Testimony of Michael Scheld, MD, Professor of Medicine, University of
Virginia

A unique private-public partnership between academicians of Africa and
North America, the pharmaceutical industry and others[^1] is attacking
the most pressing public health crisis of our time by supporting and
strengthening the medical academic infrastructure of an African nation
to better train and prepare its physicians, scientists, nurses,
pharmacists and laboratory technicians to respond to the challenge of
the HIV/AIDS epidemic in Africa.

In June of 2001, the Academic Alliance for AIDS Care and Prevention in
Africa (AA) was created to enhance the care of HIV infected people in
sub-Saharan Africa and to support preventive measures to stop further
transmission by developing a combination of clinical care, prevention
and research programs that would serve as the major training program for
African health-care professionals.

The unique aspect of this initiative was that academic physicians from
North America partnered with their academic colleagues from Uganda to
enhance the established academic structure of the Makerere Faculty of
Medicine and Institute of Public Health to achieve these training,
research and clinical objectives. This vision was shared with the
leadership of Pfizer, Inc. and subsequently funded by generous start-up
grants from Pfizer, Inc. and The Pfizer Foundation.

**The Infectious Diseases Institute of the Academic Alliance (IDI)**

The IDI is a 25,000 sq ft. clinical, prevention, training, education and
research facility that will be completed on the grounds of the Makerere
University Faculty of Medicine in February 2004, and will become an
academic institute within Makerere College of Health Sciences for the
sole support of AA programs. This will be the first new large size
facility built at the medical school in 30 years and will be able to
support the care of 10,000 persons with HIV/AIDS.

+------------------------------------+---------------------------------+
| Facility clinical resources        | > Training facilities include:  |
| include:                           |                                 |
+------------------------------------+---------------------------------+
| -   15 exam and 10 counseling      | -   medical library             |
|     rooms                          |                                 |
+------------------------------------+---------------------------------+
| -   an 8,000 sq. ft. state-of-the  | -   video conferencing and      |
|     art clinical laboratory        |     computer room               |
+------------------------------------+---------------------------------+
| -   x-ray                          | -   seminar and lecture halls.  |
+------------------------------------+---------------------------------+
| -   pharmacy                       |                                 |
+------------------------------------+---------------------------------+
| -   an AIDS Treatment Information  |                                 |
|     Center (ATIC), and             |                                 |
+------------------------------------+---------------------------------+
| -   a six bed procedure and        |                                 |
|     holding ward.                  |                                 |
+------------------------------------+---------------------------------+

**Clinical Programs**

The clinical program had been developed as an innovative model of
enhanced AIDS care that would be transferable to other urban and rural
African communities. It uses a team approach that has become the
standard of care in the western world, but which utilizes African
specific health care providers, African trained medical officers, nurse
practitioners, HIV clinical pharmacists, counselors, lab technicians and
physicians.

The program was initiated with the renovation and furnishing of new
space at Mulago Hospital for the AIDS Clinic in March of 2002.

-   The clinic expanded from 1 to 5 days a week with approximately 500
    patient visits/week and now cares for 3,000 HIV infected patients.

-   Clinical services are currently provided by senior physicians and
    trainees from Uganda and North America, medical officers, nurses,
    students and nursing aides.

The AA has partnered with the AIDS Support Organization (TASO) for
counseling services on site. To date the clinic has served as an
effective training experience for over 50 students, house staff, and
fellows from Uganda, North America and Europe.

-   Essential drugs and supplies are provided free to the patient.
    (Fluconazole has been donated by Pfizer and is currently being
    distributed in the clinic to over 200 patients with Cryptococcal
    meningitis).

-   Expansion of the Pediatric AIDS Clinic funded by a construction
    grant from the CDC, which has allowed the AA to support the care of
    approximately 500 children with HIV/AIDS.

-   An information technology system is being developed that will enable
    accurate data capture, storage and retrieval for efficient patient
    care and support for management of the expanding AA cohort and
    research.

