In fifteen questions, HIV@MSD will update you on an initiative in the field of Biological Retrovirology that has been taking place in Dakar over the last two years. Its coordinators, Prof. Souleymane MBOUP, Department of Bacteriology and Virology at Le Dantec University Hospital, Dakar, Senegal, and Prof. Laurent BELEC, Virology Unit at Georges Pompidou Hospital, Paris, France, share with us their hopes and challenges in this research area.

Source: Le Dantec Hospital
Prof. S. Mboup (on the left) with Dr D. De Korte (MSD)

These markers have to be done in a context of "extended" biological skills:

Laboratory best practices

Cold chain

Internal and external quality control

Use of markers in clinical practice

Biological equipment maintenance and repairs

Validation of reagent kits in field conditions

Supply procedure (tender), shipment, payment, reagents storage

In fact, these markers guide the clinician all along the complex steps of managing infected patients, including therapeutic management, prevention and therapeutic failure.

Q3. Why is the importance of biological markers in patient monitoring often minimized in developing countries?

The reasons for them lagging behind in comparison with Northern countries are partly historical and economic.

In the beginning, patients would come and see their family doctor at a late stage of their illness. Almost all of them were symptomatic and had to be given treatment right away in order to keep them alive. The need to resort to biological retrovirology to discover the patient's exact status was therefore not a priority.
Now, many patients come to be tested at an earlier stage. Biological monitoring allows us to check their viral load and CD4 count until the time is right to initiate their treatment, or when there is a need to change treatment due to bad biological results. Here again, the importance of biological retrovirology is becoming much more obvious, but it faces an economic issue.

Equipment, and particularly reagents being sold in Africa, are still too expensive to be used on a large scale. It is often cheaper for a hospital to send samples to a foreign centre for analysis.
The impression that it is more efficient and cost-effective to perform these tests outside of Africa encourages questions regarding the need of using such markers in Africa, since it appears to manage without them.

People start thinking differently nowadays and the World Health Organization recently (August 2006) emphasized the role played by biology and in particular by immunological and virological markers, in the prevention and management of therapeutic failure in adults and children.

Source: Le Dantec Hospital
Prof. L. Belec (on the left) with Prof. S. Mboup

Q4. Why did you create training in biological retrovirology?

Our experience has shown that there is a real gap in Africa in the field of biology. In the best circumstances, when analyses are carried out locally, only the most basic assessments are possible, due to a shortage of means and personnel. Skills, particularly in biological retrovirology, are sadly lacking at a time when we hope to decentralize HIV/AIDS care. We therefore decided it was urgent to reinforce local capacities with the support of our African and European colleagues.

Q5. Who are the other members of your training team?

Our team includes:

Prof. Eric Delaporte from Montpellier University Hospital, France,

Prof. Mireille Dosso, Treichville University Hospital, Abidjan, Côte d'Ivoire,

Prof. Luc Kestens, Institute of Tropical Medicine, Antwerp, Belgium,

Dr. Jean-Elie Malkin, ESTHER, Paris, France.

Prof. Papa Salif Sow, Fann University Hospital, Dakar, Senegal,

Dr Guy-Michel Gershy-Damet, WHO/AFRO, Burkina Faso,

Dr. Mariam Kassambara Sow, Secure the Future, Mali.

Each specialist gives the students the benefit of his/her particular skills and experience. At the end of the day, the patient will get the best of the bargain, because he will be better looked after by his doctor.

At present, our main sponsors are ESTHER, Secure the Future, WHO, as well as some laboratories working in the field of biological monitoring in Africa.

Q6. How do you select the candidates for this course?

One hundred and three applications were received from fifteen African countries (Benin, Burkina Faso, Cameroon, Congo-Brazzaville, Côte d'Ivoire, Gabon, Guinea-Conakry, Haiti, Mali, Mauritania, Morocco, Niger, Central African Republic, Democratic Republic of Congo, Senegal, Chad, and Togo).
Thirty one applicants from fifteen countries were chosen to participate in this Training also called "DU - Diplôme Universitaire" in Dakar, in 2007.
The committee worked on a new evaluation grid which allowed them to choose between candidates, using the following criteria:

Training	/3
Effective use of the course	/3
Alignment with the National ARV Program	/1
ESTHER SLF or other programme	/1
File evaluation	/2

All candidates with a score ranging from 7 to 9 out of 10 became eligible.
The second selection was made in terms of applications per country, according to the maximum number of candidates agreed upon per country.

