By: Aziel Gangerdine, HVTN Core, Seattle, WA, USA
Pulitzer Prize-nominated author James Martin astutely stated that we must “thwart the rapid spread of infectious diseases that could kill millions of people.” In 2007, Martin described “The 17 Greatest Challenges of the Twenty-First Century,” listing conquering disease as number 10 amongst others such as reversing poverty, preventing all-out war, defusing terrorism, and cultivating creativity.
In the US, the state of Washington (where the HVTN’s offices are located) is under a “stay home, stay safe” order, one of several measures underway to prevent the transmission of a contagious viral infection called Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2), known to cause the disease COVID-19. If asked, I’d best describe Seattle, Washington, as a young dame – breathtaking in natural beauty and kind in socio-economic experience. As can be expected, I regularly enjoy brisk walks in my neighborhood where flora meets concrete and wood in the bustling landscape of the city’s South Lake Union neighborhood. It has been two months and the sounds of nature are amplified in a deafening silence.
My recollection of when COVID-19 started to reorganize my daily pattern of life is clouded by my feeling the need for a silver lining every so often, not succumbing to the confinement of my apartment and the sense of suffocation, all as a result of the necessary State order. COVID-19 is testing our definition of freedom amongst other things. In our homes and in the workplace, measures are implemented that redefine our social and economic patterns of life.
It Seldom Rains, Instead it Pours
The impact of COVID-19 manifested quickly in the HIV prevention clinical research environment. Known for its pursuit of a safe and globally effective preventive HIV vaccine, the HIV Vaccine Trials Network’s (HVTN) study teams are now facing off with a “new pathogenic kid on the block,” in addition to conducting clinical trials to help end HIV. I suspect that Martin would applaud the Network’s efforts to quell the potential impact of SARS-CoV-2 at the same trial sites where HIV prevention trials are underway.
“Our study teams are dedicated to finding solutions for health problems that have affected our communities in a profound way,” says Dr. Azwi Takalani, one of the HVTN’s Regional Medical Liaisons in Johannesburg, South Africa. Study teams at trial sites were empowered to implement measures, aligned with recommendations from their local public health authorities, to prevent the possible transmission of SARS-CoV-2.
My most recent in-person meeting with Dr. Takalani, fondly known as “Azwi,” was at the 2019 International Conference on AIDS and STIs in Africa (ICASA), held in Kigali, Rwanda. She has a booming laugh and a memorable smile to complement her engaging personality.
“A lot of children in my community were/are being raised by their grandparents or elderly aunts and uncles after losing their parents to HIV/AIDS,” said Azwi, illuminating the context in South Africa. Immediately, I was reminded of the devastation the four-decade old HIV/AIDS epidemic had on families and communities in the country. This impact was replicated in many communities globally.
Although I could not enjoy Azwi’s in-person conversation, it was clearly evident that her responses were saturated with a deep sense of concern as we delved into her thoughts on the circumstances in South Africa.
She started to peel back her thoughts about the ripple effects set in motion by the “new kid.” “The realization that the population group that filled the parenting gap is also probably the most vulnerable to severe COVID-19 illness is an important factor to consider when we re-organize life as a community during and after this pandemic.”
Since it first emerged in late 2019 in China, a significant number of people around the world succumbed to the disease, prompting the World Health Organization to officially declare it a pandemic on March 11, 2020.
“The global picture of the impact of the pandemic is sobering. While a lot of work is ongoing in South Africa toward COVID-19 preparedness, the inherent weaknesses in our health care system and endemic HIV and TB infections are an additional source of concern for South Africa,” Azwi said, summarizing the on-the-ground circumstances and coloring the deep concern I read between the lines of her responses.
The world is mobilized and making every effort to save lives and to prevent the transmission of SARS-CoV-2. On March 23, 2020 the President of the Republic of South Africa ordered a 21-day nationwide lockdown, a period later extended on April 9 for an additional two weeks. The President delivered the executive order altering the lives of all citizens, and the aftermath of the decision started to manifest in communities as the country transitioned to an “essential services only” way of life.
Among these essential services, study staff at the sites are frontline responders who have in their hands the health and safety of study participants enrolled in HIV prevention clinical trials. They have the responsibility to maintain the scientific integrity of each study, and at the same time, protect themselves and the participants from the possible transmission of SARS-CoV-2.
