that thunders.”

But the people of Zambia are all too familiar with a different, and more recent, kind of manmade smoke and thunder: deadly riots and attempted political coups that savaged the nation during the 20th century, pitting rich against poor and poor against poorer, across countrysides where ruined antebellum-style mansions from the British Colonial era loom above the undergrowth like abandoned movie sets.

Today the country has a stable, democratically elected government and a growing tourism trade. But Zambia now faces a new kind of threat to its future, a threat that is silent and sometimes invisible: a rampaging epidemic of HIV/AIDS.

The numbers alone are staggering: Driven by the epidemic, Zambia’s death rate has catapulted to the fifth highest in the world. Of the country’s roughly 10 million people, two million—one in five—are estimated to be HIV-positive. In Zambia’s urban capital city, Lusaka, the infection rate is one in four. As many as 40 percent of women with HIV will transmit the disease to their babies, whose life spans are then reduced to a year or two.

The number of indirect victims is skyrocketing, as well. An estimated 630,000 Zambian children have already lost one, or both, of their parents to AIDS. And in an incredibly young country—half the population is age 15 or below—the next generation is rapidly becoming the next crisis, with tens of thousands of adolescents already carrying the virus themselves and passing it on to others.

But there’s hope on the horizon. An ambitious and unprecedented health initiative, led by the UAB Center for Infectious Disease Research in Zambia (CIDRZ) in partnership with the country’s Ministry of Health, is fighting AIDS on a number of fronts—from a public-information campaign that encourages testing and treatment to support for government clinics that dispense lifesaving anti-retroviral drugs free of charge, as well as a network of support groups that help HIV sufferers cope with the emotional devastation and the cultural stigma of contracting the illness.

Deadly Silence

Stigma has been perhaps among the major reasons the AIDS epidemic spiraled out of control after Zambia’s first diagnoses were made in 1984. Part of the problem is simple human nature—as evidenced by America’s reluctance to acknowledge its own AIDS crisis in the beginning, even as the death toll mounted, and the panic that ensued when the public believed (wrongly, as it turned out) that the disease could be spread by casual, everyday contact.

But two other factors exacerbated the situation in Zambia, says Isaac Zulu, M.D., a physician consultant for CIDRZ, a graduate of the UAB School of Public Health, and a Zambian native who watched with growing dread as the epidemic worsened: the country’s traditional belief system and political pressures.

“A large segment of the general population refused to believe that the disease really existed, even though there was some response from the government as early as 1986, establishing a program to protect the safety of blood transfusions. The sense of denial, sadly, continued throughout most of the 1990s. There was a silence so intense that it seemed almost like an official policy.”

 

Many Zambians don’t believe that accidents and illnesses are random life crises. Rather, they insist that such tragedies happen as judgment on individuals who either have done something wrong or have been bewitched by a supernatural spell. As a result, it’s not uncommon for wives who are diagnosed with HIV to be beaten and thrown out of their homes by their husbands—even though the husband is often the source of the transmission, because even married men frequently have multiple sexual partners. There’s also a superstition that a man with HIV can be cured by having sex with a young woman who’s a virgin.

Add to all of this the fact that the AIDS epidemic came at a time when foreign tourism was playing an increasing role in Zambia’s economy. Not surprisingly, political leaders were reluctant to acknowledge the full extent of the problem for fear of discouraging tourists.

But both the societal and political denials finally began to give way under the sheer volume of deaths, Zulu recalls: “When it got to the point where almost every family had lost someone, people started to realize that the silence was not helpful. By 1998, the local press started writing about the problem and calling on the government to do more work. That helped a lot with attitudes, and we saw more and more people coming forward for testing services. The stigma hasn’t all gone away, but fortunately we’ve seen a lot of change.”

Uphill Battles

The nerve center of UAB’s CIDRZ is a guarded clinic compound in a part of the capital known as the Kanyama district. The surrounding homes are mostly ramshackle and the people impoverished. Pit latrines serve as sewers, and during heavy tropical rains the flooding can start an outbreak of cholera. On a typical day, dozens of AIDS patients pass through the clinic’s front gate for testing and treatment. Most of them arrive on foot, others on bicycles. Patients who are too sick to walk are often brought by their families in wheelbarrows.

Clinic workers reported an increase in traffic after word began to spread in the community about recovering HIV patients who had previously been given up for dead. The improvements in their conditions were so dramatic that some residents attributed the change to witchcraft. But the true cause was new anti-retroviral drugs, given for free to patients who can’t even afford the government-subsidized cost of about $8 a month.

“Here, it’s the system that tends to fail, not the patient. So we continue to help strengthen that system, and it’s clearly getting better.”

