Medicine: Fighting AIDS on Many Fronts
Hadassah has been battling HIV and AIDS for over a decade, targeting the immunological disease both in Israel and abroad in Ethiopia.
When the ball cut open the boy’s head, Li’el Ronen’s impulse was to run and wipe the blood from the child’s eyes. a Even as she checked herself, however, the other youngsters had called to her, then raced off to fetch her rubber gloves. She didn’t understand the Amharic words, but their meaning was plain: “Don’t touch him without gloves, Miss! It’ll kill you!”
It was August 3, 2005, 23-year-old Ronen’s second day volunteering with 400 children with HIV, the retrovirus that causes AIDS, at the Mother Teresa Missionaries of Charity Orphanage in Asco, a suburb of Ethiopia’s capital, Addis Ababa. A student at the Henrietta Szold Hadassah–Hebrew University School of Nursing in Jerusalem, she was there for a month to provide the “plus” in the treatment-plus ART, JOY & love program launched in the orphan shelter six months before by Dr. Dan Engelhard.
Dr. Engelhard is head of pediatrics at the Hadassah–Hebrew University Medical Center at Ein Kerem and chairman of Israel’s Pediatric AIDS Group. “When I first visited the [orphanage] in February of last year,” he says, “not one child was treated for their HIV infection. Each year, around 60 of these kids died, always replaced by more of Ethiopia’s estimated 720,000 children with AIDS.”
With Hadassah and Ethiopian colleagues, Dr. Engelhard convinced the United States Centers for Disease Control and Prevention to include the orphanage on its antiretroviral drug allocation list. Since February 2005, the CDC has provided medication for 130 children at Asco. Only 3 of these 130 have died.
Dr. Engelhard attributes this dramatic statistic not only to the drug cocktail. Integral to the Asco program’s success, he says, are the Israeli volunteers who come to the orphanage for a month at a time. Their main role is to love the children. When he can, Dr. Engelhard buys volunteers their airline tickets. Many, like Ronen, purchase their own.
Dr. Engelhard’s work with the Asco orphanage is his own initiative. “I saw how desperately these children needed help,” he explains. But it dovetails with a decade-long battle against HIV and AIDS fought by Hadassah and Ethiopia, jump-started by Ethiopian immigration to Israel.
In Israel, incidence of HIV is relatively low, but it is problematic within certain communities.
“We see new HIV infections among homosexuals and drug abusers, as elsewhere in the West,” says Dr. Shlomo Maayan, head of Hadassah’s AIDS Center, which serves Gaza and West Bank Palestinians and greater Jerusalem. “We also find it among immigrants from the former Soviet Union. Mostly, however, it’s in Israel’s Ethiopian Jewish immigrant community.”
With over 300 adults in active treatment at the Adult AIDS Clinic and 25 children cared for in its Pediatric AIDS Center, Hadassah has devised a unique and highly successful dual approach to battling the disease. The proven lifetime therapy of antiretroviral drugs, available since 1996, is one important part.
The other is a framework of intense, ongoing emotional and psychosocial support from a multidisciplinary team: AIDS-specialized physicians, nurses, pharmacists, psychologists, social workers, nutritionists, medical clowns, cultural mediators and volunteers. One Hadassah volunteer program has Jerusalem women visiting HIV-positive Ethiopian women each week in their homes. Another (in which Li’el Ronen was enrolled for a year before she went to Ethiopia) brings Hadassah students on weekly visits to pediatric AIDS patients at home.
“This dual approach supports patients, ensures compliance with medication and so transforms a fatal disease that has killed 25 million people worldwide in 25 years into a chronic illness,” says Dr. Maayan.
“At Hadassah, we haven’t lost a child to AIDS in 10 years,” Dr. Engelhard points out.
Hadassah’s experience in treating Ethiopian adults and children with HIV and AIDS in Israel has familiarized it with Ethiopian responses to the disease.
“We learned that the community has cultural needs and perceptions of health and family that differ from ours,” says Dr. Maayan. “We also learned they carry a different strain of the HIV virus, subtype C, not B, which is more common in the West. This awareness, together with Hadassah’s 40 years of medical outreach to African countries, combined to involve us deeply in Ethiopia’s fight against AIDS.”
As the global AIDS pandemic took hold, Hadassah’s help began with personal initiatives. The first was in 1994, before antiretroviral drugs existed, when Dr. Maayan set up the Ethiopian-Israeli Medical Research Program, which launched a close, ongoing relationship between Hadassah, the Ethiopian Health & Nutrition Research Institute (EHNRI) and Addis Ababa’s Black Lion Hospital.
One joint clinical research project he conducted there, completed three years ago, found that a single dose of antibiotics reduces the level of the HIV in women’s genitalia by 50 percent. “This intervention may well reduce sexual transmission of the virus,” Dr. Maayan says. Easily administered and, at less than $1 per patient, affordable, this treatment is now widely practiced in Ethiopian clinics.
Hadassah’s role in Ethiopia’s war on AIDS greatly expanded in 2003, when President Bush launched the President’s Emergency Plan for AIDS Relief (PEPFAR), a $15-billion program that dispenses free antiretroviral drugs. In Ethiopia, it is administered by the CDC in cooperation with the International Training and Education Center on HIV (I-TECH) at the University of Washington in Seattle. A four-partner collaboration—CDC, I-TECH, EHNRI and Israel’s Consortium on AIDS Medicine (ICAM), which Hadassah leads—has been formed to transfer Israel’s experience to AIDS medicine in Ethiopia.
