Penn helps - and learns from - Botswana's HIV epidemic

When Ofole Mgbako, a fourth-year medical student, saw a patient having trouble breathing, he was at a loss about how to treat him. Back in the States, he would have ordered tests that would come back in 30 minutes or less and been able to draw up a care plan.

But in Botswana, where Mgbako, 26, was spending his summer with a University of Pennsylvania program, these tests were not always available. So he used his physical-exam skills to judge what drugs to prescribe, and the man soon recovered from respiratory distress.

Mgbako is one of many Penn students who travel to Botswana as part of a partnership among the Ivy League school, the University of Botswana, and the government there. The goal of the Botswana-UPenn Partnership is to improve and create systems to deal with the country's HIV/AIDS epidemic.

The program was established in 2001 in response to a request from the Botswana government for the Perelman School of Medicine's experts to help train local providers for its national HIV treatment and prevention programs.

On the ground, program staffers help distribute antiretroviral drugs, treat tuberculosis, and screen for cervical cancer. They also have helped in the founding of the country's first medical school.

About 110 doctors and staff from Penn now live and work full-time in Botswana. And hundreds of Penn students, residents, researchers, and faculty have traveled to the southern African country for short stints. They're primarily based at the Princess Marina Hospital in the capital, Gaborone, but they also travel to other hospitals and clinics around the country. The partnership has worked with the University of Botswana School of Medicine to get it launched and help train its faculty and students. The school will graduate its first medical students in the spring.

The partnership receives about $9 million a year in grants, about one third from the U.S. Public Health Service. The rest comes from National Institutes of Health grants, a Gates Grand Challenges grant, other agencies, and the Penn Center for AIDS Research.

Botswana has one of the world's highest HIV rates, but it is also one of the region's most economically stable countries "Their leadership was taking the crisis seriously," said partnership director Harvey Friedman, a professor of medicine in the division of Infectious Diseases. "It was a good place in which to invest our efforts."

HIV care has improved dramatically in the country since 2001. According to a 2012 United Nations report, Botswana leads sub-Saharan Africa, with 95 percent of infected people receiving antiretroviral care. Life expectancy has risen from 49 to 53 years in the last decade. Since distribution of antiretrovirals began, fewer than 4 percent of infants born to HIV-positive mothers are becoming HIV positive.

But Penn can't take all the credit.

"We had a role, not the role," Friedman said. "The government there gets great credit for what they've done."

The Botswana government under Festus Mogae, president from 1998 to 2008, became more proactive in fighting the epidemic. The Gates Foundation, the Harvard AIDS Initiative, and drug firms Merck and Bristol-Myers Squibb helped with antiretroviral distribution, and the government introduced routine testing for citizens.

Penn did play a major role in treating tuberculosis, which HIV patients are more susceptible to. Since its inception, the partnership has helped run a program to fight drug-resistant tuberculosis. It also created a screening and treatment program in 2009 for cervical cancer for women living with HIV.

But Botswana native Doreen Ramogola-Masire, the partnership's country director, struggles to get money for women's health efforts.

"We have to step back and look at the biggest problem - that most people are not aware of the link between HIV and HPV," she said.

HPV, or genital human papillomavirus, is the most common sexually transmitted infection. HIV patients may be less able to resist the papillomavirus, which causes certain cancers. But most resources go to HIV.

"About the time the country decided to provide [antiretrovirals], we lost a lot of donors," she said. "Our biggest issue is resources."

Friedman added that another challenge is "knowing what we should or shouldn't do. We're guests in the country, and it's important that we listen to what they need, rather than what we want to do. It's a fine line between doing too much and doing too little, and, at the same time, not trying to take over."

The Penn students at times find the lack of resources challenging. "It was frustrating to not always be able to diagnose patients and treat them the way we've been trained to treat them," said fourth-year medical student Julie Caplow. "The worst part was seeing a patient die from conditions that wouldn't have killed them here."

Mgbako agreed. "There were so many young people, my age, coming in at incredibly advanced stages of the disease. That was tough to see."

Botswana still faces many challenges. Though care is readily available, the government has to work on lowering new infections - nearly one-quarter of the population still lives with HIV/AIDS.

The success of Botswana's diamond-mining industry has also spurred the spread of HIV, putting miners in contact with multiple partners, concluded a 2003 study by the HIV research institute at the University of California, San Francisco.

Still, their time in Botswana is an experience the students wouldn't trade. Nazlee Navabi, a fifth-year medical student now in Botswana, is focused on improving her physical exams when tests are unavailable at Princess Marina. At the same time, much of what she sees in patients reminds her of those in Philadelphia.

She recalled one man who had chronic lung damage after years of toiling in the diamond mines.

"I enjoyed checking in on him, despite the language barrier," she said. "We made a connection, which is hard to describe, but it just felt very nice to be able to do that."

Heather Calvert, an associate director of the partnership, said, "The health story for Botswana is one of hope . . . they have gotten through the worst part of their AIDS crisis, but now they will need to finance a lifetime of [antiretroviral] therapy" for many people.

"And as people now live with HIV, the emerging diseases - they were always there, but people were dying so quickly we couldn't worry about them - are the same things that kill Americans: diabetes, heart disease, cancer."

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