“The stigma surrounding AIDS is a problem anywhere,” says Jeffrey Stringer, M.D., a UAB obstetrician/gynecologist, who directs the CIDRZ clinic along with his wife, Elizabeth Stringer, M.D., also a UAB ob/gyn physician. “In the U.S., we finally saw the tide start to turn for that stigma when we developed treatments that converted HIV from a death sentence to a chronic disease that has to be managed very carefully. And we’re starting to see that tide turn here in Zambia, where people are increasingly willing to come out and be tested.”

It’s been a hard-won victory, particularly in a country where women are “sometimes viewed as second-class citizens,” Elizabeth Stringer says. “They have to get permission from their husbands about so many things, such as pregnancy testing. All of that contributes to the stigma.”

Another complicating factor is the U.S. government’s current restrictions on recommending condom usage to Zambians. The President’s Emergency Plan for AIDS Relief (PEPFAR) program, launched in 2003, has provided an unprecedented amount of money, drugs, personnel, and equipment to fight HIV/AIDS in African, Asian, and Caribbean countries, but it is not provided without conditions. For example, “we are allowed to use U.S. funding to promote condoms only in ‘high-risk’ groups,” Jeffrey Stringer says. “But in a place where one in five people is infected . . . one in four, in cities . . . everybody who’s sexually active is, in a sense, at ‘high risk.’ So we have to work out ways for the funding for some of those messages to come from private sources.”

Traveling back and forth between Zambia and the United States has been a culture shock in other ways as well, the Stringers say. “It’s one of the most beautiful places you can imagine,” according to Elizabeth, “but the poverty is so overwhelming that it’s indescribable. There are wonderful rolling hills with little villages nestled in them. At first glance they look quaint and charming, but when you look closer you realize how desperately impoverished they are.

“But there are so many things to love about Zambia. Mainly, the people. For one thing, they’re so loving toward children . . . always picking them up, hugging them. Attitudes like that are a real plus.”

T-Cells Rising

As the Zambian AIDS project continues to grow, the Stringers find themselves spending more time with administrative tasks than clinical ones. The operation has outgrown its original health services building (funded by a grant from the University of Alabama Health Services Foundation), adding offices in three adjoining houses. From that base of operations, their team of some 30 Americans and 370 Zambian employees provides support services throughout a system of 24 district health clinics.

In addition to a shortage of traditional office space, the project has to overcome an ongoing “brain drain” of local medical professionals to train in HIV/AIDS care. “Because the country is so poor and health-care providers are so underpaid,” says Jeffrey, “they lose a great number of doctors to other countries—mainly the United States, the United Kingdom, and Australia.

“Our ultimate goal is to turn the program over to the Zambian government, who would coordinate, run, and fund it. All of these factors are ongoing challenges.”

What keeps the team motivated through their daily struggles, the Stringers say, are the medical success stories—which are plentiful. The number of support groups for patients is growing, and data for a recent six-month period show a substantial increase in the average patient’s T-cell count, which is evidence that they’re complying with treatment instructions and taking their medicines as prescribed.

“There’s an 11-year-old girl coming to our clinic right now whose parents both died of HIV,” Elizabeth says. “When we first saw her, she had huge ulcers on her skin, an inch deep. We thought she’d certainly die. But she’s improved to the point where she’s able to walk to the clinic and get her own medicine. It’s just incredible what these drugs can do.”

An older patient, a man who was one of the first in line to receive the free anti-retroviral drugs, weighed less than 80 pounds and was in critical condition when he began treatment. He began improving in a week or two, and has since doubled his weight.

“There’s a misperception that patients who are illiterate and medically unsophisticated can’t be trusted to take their drugs correctly,” adds Jeffrey. “But we’re finding that someone who’s poor and uneducated is about as likely to take their medicine on schedule as, say, a bank executive in the United States, if the health-care system can communicate the importance of the medication schedule.

“The larger problem here, especially in the more remote areas, is getting the drugs in the first place. If you’re receiving care back home at UAB, you’re never in a position where your medicines aren’t available. But here it’s very common for pharmacies to just run out. Shipments are often delayed during the rainy season, when so many roads are impassable. Or, you might go to a pharmacy and find that their fax machine has been out of order for months.

“Here, it’s the system that tends to fail, not the patient. So we continue to help strengthen that system, and it’s clearly getting better.”

Something else that’s improving is public awareness of HIV. Modern communication methods—from billboards to public-service TV announcements to a popular soap opera whose characters deal with HIV—are helping get the word out about the procedures for testing and treatment. And some old-fashioned outreach efforts are generating that crucial word of mouth, as well.

Street-Dance Salvation

In a scene that’s starting to play out in villages across the country, a circle of traditional native drummers and dancers gathers in a farmer’s market on the outskirts of Lusaka, bare-skinned except for their flashing grass skirts and bright-colored masks and anklets. To a casual passerby, the spectacle might easily seem to be a performance from a festival of centuries past, except for two prominent anachronisms: the group’s minivan parked nearby, and a promoter shouting into a battery-operated bullhorn, helping to draw a crowd.

