So it's now been about 1.5 months since I arrived in Malawi. You might be wondering, alright so when is he coming back from this 'extended vacation'. I should probably let you know that I'm not coming back anytime soon (well that's a lie, as I'll be back next month for a couple weeks for my sister's wedding) and that I'm not here for a vacation of any sorts. Of course, I will take vacations while here because how can you not go on a safari while in sub-Saharan Africa, but let's also not forget how much more the beautiful continent has to offer.
Hotel view from Blantyre, Malawi in the Southern region
A throwback to Lake Malawi because I just can't get over how gorgeous this lake is
So let me take you back real quick 5 years ago to when I was in graduate school. I was 22 years-old at the time and knew I was really interested in population health, infectious diseases, and outbreak investigations. I remember watching the movie contagion in one of my epidemiology courses and the whole outbreak investigation process for disease detection absolutely fascinated me. The steps and basic principles of epidemiology diving into the who, what, where, when, and why/how reminded me very much of the childhood board game I used to play called 'Clue'. The premise of the game is to gather clues and evidence to investigate and deduce which suspect murdered the game's perpetual victim. As weird as it may sound to many people, I was very intrigued and fascinated with serial killers and crime detective shows/stories growing up. I loved learning about what made people tick and behave the way they did as well as solving the missing pieces to an evolving and complex puzzle. Likewise, infectious disease epidemiology presented similar scenarios with complexity in terms of demographics, severity, mode(s) of transmission, mitigation and treatment options, as well as barriers to accessing care while keeping in mind equity and inclusion for all involved. As we have seen with the current pandemic, what happens in one part of the world can have detrimental or beneficial impacts on another region of the world. It's important to keep in mind that the pandemic will not end for anyone until it ends for everyone.
My interest in pandemic preparedness and prevention and global health in particular grew while taking a global infectious disease topics course during graduate school. It was a multidisciplinary course with a diverse range of students and faculty from all walks of life. We were discussing the response to the West African Ebola virus epidemic from 2013-2016. There was one editorial I recall reading that stood out to me. It stated, "the response to outbreaks and emergencies must start and end at ground level- which means that certain key capacities have to be in place before launching a response, including leadership and coordination, technical support, logistics, management of human resources, and communication. It also has shown that the organizations working to contain outbreaks and emergencies must work together closely and respectfully". During a public health emergency, leave out the egos and power dynamics and initiate collaboration, not competition. Work together and share ideas from all stakeholders involved, regardless of stature, race, religion, income, sex, or title. Oftentimes, listening is more productive than talking. Hearing and reading this as we worked together in cross-collaborative working groups for the course made me envision a future version of myself doing similar work with global agencies and stakeholders on the ground to solve complex health issues for populations.
Five years later and after multiple applications and interviews for a chance at this opportunity, I was offered the position of Global Surveillance and Epidemiology Fellow within the Division for Global HIV and Tuberculosis with the Center for Disease Control and Prevention based in Lilongwe, Malawi. The initial contract is for 1.5 years until August 2023. Having not much knowledge about Malawi as a whole, besides the fact that Madonna had invested in building several schools for children and adopted her son from there in 2006, I decided it was time to do some further digging. Malawi is a landlocked country with one of the largest lakes in the world running north to south of it. Lake Malawi also contains the most biodiverse species of fish of any lake in the world with over 1000, making it a prime destination for snorkeling and scuba diving. It is surrounded by Tanzania to the north, Zambia to the west, and Mozambique to the south and east.
It is often referred as the 'Warm Heart of Africa' due to the kind and hospitable nature of its inhabitants. One thing you'll have to get used to while here is making sure to always greet everyone you meet. Oftentimes in the US, we may ask someone how they are doing out of courtesy, but not even give them the proper time to respond and then subsequently allow them to ask the question back and receive a response. That won't swing here, and some people will not proceed forward until both parties have been offered adequate time to ask and respond to the question of 'how are you doing?' or 'Muli bwanji?' in Chichewa. Maybe something to learn from and consider the next time we ask the question or respond to it.
All that aside, I started to look a bit further into the health concerns and prevalence (total amount of new and existing cases in a population) of HIV/AIDS in the country.