A major commitment for the AA has been to find antiretroviral drugs for
its patients. Currently approximately 300 patients are receiving ART
from a combination of donations, self-pay and participation in research
studies. There are currently 200 patients receiving ART as part of the
Rockefeller Foundation funded DART study in partnership with the JCRC.
The Ministry of Health has committed ART for 600 patients from the
Global Fund allocation to Uganda and MAP 1 funds from the World Bank.
Glaxo, Abbott and Gilead have agreed to provide ART for clinical trials
for up to 350 patients. With the new facility opening in February 2004,
the clinic could treat up to 7,500 patients with ART by the end of 2005,
if resources for drugs and laboratory tests became available.

**Training Program for African Physicians**

A major focus of the AA initiative is to train health-care providers
from sub-Saharan Africa in enhanced AIDS care and prevention. An
intensive one month course was designed and a dynamic curriculum was
developed and is being constantly updated by the AA.

-   **Selection:** Trainees are selected by a committee of African
    physicians including the Ministry of Health on the basis of their
    potential for training others. The goal of the AA is to train 200
    African physicians each year.

-   **Content:** The trainee/trainers become competent to deliver high
    quality care including use of anti-retroviral therapy and are
    capable of training others.

**Accomplishments**

The first class graduated on May 31, 2002, and since then 130 physicians
from 10 countries in sub-Saharan Africa have completed the course and
are training other African caregivers. They represent a potentially
powerful group of providers for introducing and managing ART in the
region.

Additional training activities include:

-   **Academic Alliance Fellowship in Infectious Diseases:** The AA is
    committed to train future academicians for African medical schools,
    has initiated a three year fellowship program for young physicians
    committed to a career in Infectious Diseases/HIV/AIDS in Africa. Two
    fellows are now in training.

-   **Academic Alliance/Trinity College Training Program in HIV Clinical
    Pharmacy:** The AA has identified a need to train clinical
    pharmacists with expertise in ART and other AIDS treatment. A pilot
    training program has been initiated, in partnership with Trinity
    College in Dublin, Ireland, for four African pharmacists/yr to spend
    6 weeks gaining expertise in ART in Dublin and then returning to the
    IDI for further training in the IDI clinic.

**Future Training Directions**

The AA is currently in negotiations with the World Bank to participate
in an expansion of its program to train physician/teachers from
Ethiopia, Kenya & Tanzania by the summer of 2004. This is part of a MAP
2 program for building infrastructure for delivery of AIDS care for
sub-Saharan Africa. The AA also plans to develop similar courses for
nurses and laboratory workers.

**Outreach into the local and distant communities**

Outreach is a stated goal of the AA. The AA has engaged the Ugandan and
US government infrastructure (especially the Ministry of Health, The
Ugandan AIDS Commission and USAID) and other NGOs to help facilitate
communication and program development relative to the HIV prevention and
care. To date this effort has secured commitment to:

-   **Develop the first AIDS Treatment Information Center (ATIC) in
    sub-Saharan Africa** **to provide up-to-date essential clinical
    information for physicians & other health care providers caring for
    HIV infected patients**. Care-givers (especially graduates of the AA
    training program) will be linked to the center via phone, fax and
    e-mail, and will receive expert advice and information on their
    queries related to treatment including ART. The ATIC will also
    provide a mechanism for delivering continuing medical education to
    practicing clinicians caring for these patients. African HIV
    clinical pharmacists trained through the Drug Information Center, St
    James Hospital/Trinity College, Dublin-AA collaboration, will
    provide content.

-   **Publish a newsletter for care providers throughout Africa (*News
    From the ATIC*),** which will contain new information related to
    HIV/AIDS in the area and from abroad and to promote its services.
    The ATIC will be the interface between the AA and the outside world.

-   **Partner** with Hospice of Uganda, TASO. MildMay, the Joint
    Clinical Research Center (JCRC) and other AIDS clinical entities for
    in-service training, operational research and patient care
    activities.

In addition, the AA has already:

-   **Sponsored three seminars** on the relevant topics of prevention of
    HIV transmission in Uganda, Maternal to Child transmission (MTCT)
    for public health officials, academicians, clinicians, and for
    Ugandan and other African opinion leaders.

    -   **Organized three Continuing Medical Education (CME) courses**
        in Kampala and Masaka for its graduates and other Ugandan
        clinicians on advances in HIV/AIDS knowledge.

    -   **Facilitated the construction of an HIV/AIDS clinic** for its
        training graduates in the town of Rakai.