As the bystanders increase and the dance progresses, its narrative suddenly takes a ribald, present-day turn. The star of the show jumps into the center of the action—the audience realizes it’s a man dressed in women’s clothing and, after initial confusion, they respond with laughter, catcalls, and applause. Before long, some of them join the dance themselves. Soon, the dance company gives way to a brief dramatic scene, a married couple having a dispute over whether they should be tested for HIV.

The performers are members of the Chipata Jungle Theatre, and their eye-catching burlesque is only the window dressing for a very serious message: Get tested and treated for HIV/AIDS, and use condoms to prevent the condition from spreading. In one shantytown, an audience of some 800 people recently gathered for the show. As each performance concludes, a community activist takes the megaphone and tells the crowd about clinic locations where the tests are performed.

The most common question: How much does it cost? The answer: Free. (To say that Zambia’s health-care resources are limited is an understatement. Even medicines to treat the side effects of AIDS, such as pneumonia, are too expensive for most people. A full course of anti-retroviral drugs for one AIDS sufferer runs about $5,000 per year, which means that the full cost of treating one million Zambians with AIDS, some $2 billion a year, would be more than half of the country’s gross domestic product.)

But not everyone in the audience is appreciative of the health message being delivered. From the edge of the crowd, a man shouts angrily that condoms are a sin, and people should practice abstinence instead. It’s a contentious point in a country where the most dominant of the Christian denominations is Catholicism, which preaches against contraception methods the church considers unnatural. The activist replies that abstinence is good, but that people who don’t abstain should use condoms for safety.

Though proven methods for prevention and treatment are being made accessible around the country, the religious controversy is not the only stumbling block to making those methods work. Patient compliance is another. As an old proverb puts it, “The devil is in the details.”

Studying the Strategies

Making those details work to the patient’s benefit was the mission last summer of UAB medical student Rob McDonald. Most days, McDonald and his team members ventured far into the countryside, to one of the dozen district clinics involved in the PEPFAR program.

“Basically, it’s about saving a continent.”

—Michael Saag, who contributed to an exhibit about UAB’s programs in Zambia as part of the Birmingham McWane Science Center’s Inside Africa exhibit, which runs through May 7.

“Our job was to collect information on missed clinic visits, by talking to teams of home-based caregivers who go to see patients who have missed appointments,” says McDonald. The reasons for missed appointments go into a database, and the information helps the decision-makers at CIDRZ spot trends and problem areas in the caregiving system. A sample finding: Many patients who miss appointments also give false home addresses to the clinic. Apparently they’re worried that strangers coming to their homes to deliver follow-up care might cause their neighbors to gossip.

McDonald and his colleagues also tracked patients who might have been given a drug called single-dose NVP in recent years. “Single-dose NVP has been the standard of care in much of the developing world for preventing mother-to-child HIV transmission during pregnancy,” he says, “and a research question of great practical significance right now is whether women who have taken that drug in the past will respond differently than non-NVP patients to the highly active anti-retroviral therapy for treating their long-term HIV.” Since far more women than men have come to clinics for testing and treatment thus far, such paperwork is no small task. In his first 11 weeks on the job, McDonald’s team reviewed more than 20,000 patient charts.

“So Many Funerals”

When McDonald first traveled to Zambia in 1997, it was for on-the-job training in administration at a research clinic after completing UAB’s MPH-MBA program, a hybrid degree in business and public health. He had no way of knowing the experience would change the course of his life.

“At the time, I couldn’t have cared less about HIV. I was just there to gain career experience. But I came away caring more about HIV than just about anything else. While I was working in Lusaka, seeing so many friends and co-workers die from the disease had a big impact on me.” He also began dating a young Zambian woman named Maggie who worked at the clinic, and as they grew closer, McDonald says, “I began to see, through her eyes, the true extent of the HIV epidemic here. So many funerals, so many lost young people.” This past October, Rob and Maggie celebrated their fifth wedding anniversary.

“I found a wife, a vision, a mission, and a focus for my life, all in the same place,” says McDonald. “I started medical school a year ago and became involved with local, national, and international community-based HIV organizations. I want to do whatever I can to improve the lives of people affected by HIV.”

Though he’s seen stories of hope in Zambia that amount to what he calls “the Lazarus effect, of people at death’s door responding to the anti-retroviral drugs and re-entering their previous lives again,” he’s also learned that the big picture is far more complicated than testing and treatment alone: “I realize I need to expand my focus to include public-health issues like clean water and transportation, and to address other diseases like tuberculosis and malaria that are important in areas where HIV hits the hardest. So I want to train in internal medicine, followed by learning more about infectious diseases. One day I’d like to practice medicine in Lusaka, providing care to the people who need it most, and also maintain ties to UAB, helping promote the transfer of technologies between the two places.