More than 37 million individuals are now living with HIV worldwide. The hardest-hit region is sub-Saharan Africa, which accounts for 70% of all HIV/AIDS cases, followed by South and Southeast Asia, Latin America, and the Caribbean. The CDC Division of Global HIV/AIDS (DGHT) and Tuberculosis is part of the US President’s Emergency Plan for AIDS Relief (PEPFAR), the largest international health initiative ever by any nation dedicated to a single disease. It was started in 2003 by former president, George W. Bush. DGHT implements PEPFAR by providing direct government technical assistance to Ministries of Health and local implementing organizations to expand HIV/AIDS care and treatment services, implement effective HIV/AIDS prevention programs, conduct research on program impact and cost effectiveness, and build sustainable public health information, laboratory and management systems, and local workforce capacity.
While Malawi has a population of nearly 20 million people, the population started off with just 4 million after gaining independence from the British back in 1964. Among adults15-64 years-old in Malawi, about 10.6% are living with HIV with females at 12.8% and males at 8.9%. In contrast, the US has a total population of about 330 million and a HIV prevalence of about 0.4%. With the support of PEPFAR and advancements of HIV and treatments, major progress has been made in reaching epidemic control. For the role, in collaboration with the Ministry of Health and other implementing partners, I will be tasked with the analysis, response, evaluation, and implementation support of TRACE (Tracking with Recency Assays to Control the Epidemic) both within Malawi and for several neighboring countries. TRACE was launched in Malawi in 2019 to establish recent HIV infection surveillance systems in routine HIV services to detect, characterize, monitor, and intervene on recent infection (within the past 12 months) among newly diagnosed people living with HIV (PLHIV). Due to the pandemic, the expansion of the program was halted, but is now regaining momentum as COVID-19 resides in the region. The initiative is being implemented across many PEPFAR-supported countries, including in Cambodia, Caribbean, Central America, Ethiopia, Eswatini, Kenya, Lesotho, Malawi, Namibia, Nigeria, Rwanda, Tanzania, Thailand, Uganda, Vietnam, Zambia, and Zimbabwe. Several additional countries, such as South Africa, Nigeria, Kyrgyzstan, Tajikistan and others are expected to implement TRACE in the coming year.
TRACE utilizes a Sedia Biosciences developed Asante HIV-1 20 minute immunoassay point-of-care rapid test for recency infection that differentiates between recent and long-term HIV infection. It provides 'real-time' surveillance of recent HIV infections in a geographical region and helps provides more accurate estimations of the true incidence (new cases of disease in at-risk population over specific period of time) in a specified population. It is extremely fast, accurate, easy to use and implement, cost effective, and requires no laboratory infrastructure, which enables field testing and collection of recency data in resource constrained areas. It simply involves a finger-prick for blood collection from a lancet and within 20 minutes can provide whether the HIV-1 infection is classified as recent (within the past 12 months) or long-term (>12 months). It is also important to note that the test is intended for surveillance (population level) rather than diagnostic (individual level) purposes.
One line (control line) means negative result, two lines (control and verification) means recent HIV infection, and three lines (control, verification, and long-term) means long-term infection
For confirmation purposes, if the result comes back as recent infection, a dry blood spot sample is then collected to test for viral load count of the virus in the blood. If there are greater than 1000 copies/mL, we then confirm that the infection is in fact recent. If there are less than 1000 copies/mL in the blood, then we reclassify the infection as long-term (which can happen if a person was previously diagnosed with HIV and is currently on anti-retroviral medication to keep viral load low and then got retested). If there are a cluster of recent infections in a geographic region, we can likely attribute this to active ongoing transmission of the virus, in which tactical prevention resources and interventions need to be targeted. On the other hand, if the infection is classified as long-term we then can likely attribute this to a poor job of staying on top of the virus in detecting cases and getting infected people the anti-retroviral treatment they need in a timely fashion.
Malawi HIV Recency Training Seminar in Blantyre, Malawi this past week
The lab practical team
Thankfully someone knew how to take a proper selfie
My friend, lab partner, and translator
My friend and lunch buddy