Several clinical and research projects are already running under this collaboration. One is an AIDS treatment program at Addis Ababa’s St. Paul Hospital, which tracks development of resistance to the AIDS virus in adults. A program at the Asco orphanage is planned to track resistance in children.
Last summer, Hadassah-ICAM, the CDC and the University of Washington twinned with Gondar University in northern Ethiopia. Over a third (600,000 of 1,500,000) of Ethiopians infected with HIV live in Gondar. At I-TECH’s request, Hadassah will help develop a center of excellence in AIDS medicine there, which will run a prevention program for the region and build an infrastructure within which antiretroviral drugs can be efficiently administered.
“Integral to the project’s success is Hadassah’s multidisciplinary approach,” says Dr. Maayan. “Groups of Ethiopian physicians and nurses are coming to Israel to learn it.”
“I have attended training programs in the United States, United Kingdom, France and Germany, but I’ve never had a training experience like this,” comments Dr. Shitaye Alemu, assistant professor of medicine at Gondar University Hospital. “Israeli practice of HIV medicine is the next stage. It’s about living with AIDS, not dying from it.”
“I’ll be introducing what I’ve learned in Israel into our practice of AIDS medicine in Ethiopia,” says her colleague, pediatrician Dr. Abubaker Bedri, former dean of the Faculty of Medicine at Addis Ababa University.
Ethiopian lab technicians, too, are being brought to Israel for training. And the Hadassah AIDS Center is preparing seven Ethiopian-born Israeli women, all veteran case-managers on AIDS teams, to help develop a comparable program in Ethiopia.
While the war on hiv and aids aims to turn a killer disease into a chronic one with lifetime antiretroviral drugs and psychosocial support, a far better solution may lie ahead. Since 1994, Dr. Rivka Abulafia-Lapid, a molecular immunologist and immunotherapist at Hadassah, has been developing a radically new treatment to control the disease. Instead of targeting the virus, it focuses on healing the patient’s damaged immune system, arming the body to fight off opportunistic infections, hopefully including AIDS infection.
“When the HIV virus first appears, it kills off white cells, known as CD4 cells, which defend the body,” Dr. Abulafia-Lapid explains. “The virus may then sink below detection level for years, but the immune system keeps killing these crucial CD4 soldier-cells, making the body increasingly vulnerable.”
Working on the theory that the virus corrupts immune-system cells, “teaching” them to identify CD4 cells as enemy and destroy them, the Hadassah team has developed a kind of vaccine to rehabilitate the body’s damaged immune system. It is designed to “turn off” the corrupted autoimmune process and repair the damage under way, something the antiretroviral cocktail cannot do.
“Three injections of vaccine are prepared for every patient from their own blood,” explains Dr. Abulafia-Lapid. “The procedure takes a month. We filter out the corrupted cells, which are killing the CD4 cells, multiply them, kill them and inject them back into the patient, in this way vaccinating patients against their own blood cells and ‘educating’ the body to turn against the corrupted cells and annihilate them. Once these corrupt cells are killed, the CD4 soldier-cells survive and proliferate, able to mark down and help kill the virus.”
First-phase clinical testing yielded exciting results: Not only is the procedure safe and viable, but in almost all patients tested at Hadassah, the vaccine increased the level of CD4 cells by at least 50 percent.
Several years of larger, multicenter studies lie ahead before the vaccine becomes a general treatment, along with finding a way to make it quickly and inexpensively. However, Dr. Abulafia-Lapid believes this could be “a good answer” to AIDS.
The research community agrees: Her work has recently been published in the Journal of Clinical Virology and Vaccine, and an Italian research group wants to collaborate with her team.
Meanwhile, the antiretroviral cocktail remains the most effective weapon against AIDS, administered with the all-important “plus” provided by the multidisciplinary teams or, when there is no such team, by volunteers such as Li’el Ronen.
“I don’t remember deciding to go to Ethiopia,” Ronen recalls. “When I heard about the program, I just knew I would. My first couple of days there were overwhelming: There were so many children, all orphaned and all ill. They were clean and well fed, but there weren’t enough people to relate to each one.
“I quickly saw I didn’t have to deal with 400 at once, just one at a time. I played with them, hugged them, gave them their medication. A hug is the whole world for such a child. Spoken language rarely seemed necessary.
“The staff of five nuns and Ethiopian workers is wonderful…. I did not know how much I loved the kids till it was time to leave. I’m not a particularly emotional person, but when I left I couldn’t stop weeping. I knew that even if I came back, not all would be alive.”
Ronen did go back, five months later, together with Dr. Engelhard and two of Hadassah’s medical clowns, Jerome Arouche and Dudi Barashi.
“These children had never seen clowns,” she says. “Jerome and Dudi made the week one big party, bringing their own kind of joy and care. One 15-year-old girl who had lain in bed weeping since giving birth some weeks before sat up and smiled when the clowns came in.”
Most of that week was spent at Asco, but it also included a day at an AIDS orphanage at Debre Markos, 125 miles north of Addis Ababa, where only 2 in every 70 children receive antiretroviral therapy. Hadassah plans to work with this center, too. This August, Li’el Ronen plans to divide her time between the Asco and Debre Markos centers.
Hadassah sees its intervention in the AIDS crisis in Africa and elsewhere as consonant with the Jewish imperative to save life.
“Knowledge gathered at Hadassah in AIDS medicine stands to make a big difference in the lives of hundreds of thousands of people in Africa in the years ahead,” explains Dr. Maayan.
Says Dr. Engelhard, “I believe we can go as far as demanding no deaths from AIDS in Ethiopia.”