Quarraisha Abdool Karim: investigating HIV/AIDS in South Africa

Abstract

Since the start of the HIV/AIDS epidemic, South African epidemiologist Quarraisha Abdool Karim has helped to understand how the disease is decimating her country's population, most notably by investigating how the epidemic affects women and how to prevent its spread through greater engagement with communities and participants in HIV prevention trials.While studying in the USA for a masters degree at Columbia University in 1988, under the mentorship of Zena Stein, Abdool Karim became aware of the two different HIV epidemics in New York: one prevalent in men who have sex with men and the other among injecting drug users. In 1989, she returned to a South Africa “on the brink of political change” and shortly thereafter investigated the prevalence of HIV in the general population; it turned out to be less than 1% at that time, but subsequent surveys soon “hinted at the rapidity with which HIV was spreading”, she recalls. Not only was HIV spreading, but it was three times more common in women than in men. As an activist during apartheid, Abdool Karim was attuned to issues of injustice; realising that social inequality meant that HIV/AIDS affected women disproportionately she pursued research aimed at unravelling this gender difference, including how sexual and reproductive rights and access to services affect HIV acquisition.In 2000, she completed a PhD about gender barriers to HIV prevention. Her supervisor Hoosen Coovadia, the Victor Daitz Chair in HIV/AIDS Research at the University of KwaZulu-Natal, acknowledges her role in highlighting the plight of women with HIV: “she introduced many of us to the centrality of women's issues, such as the urgency of finding women-controlled prevention methodologies, to control the spread of HIV. Long before most scientists had entered the field of HIV in South Africa, she accomplished one of the earliest epidemiological studies on HIV prevalence in KwaZulu-Natal, which provided a model for others and an idea of the spread of the infection across the country's porous borders.”As women move from their teens to their early twenties, their risk of HIV infection rises—about half of pregnant women aged 20–24 years who attend public-sector health clinics in KwaZulu-Natal are likely to be infected with HIV, she says. Many women are abstinent until marriage, but their husbands are either already infected or will become so during the course of the marriage. So, explains Abdool Karim, in this context the “ABC mantra”—the notion that abstinence, being faithful, and using condoms is enough to prevent HIV—falls short. Abdool Karim's work with women in South Africa has also revealed a complex picture of the definition of sex work: “There are women for whom it is a job, but others for whom it may be an occasional exchange of sex for money. In either case, it's an issue of survival.”Abdool Karim's focus on respect for human rights means she is just as concerned about the ethics of a research trial as she is about its results. In the early 1990s, Coovadia discussed a concern he had about how none of the mothers his team sought to recruit to an HIV study had refused to take part and he worried that they felt coerced. This got Abdool Karim thinking: “how do you assess whether participation is voluntary or coerced?” Because of South Africa's history, many people, herself included, had grown up deprived of many rights. Would disadvantaged groups, she wondered, appreciate their right to refuse participation in a trial or fully grasp the concept of consent forms? “If you've never had rights, how do you make sense of it?” In trials she ran, she began to establish with the local community what their understanding of the study was, and began to “develop my own criteria that could withstand scrutiny”, she says.Abdool Karim describes her career as a series of “serendipitous” events, but hard work clearly underpins everything she does. She divides her time between the USA—where she is co-Chair of the HIV Prevention Trials Network and Director of the Columbia University Southern African Fogarty AIDS International Training and Research Programme—and South Africa, where she is Associate Scientific Director of CAPRISA in Durban and an associate professor in public health and family medicine at the Nelson R Mandela School of Medicine, University of KwaZulu-Natal. This means that whichever country she's in, she works to both South African and US time zones, but “hours don't matter”, she says. Abdool Karim's husband, Salim, is also a respected HIV researcher, but there is no professional rivalry she says as their approaches are “complementary—he works at the detailed, molecular level; I am much more focused on the nexus between science, advocacy, and policy”.Any conversation about HIV in South Africa invariably turns to politics. After the denialism under Thabo Mbeki, it would seem that things can only get better. In 2007, Abdool Karim became part of the committee appointed by the Deputy State President in the Mbeki administration that developed the country's current 5-year strategic plan on HIV and she is positive about Jacob Zuma's presidency: “I am optimistic that under Zuma's leadership HIV is a priority.” But she adds that “A major challenge is ensuring delivery of prevention and treatment programmes to where they are most needed. HIV has shattered South Africa's hope of prosperity in the aftermath of apartheid—this virus affects the very fabric of society, bringing gender, racial, and economic inequities into sharp relief.” Since the start of the HIV/AIDS epidemic, South African epidemiologist Quarraisha Abdool Karim has helped to understand how the disease is decimating her country's population, most notably by investigating how the epidemic affects women and how to prevent its spread through greater engagement with communities and participants in HIV