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The rise of a scourge

Manitobans played pivotal role in identifying AIDS epidemic

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Piecing the Puzzle: The Genesis of AIDS research in Africa

In 1984, Kenyan men were coming to the Casino Clinic in steady numbers loaded with infections and complaints.

The rural-Manitoba-born doctor, Frank Plummer, assisted by Kenyan administrator Ann Maingi, had been asking them about their sexual activities, and the answers laid out a pattern. In case after case, the infected men had visited prostitutes, known locally as commercial sex workers, and overwhelmingly the location was identified as a nearby shantytown.

Pumwani-Majengo is a densely-populated enclave of tin-roofed shacks that could stand as the quintessential definition of a shantytown. It is a community of cramped, overcrowded housing almost totally bereft of services: no electricity; water only from standpipes; sewers running open and smelly. A stream struggling behind the houses at the bottom of a ravine is totally clogged with garbage.

Few of the thousands of residents possess basic items like identity papers and nearly everybody is forced to cobble together a living in what an economist might best spin as "an informal manner."

A big part of this chaotic, informal economy is sex work: women entertaining clients in their meager huts. Hundreds of women still do such work, three to 10 clients a day, day after day after day.

The foreigners from Manitoba were not strangers to the shantytown. A year earlier a young doctor from Halifax, David Haase, doing his infectious diseases residency under the Portage La Prairie-born Dr. Allan Ronald, made the acquaintance of Dr. Elizabeth Ngugi, Kenya's deputy chief nursing officer and someone with a deep interest in the welfare of the shantytown residents.

Ngugi arranged for him to use a small clinic on the edge of the community to take care of sex workers. The building, owned by the Nairobi city council was simple but sturdy with a whitewashed facade. Nothing fancy, but in contrast to most construction in the shantytown, the glass was still in the windows, the floor remained un-cracked and the roof didn't leak.

Thirty years on, this clinic remains central to the project's operations. Then, as now, it was a squash of four or five examining rooms ringing a crowded reception. Through the open windows came an invasion of all the sights, sounds and smells of the tumultuous neighbourhood -- the market outside the clinic's front gates briskly selling everything from second-hand shoes to T-shirts, fruits and vegetables and even wedding dresses and lace tablecloths.

Every week, Haase would make his expedition not only to check the women and treat their sexually transmitted infections, but to collect serum samples which he took back with him and placed in frozen storage.

When Frank Plummer returned a year later, he decided he was going to gather a much larger cohort, maybe as many as 500 women, and from studying them, get to the bottom of the infections that were being passed back and forth and ending up on the examining tables of the downtown Casino Clinic. To make it happen, he approached Elizabeth Ngugi who promptly offered to arrange a "baraza" -- in shantytown parlance, a big party. There would be food, there would be jolliness, but the grand purpose behind it all would be addressing a local problem.

One of those present was Leslie Slaney, then a young lab technician from Winnipeg. She explains how basically everybody gathered in what was an old community hall.

"Elizabeth talked to the women about the infections and the risk and introduced the doctors from Canada who had come to help them. If they signed up, we would treat them for their infections."

Two hundred women showed up.

The baraza did its work. Great numbers of women from the Pumwani-Majengo shantytown agreed to keep coming to the little clinic near the corner of their local market.

"From then on we would see 150 women a week," says Leslie Slaney, "Wednesdays, Thursdays, and Friday morning."

The researchers took cervical swabs to test for various STIs. Slaney did the blood work and an American researcher named Joan Kreiss undertook the dark-field microscopy.

Joan Kreiss, though young when it all happened, is one of those pivotal figures who, wittingly or not, turned AIDS research, in the first heady days of the epidemic, in a direction from which it could never be turned back. She had started her medical education at UCLA, which placed her in Los Angeles at the time when the first cases of AIDS were recognized and reported.

After finishing her fellowship at UCLA, she moved to Seattle to study under the tutelage of King Holmes. Determined to continue working on this new disease, HIV, she persuaded Holmes to send her to Nairobi. There, though Plummer and Holmes tried to get her to help them with their studies on gonorrhoea, Kreiss had her heart set on HIV, and learning that Belgian researchers had located cases of it in Rwanda, insisted on pursuing the new mysterious disease. Holmes and Plummer relented.

When she set to work, Kreiss wanted a sub-set of the women already frequenting the Majengo clinic, five each day, among whom she was going to look for HIV. She set up two cohorts, one with those Majengo women and then another with a group of sex workers downtown.

"Prostitutes in different settings had different kinds and nationalities of partners," she explained as her rationale. "So I wanted to study women from a higher socioeconomic class setting."

She selected a bar attached to a downtown tourist hotel and persuaded the proprietor to rent her a room to be used as a temporary clinic. The bar, called "Buffalo Bill's, wanted you to believe you were in the American wild west, not Africa," Kreiss recalls.

"Its very distinctive and bizarre décor lent a somewhat surreal quality to the whole endeavor."

The research technique was to draw 25 millilitres of blood from each participant. Technologies designed to read what the samples showed were, at that time, rudimentary. Now, going on 30 years later, every clinic in Kenya can tell you within 15 minutes what your HIV status might be after the simple prick of a finger.

In 1984, this was far from the case. A local lab technician at the Kenyan Medical Research Institute was able to quantify T Cell subset numbers in the samples, which was immensely useful. In the absence of a proper serologic test, abnormalities in the T cell subsets was considered a useful surrogate marker for HIV infection, and seeing them gave the researchers some idea what they were looking at.

But getting a definitive result required a great deal more time and patience. The samples needed to be carried to America, to a lab at the National Institute of Health in Bethesda, Maryland, where the serum was tested for antibodies to HTLV-III. Then, for confirmation, they were submitted to something called the Western Blot test.

It took eight months for the official word to come back, and when it did, it was devastating. Of the 64 poorer sex workers from the Pumwani cohort, average age 29 years, 60 per cent were HIV positive.

Of the 29 women tested at the downtown bar, average age 24, 31 per cent were HIV positive.

Eight per cent of 40 men from the Casino Clinic were positive as was one person from the 42 medical students and lab staff who were tested as a control. There could be no doubt: HIV was in Kenya.

"Everybody was totally shocked," says Frank Plummer. "Here we had HIV already infecting two thirds of certain groups."

"We knew," adds Allan Ronald, "that we were looking at an epidemic."

Almost instantly, Plummer mapped out enlarged follow-up studies. One of them would be with a still larger group of commercial sex workers; the second promised to continue to follow women who were not infected with HIV in the first study to see if (and when) they might seroconvert.

Leaving no stone unturned, the researchers also went into the specimens collected by David Haase (with a kind of serendipitous foresight even though he claims he did not have AIDS in mind when collecting the samples and barely knew about the disease at the time), had them tested, and discovered that in 1983 there was already a four per cent infection rate, a rate that then jumped to 25 per cent two years later.

 

Piecing the Puzzle: The Genesis of AIDS Research in Africa by Larry Krotz is published by the University of Manitoba Press.

Award-winning journalist and filmmaker Larry Krotz has travelled to a number of African countries in the process of making documentaries and reporting for magazines and newspapers over the last 20 years. He has a special interest in scientific research and foreign aid projects in Angola, Zimbabwe, Tanzania, Rwanda and Kenya. Piecing the Puzzle: The Genesis of AIDS Research in Africa tells the story of University of Manitoba researchers doing some of the first HIV/AIDS research in Africa.

Republished from the Winnipeg Free Press print edition June 9, 2012 J14

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