**Operational Research**

It has been the goal of the AA to establish a first rate program for
patient-based investigation focused on understanding the unique aspects
of HIV infections and other infectious diseases as they apply to Africa
and to determine the most effective and efficient approaches to
management and prevention.

To assist in guiding this effort, the AA has established:

-   A **Community Advisory Board** under the direction of Professor
    Edward Mbidde that includes representatives of business, government,
    the clergy, academia and persons living with HIV/AIDS who evaluate
    AA programs and particularly research protocols.

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-   An **International Scientific Advisory Board** giving direction to
    the training and research programs. Members include: King Holmes,
    University of Washington, Chairman; Ruth Nduati, Nairobi,
    Co-chairman; Joep Lange, IAS, Amsterdam; Alex Coutinho, TASO,
    Kampala; John Bartlett, Johns Hopkins, Baltimore; Q.A. Karim, U of
    Natal, South Africa; Cathy Wilfert, Elizabeth Glaser Pediatric AIDS
    Foundation, Durham; and Fred Mhalu, Tanzania.

**Current Operational Research Projects funded by public/private
support:**

-   **Clinical trials of antiretroviral therapy in the AA cohort**:
    Nearly 300 patients have been started on ART as part the DART study.
    The aim is to determine the potential value of managing AIDS
    patients using clinical criteria rather than expensive standard
    laboratory tests (CD4 and viral load) as markers for initiation of
    ART and monitoring for success or failure of treatment.

-   **Adherence:** An important focus of AA investigations has been to
    understand factors that affect adherence to ART. These studies have
    already determined that African patients take their medication
    better than American populations (93% adherence).

**Other funded efforts include a Gates Foundation grant for 2 years
(\$3.6 million):**

1.  To study the prevention strategy in the era of ART

2.  To develop African-specific clinical protocols for the management of
    HIV/AIDS related symptom complexes.

3.  To determine the most efficient laboratory methods necessary to
    effectively initiate and monitor ARV treatment.

4.  To develop the first in-hospital program in Africa to provide
    universal access to free voluntary, counseling & testing services

> **Founding Member of the Academic Alliance**

-   Professor Nelson Sewankambo, Dean, Faculty of Medicine, Makerere
    University, Uganda and Co-Chair of the Academic Alliance

-   Merle A. Sande, Professor of Medicine, University of Utah, USA and
    Co-Chair of the Academic Alliance

-   Jerrold J. Ellner, Chair, Department of Medicine, New Jersey School
    of Medicine, USA

-   Moses Kamya, Senior Lecturer, Makerere University, Uganda

-   E.T. Katabira, Professor, Internal Medicine, Makerere University,
    Uganda

-   Harriet Mayanja, Head Internal Medicine, Makerere University and
    Mulago Hospital, Uganda

-   E.K.Mbidde, Director Ugandan National Cancer Institute, Mulago
    Hospital, Uganda

-   Roy D. Mugerwa, Professor, Internal Medicine, Makerere University,
    Uganda

-   Phillipa Musoke, Senior Lecturer, Paediatrics, Makerere University,
    Uganda

-   Thomas Quinn, Professor of Medicine, International Health,
    Epidemiology and Immunology, Johns Hopkins University, USA

-   Allan Ronald, Distinguished Professor Emeritus, University of
    Manitoba, Canada

-   David Serwadda, Professor, Institute of Public Health, Makerere
    University, Uganda

-   Michael Scheld , Professor of Medicine, University of Virginia, USA

-   Fred Wabwire-Mangen, Director, Institute of Public Health, Makerere
    University, Uganda

**The Academic Alliance Foundation (AAF)** has recently been established
in Washington, DC, and will soon be registered in Uganda, for the
purpose of supporting and sustaining the activities of the Academic
Alliance and the programs and services of the Infectious Diseases
Institute.

For additional information contact: **Academic Alliance
Foundation,**1601 North Kent Street, Suite 1200, Arlington,Va 22209 USA
tel (703) 294-6551 fax (703) 522-6741

[^1]: Other major partners include: The Infectious Diseases Society of
    America (ISDA), Pangaea Global AIDS Foundation and Makerere
    University.