prevention trials. While studying in the USA for a masters degree at Columbia University in 1988, under the mentorship of Zena Stein, Abdool Karim became aware of the two different HIV epidemics in New York: one prevalent in men who have sex with men and the other among injecting drug users. In 1989, she returned to a South Africa “on the brink of political change” and shortly thereafter investigated the prevalence of HIV in the general population; it turned out to be less than 1% at that time, but subsequent surveys soon “hinted at the rapidity with which HIV was spreading”, she recalls. Not only was HIV spreading, but it was three times more common in women than in men. As an activist during apartheid, Abdool Karim was attuned to issues of injustice; realising that social inequality meant that HIV/AIDS affected women disproportionately she pursued research aimed at unravelling this gender difference, including how sexual and reproductive rights and access to services affect HIV acquisition. In 2000, she completed a PhD about gender barriers to HIV prevention. Her supervisor Hoosen Coovadia, the Victor Daitz Chair in HIV/AIDS Research at the University of KwaZulu-Natal, acknowledges her role in highlighting the plight of women with HIV: “she introduced many of us to the centrality of women's issues, such as the urgency of finding women-controlled prevention methodologies, to control the spread of HIV. Long before most scientists had entered the field of HIV in South Africa, she accomplished one of the earliest epidemiological studies on HIV prevalence in KwaZulu-Natal, which provided a model for others and an idea of the spread of the infection across the country's porous borders.” As women move from their teens to their early twenties, their risk of HIV infection rises—about half of pregnant women aged 20–24 years who attend public-sector health clinics in KwaZulu-Natal are likely to be infected with HIV, she says. Many women are abstinent until marriage, but their husbands are either already infected or will become so during the course of the marriage. So, explains Abdool Karim, in this context the “ABC mantra”—the notion that abstinence, being faithful, and using condoms is enough to prevent HIV—falls short. Abdool Karim's work with women in South Africa has also revealed a complex picture of the definition of sex work: “There are women for whom it is a job, but others for whom it may be an occasional exchange of sex for money. In either case, it's an issue of survival.” Abdool Karim's focus on respect for human rights means she is just as concerned about the ethics of a research trial as she is about its results. In the early 1990s, Coovadia discussed a concern he had about how none of the mothers his team sought to recruit to an HIV study had refused to take part and he worried that they felt coerced. This got Abdool Karim thinking: “how do you assess whether participation is voluntary or coerced?” Because of South Africa's history, many people, herself included, had grown up deprived of many rights. Would disadvantaged groups, she wondered, appreciate their right to refuse participation in a trial or fully grasp the concept of consent forms? “If you've never had rights, how do you make sense of it?” In trials she ran, she began to establish with the local community what their understanding of the study was, and began to “develop my own criteria that could withstand scrutiny”, she says. Abdool Karim describes her career as a series of “serendipitous” events, but hard work clearly underpins everything she does. She divides her time between the USA—where she is co-Chair of the HIV Prevention Trials Network and Director of the Columbia University Southern African Fogarty AIDS International Training and Research Programme—and South Africa, where she is Associate Scientific Director of CAPRISA in Durban and an associate professor in public health and family medicine at the Nelson R Mandela School of Medicine, University of KwaZulu-Natal. This means that whichever country she's in, she works to both South African and US time zones, but “hours don't matter”, she says. Abdool Karim's husband, Salim, is also a respected HIV researcher, but there is no professional rivalry she says as their approaches are “complementary—he works at the detailed, molecular level; I am much more focused on the nexus between science, advocacy, and policy”. Any conversation about HIV in South Africa invariably turns to politics. After the denialism under Thabo Mbeki, it would seem that things can only get better. In 2007, Abdool Karim became part of the committee appointed by the Deputy State President in the Mbeki administration that developed the country's current 5-year strategic plan on HIV and she is positive about Jacob Zuma's presidency: “I am optimistic that under Zuma's leadership HIV is a priority.” But she adds that “A major challenge is ensuring delivery of prevention and treatment programmes to where they are most needed. HIV has shattered South Africa's hope of prosperity in the aftermath of apartheid—this virus affects the very fabric of society, bringing gender, racial, and economic inequities into sharp relief.” HIV infection and tuberculosis in South Africa: an urgent need to escalate the public health responseOne of the greatest challenges facing post-apartheid South Africa is the control of the concomitant HIV and tuberculosis epidemics. HIV continues to spread relentlessly, and tuberculosis has been declared a national emergency. In 2007, South Africa, with 0·7% of the world's population, had 17% of the global burden of HIV infection, and one of the world's worst tuberculosis epidemics, compounded by rising drug resistance and HIV co-infection. Until recently, the South African Government's response to these diseases has been marked by denial, lack of political will, and poor implementation of policies and programmes. Full-Text PDF