By Adapting Insights from the University at Buffalo, Zimbabwean Pharmacologist Fights AIDS in Africa

BUFFALO, N.Y. -- Amid the human catastrophe that is AIDS in Africa, the absence of health-care systems and practices that are taken for granted in other parts of the world routinely hampers efforts to care for patients even when assistance is being provided by international organizations and charities.

But in the city of Chitungwiza in Zimbabwe, a native son who is the nation's first pharmacologist is helping to remove these obstacles and provide meaningful care to HIV/AIDS patients as the result of a joint program between the University at Buffalo and the University of Zimbabwe (UZ).

As the only initiative in Zimbabwe -- and likely in all of sub-Saharan Africa -- with an exclusive focus on HIV/AIDS pharmacotherapy, the UB/UZ collaboration is ushering in new hope by adapting and applying the best pharmacy practices in the U.S. to conditions in the developing world.

"By breaking down the pharmacoeconomic barriers, one by one, we have created something that could be a breakthrough in the way African countries deal with AIDS," said Chiedza Maponga, Pharm.D., chair of the Department of Pharmacy at the University of Zimbabwe and visiting professor in the Department of Pharmacy Practice in the UB School of Pharmacy and Pharmaceutical Sciences, where he earned his doctorate in pharmacy.

These barriers not only are social and economic, but also logistical. For example, some AIDS drugs used to expire on the shelves of clinics in Zimbabwe without ever being used because the clinics had no inventory-tracking systems in place. Those systems are not just critical to the survival of Zimbabwe's AIDS patients; some charities and international aid organizations require evidence of such an infrastructure before they agree to donate resources.

During the past several years, through the UB/UZ collaboration, Maponga has been instrumental in building those systems by:

* Assisting the Chitungwiza City Health Department in obtaining a five-year, $500,000 grant from the U.S. Centers for Disease Control to develop community-based programs using lay volunteers to improve AIDS patients' adherence to treatment regimens. Maponga is the project's technical advisor.

* Serving as project consultant on a World Health Organization study of the quality of drugs available in Africa through post-marketing quality surveillance systems to detect substandard and counterfeit drugs.

* Using his position with the UB Pharmacology Support Laboratory, part of the NIH Adult AIDS Clinical Trials Group, to lay the groundwork for an International AIDS Clinical Trials Group, designed to address the problems of the developing world.

* Convincing the Zimbabwean government to declare AIDS a national emergency -- a declaration finally made in June 2002 -- which was necessary to allow for the distribution of generic drugs to AIDS patients. Maponga now serves as a member of the National Emergency Task Force on Antiretrovirals in Zimbabwe.

* Serving as a local consultant on the U.S. Agency for International Development (US AID) project, "Assessment of the Requirements for a National Antiretroviral Therapy Programme for Zimbabwe."

As a native of Zimbabwe and member of the international pharmacology community, Maponga travels easily between members of organizations that range from U.S.-based charitable groups like SAFE (Saving African Families Enterprise) and international pharmacology conferences to the U.S. Centers for Disease Control to women's groups in the community and traditional healers.

"We go where the issues are, and find ourselves becoming catalysts for all these groups, combining our expertise and theirs," explained Maponga. "We are networking all of them so we can look at their total impact and measure total outcomes so we can see what is working and what is not."

He noted that he worked with the Chitungwiza City Health Department to prepare the proposal that resulted in the $500,000 grant, as well as with SAFE, which ultimately donated the funds to allow for the distribution of the first generic drugs.

"How do you enable citizens to successfully communicate with charities," asked Maponga. "How do you help people write grant proposals that are worthy? How do you provide adherence training for lay volunteers in their communities? We have put systems into place that do all of these things through our collaboration with UB.

"We have actually started to raise hopes in the community," he said. "We don't want to write our manuscripts and leave. They are expecting us to continue."

This summer, Maponga was involved in facilitating Zimbabwe's first public program to administer triple-therapy antiretroviral drugs to AIDS patients. The antiretrovirals are considered state-of- the-art therapy for AIDS patients in the developing world since they have a known track record in prolonging life.