“And it’s not just a transfer of ‘rich country’ to ‘poor country,’” he notes. “It’s a two-way street. I think what we’re doing in Zambia with community sensitization and mobile voluntary counseling and testing centers could be implemented in Birmingham and elsewhere.”

Sequels of Success

Another member of the UAB project who’s finding the treatment data from Zambia to be cause for excitement is Michael Saag, M.D., director of the UAB Center for AIDS Research and of UAB’s 1917 Clinic for HIV/AIDS patients. Though most of Saag’s work with CIDRZ—such as designing Zambian treatment protocols for the anti-retroviral drugs—has been done at a distance, he visited last year to see the results firsthand. He and his teenage son Harry shot hours of video and created a short documentary titled The Plague That Thunders, which screened at Birmingham’s Sidewalk Moving Picture Festival in September 2005.

“We’ve now treated some 20,000 individuals,” Saag says. “And as far as we can tell, the outcomes—particularly the reduction in mortality—are remarkably similar, if not identical, to the results we’ve gotten in the U.S. The one area where we see some differences is in the range of available drugs, which isn’t as extensive in Zambia as here.”

In fact, the HIV/AIDS successes are so dramatic that they’re creating another health care challenge. Ironically, common conditions such as tuberculosis, diarrheal illnesses, and malaria are on the increase because people with AIDS are living longer. Tuberculosis is a special focus, Saag says, because patients with drug-resistant TB—who would already be dead of AIDS without the breakthrough of anti-retroviral drugs—are surviving and spreading their tuberculosis to others.

Doing More with Less

Some difficult choices remain for the CIDRZ, in fine-tuning the standard treatment program for Zambian AIDS sufferers. For example, Saag says that the center is about to launch a new study that will determine the benefits of a diagnostic test of “viral load”—the amount of detectable HIV in the blood—that’s routinely used in the U.S.

“We’ve elected not to use that particular test in Zambia, so that we can use the resources we have available to treat more patients. But we don’t know if we’re doing some harm by not checking viral load and changing failing regimens before the patient’s virus becomes resistant to available drugs. So, we’re comparing groups with and without the viral load test, who receive the same standard of care otherwise, to see if the test makes a difference in either health outcomes or the number of drug-resistant infections.”

UAB professionals from other disciplines who have toured CIDRZ say that the efficient use of resources is one of the most impressive aspects of the project. “What I saw is a remarkable initiative to create a fairly sophisticated health-care infrastructure for HIV treatment on top of a developing primary-care system,” says Max Michael, M.D., dean of the UAB School of Public Health. “I think that’s a tribute to the extraordinary partnership between local health officials, UAB investigators, and the Zambian people—who are kind, gentle, hard-working, and very focused on trying to solve a complex problem with limited resources.

“By necessity they’ve had to be creative in overcoming problems with consistent communications, effective medical records, data handling, transporting pharmaceuticals, and many other factors. And what they’ve achieved in that regard is extremely impressive.”

UAB provost Eli Capilouto, D.M.D., Sc.D., agrees. “It’s very satisfying to know that this international project had its seeds in classrooms and seminar rooms here at UAB, where physicians and students from both countries worked side by side to forge new approaches for treatment and research. It’s just a beautiful manifestation of the kinds of partnerships that can arise through education, research, and a shared passion for saving lives and improving the quality of life.

“The clinics, hospitals, and hospices that we visited previously were once overflowing with people—every bed was filled, and there were even beds on the floor, so it was difficult to walk. But this time the aisles were clear, because thousands of patients who once were near death are now living fairly normal lives. Their courage, perseverance, and commitment are an inspiration to us and give real meaning to the word hope.”


“What they’ve achieved in a modest infrastructure, particularly with their use of electronic databases, is very impressive,” says Robert Rich, M.D., dean of the School of Medicine. “Trying to understand what’s going on with care and treatment would be impossible without access to computer records, and they’ve been very savvy in making it all work.

“Of course, there are huge mountains still to climb. But I came away from that trip thinking that if all the HIV efforts around the world were functioning as well as UAB’s, we’d be in a much different situation.”

For Saag, the results so far show that the Zambia project has the potential to impact the country on two crucial fronts: “Our hope is that, as we treat more and more patients and their viral loads drop, not only will we be keeping people with AIDS alive, but we’ll also be fighting the epidemic by reducing their likelihood of transmitting the disease to other people. In addition, by reducing the mortality rate among young people living with AIDS, the productivity of the society will increase.

“Basically, it’s about saving a continent,” Saag says. “That’s a lofty goal. But believe it or not, it’s achievable.”

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