Q7. How many candidates have you trained over the last two years?

We have trained 61 candidates.

Q8. What does the course consist of, and what are its objectives?

The biological retrovirology course, delivered in French by eminent African and European HIV specialists, is a four-week international training course, broken down into lectures, round-table discussions, and workshops. The program covers six modules. Trainees are rewarded with a diploma from the Sheikh Anta Diop University, Dakar, Senegal.
At the end of the course, a 1 to 3 month in-depth course will be offered to three students in a host laboratory, under the supervision of a training master, who is part of our training team. It will end with an oral examination for thesis.

There are three objectives to this course:

Train and enable senior lab technicians and biologists to use and interpret biological markers that are needed to manage HIV-infected patients in Africa, in a more reliable way.

Provide biologists and clinicians with a communication platform to improve the management of patients in terms of therapeutic treatment or possible treatment failure.

Develop an international network of competencies in biological monitoring, aiming at a North-South and South-South cooperation.

Q9. What topics do you cover in these six modules?

The 1st module is devoted to diagnosis in adults and children,
The 2nd, to CD4 T lymphocytes,
The 3rd, to viral load,
The 4th, to treatment failures and resistance,
The 5th to co-infection with HIV and viral hepatitis,
And the last one, to laboratory organization.

Q10. Do the students have course support materials to help them with their work?

Yes starting this year, they have a web site www.rarslbv.org, dedicated to biological retrovirology in Africa. This serves as a link between teachers and students, who can ask questions at any time in order to enhance their understanding. We are also going to open access to this site to non-biologist medical and paramedical staff involved in the fight against HIV/AIDS in the South.
Each year, students also receive a CD-ROM containing the full course.

Q11. How does the biologist in retrovirology fit into the healthcare team?

The biologist in retrovirology must be able to guide the clinician in his/her choice of options at complex stages of patient's management, whether at the start of treatment, or if treatment failure occurs. He/she provides the necessary evidence for decision taking. His/her role, which is too often seen as complementary, is actually fundamental, and each hospital should ideally have a laboratory specialized in retrovirology.

Q12. How could such a scenario become possible?

First of all, one would need to increase government funds, or find a way to co-finance the necessary test equipment with research agencies in order to finance the maintenance of such equipment, and the training of specialized personnel.

Products would need to be less expensive in order to be used on a larger scale, thus maximizing the country's potential. We have seen a reduction in the cost of drugs, so why not think of reducing the cost of reagents?
Manufacturers should re-think their diagnostic kits, adapting them to the context of developing countries. In Africa, it would imply:
- An affordable price
- The possibility of diagnosing truly African pathologies
- A price reduction of the currently high priced pediatric diagnosis and why not a subsidy from decision makers?

Finally, students who have taken our courses must become advocates for biological retrovirology within their local health institutions, taking a stand at an international level, by taking part in conferences and publishing their work in internationally recognized journals. In Africa, too few people publish the results of their research work.

Q13. Do courses similar to yours exist in other African countries?

There is no other course strictly focusing on laboratory management and biological monitoring of the HIV infection. Other University Diploma or Inter-University Diploma exist, such as the Ouagadougou University Diploma in Burkina Faso*, but they are meant primarily for clinicians.

Q14. What would you like to say to future African students in biological retrovirology?

We would like to encourage them in the choice of their career. We will need more and more of them in the coming years, and they will be required to permanently increase performance. Africa has young talents; it needs qualified people to stay in their home countries. Let's do what is necessary with our international partners to help these young African biologists find their place in our society and enhance our efforts in the fight against HIV/AIDS. Biological retrovirology has definitely a great future.

Q15. The next ICASA will take place in Dakar in 2008. Will you particularly emphasize this discipline during the conference?

The 15th ICASA has a triple dimension; It covers Science, Community and Leadership.
Biological retrovirology will be part of the scientific and leadership programs, which will look at all aspects of the fight against the HIV infection.
The 15th Conference will be a place for an exchange and convergence of ideas on all HIV/AIDS-related issues. It will include the participation of world famous scientists, as well as a good number of Senegalese scientists.
It will offer a framework for dialogue, sharing experiences, and evaluating the progress made in research and treatment in the field of HIV/AIDS and Sexually Transmitted Infections in Africa.

* IUD October 2006:
www.hiv-msd.info/partnerships/Burkinafaso/burkinafaso.php



Next course: Dakar, March 3 - April 2, 2008
Deadline for registration: December 16, 2007

Interviews and article by Sophie d'Aurelle de Paladines.