But it's not just drugs that Maponga and his colleagues are delivering.

"What we are providing now is not just the delivery of drugs, but coordination among all of the services, providing infrastructure, technical support, psychosocial support and pharmacology laboratory expertise to look for drug interactions and test generics for counterfeit ingredients," Maponga said.

Only a comprehensive pharmacological approach will work, he said, because so much is at stake.

For example, he explained, with the first administration of antiretroviral drugs, every effort is being made to ensure that the therapy is successful.

"For the first month that they are on this triple therapy, the women taking the drug are under severe scrutiny," he said.

The 20 women on therapy have been provided with cell phones so that they can immediately contact a nurse as soon as they notice a reaction.

Swift intervention is key not only to the individual patient's outcome, but with it comes risk -- the risk of losing patient trust throughout the community.

"If something fails, you have a major drawback," he said.

Maponga explained that the 20 women are the mothers of infants who were among the first in Chitungwiza to receive six months of treatment with nevirapine, a drug that prevents transmission of HIV to babies through breast milk.

"The first baby treated with nevirapine died after two days," recalls Maponga, noting that a tragedy like that could have jeopardized the whole effort. "It was baptism by fire," he said of the incident's potential impact.

However, working closely with the other mothers and using lay volunteers helped keep the other women committed to giving their babies the drug.

Maponga said that once the six months were up, the adherence-program volunteers continued to work with the mothers, forming support groups, emphasizing healthy lifestyle habits and treating opportunistic infections -- making them even better candidates for the antiretroviral therapy once it became available.

That holistic approach to HIV/AIDS, he explained, is critical to the new themes of expansion and sustainability of treatment called for by Nelson Mandela at the recent International AIDS Society in Paris.

And Maponga seems well-suited to delivering it.

He is the key to the bi-national collaboration, spending several months at a time each year at the facilities of UB and affiliated hospitals, such as the Erie County Medical Center (ECMC) in Buffalo, and then returning home to Zimbabwe for several months.

Maponga's UB position is funded by a fellowship from the National Institute of Allergies and Infectious Diseases of the National Institutes of Health.

While the fellowship runs out in December and funding for the program's future is uncertain, UB and UZ envision that at least five additional years of funding is necessary to expand the efforts with the training of additional pharmacologists.

In Chitungwiza, a city with a population of 1 million located just outside the Zimbabwean capital of Harare, Maponga has trained more than 250 community volunteers, including members of women's clubs and youth groups, schoolteachers and traditional healers to learn how to promote the safe use of medicines and adherence to treatment regimens among AIDS patients in Zimbabwe.

The UB/UZ collaboration recently purchased eight bicycles to allow some of the volunteers to travel into villages where some AIDS patients live, to deliver drugs and to counsel them on taking their medications.

"Our initial objective was to develop the adherence project," said Maponga, "but while we were doing that, it was not the only thing we were called on to do."

"Chiedza wears a lot of different hats," said Gene Morse, Pharm.D., chair of the Department of Pharmacy Practice and associate dean of clinical education and research with the UB School of Pharmacy and Pharmaceutical Sciences.

"It's not that common to find an individual with all of these capabilities," he added.

At UB, Maponga works in UB's Pharmacology Support Laboratory, part of the National Institutes of Health Adult AIDS Clinical Trials Group (ACTG).

According to Morse, who has chaired the Adult ACTG Pharmacology Committee of the NIH, the UB laboratory is an ideal environment for providing integrated HIV pharmacotherapy training, since it is one of very few places in the U.S. that combine research, education, clinical practice, training in adherence and state-of-the-art laboratory analysis.

Morse added that he believes that an international orientation is becoming essential to the future success of all aspects of HIV pharmacotherapy.

"UB's Department of Pharmacy Practice is well positioned to take a leadership role in shaping that international perspective -- through this collaboration with the University of Zimbabwe and others -- in HIV pharmacotherapy research, training and clinical service," he said.

The University of Rochester School of Medicine and Dentistry is collaborating on the UB/UZ project.