L – R: The Kliptown clinical trial site in Soweto, South Africa reorganized its clinic to practice physical distancing to minimize potential exposures to SARS-CoV-2 in the waiting area, and made resources available such as hand sanitizer to disinfect hands.
Credit: Tricia Phillip
Frontline responders are known to many as heroes. I am in awe of their courage and the bold relentlessness they demonstrate in the face of a new global pandemic, while not losing sight of the charge to respond to a four-decade old epidemic, when both infectious diseases are claiming lives and impacting communities. I cannot help but draw inspiration from their actions. While on duty and in service to their communities and countries, study teams must take every measure necessary to protect the families they go home to at the end of each working day. I cannot pen in these pages the weight of such an emotional and mental burden.
“It is certain that life as we knew it has already changed, and will continue to do so in the near future,” Azwi concluded.
Navigating Unchartered Waters to Support Our Frontline Responders
COVID-19 drew new battle lines in the sand at each clinical trial site and decisive action was needed to equip study teams with specialized personal protective equipment (PPE) for their daily showdowns with COVID-19. The global demand for PPE, largely produced by the People’s Republic of China, increased significantly as response efforts gained momentum. However, travel and export restrictions set in motion to curb the spread of SARS-CoV-2 led to unintended consequences such as restricted shipment of PPE items globally. In South Africa, sites were having difficulty obtaining the necessary items they needed to appropriately protect their staff members. My university professor used to say that there are three kinds of people: those who watch things happen; those who wait for things to happen; and those who make things happen.
Fittingly, I think of Yunda Huang, PhD, Principal Staff Scientist at the Fred Hutchinson’s Statistical Center for HIV/AIDS Research & Prevention (SCHARP), as the latter of the three personalities. A US citizen, responding from her home in Shanghai, China, she described what it took to equip study teams in South Africa with much-needed personal protective equipment (PPE).
Yunda is the lead statistician on other “normal” HVTN projects, and worked to obtain the PPE while carrying out her research duties. “Procuring PPE in such a political and epidemiological climate was simply a non-existent type of job before this pandemic. Although I felt a tremendous responsibility to help, I severely underestimated the complexity of the mission,” she stated.
According to Yunda, vetting business partners became the most important step in a very complex process involving a “sea of connections.” Navigating the uncharted waters also meant that she would be in direct competition with governments and large medical supply companies, all in need of the same approved PPE, and who, unlike Yunda, demonstrated significant purchasing power.
A series of reports such as the CBS news story on April 13, titled “As world turns to China for PPE, U.S. buyers risk knock-offs and price gouging,” confirmed the race to locate and procure the coveted PPE, ultimately increasing the demand even more.
I tried to imagine the moments of unrelenting pressure Yunda must have endured while managing all communications, coordination and decision making. The entire process is evidently risk prone. “The demand took a toll on my sleep time, family time and “normal” work time, but I feel fortunate that I could help,” she shared.
Yunda explained that the purchase of N95 masks, for example, is only possible when paying cash up front, and is considered successful only when the item is delivered and in your hands. Sellers readily accept new offers from buyers if the profit margin can be doubled, and the generated revenue would settle the payment of penalties incurred for breach of contract with the first buyer. While your payment could be refunded from a breach of contract, such an incident would delay the shipping timeline, which was scheduled based on the purchase agreement before the seller opted to cancel because of a more lucrative sale.
“Just for one shipment, I had to use a lot of free consultation time from my lawyer friend to help me comb through 11 legal agreements to make sure the purchase was legitimate, protected our rights and funds, and ultimately made the delivery of about 10 different types of PPE items possible,” Yunda described, as she reflected on the important details needed to mitigate the potential risks to the HVTN.
All of this was further complicated by international travel restrictions and the ever-changing export policies in China. Every delay to planned shipping schedules inevitably derailed all of the anticipated delivery of the PPE items to the research sites. Eventually, the clouds did part and a silver lining appeared.
“It took only three weeks between the moment the mission was ‘assigned’ and the moment that first-rate PPE was safely delivered in South Africa from China. If that is not a miracle, what is?” Yunda said.
L – R: Kentse Khuto, HVTN Senior Site Liaison Manager with Dr. Azwidhwi Takalani, M.D., HVTN Regional Medical Liaison and Michelle Nebergall, PhD, HVTN Clinical Trials Manager, pictured in Johannesburg, South Africa at the delivery of the PPE from China. The team arranged the delivery of smaller batches of PPE to each site.
Credit: Kaelin Ragavan, Operations Manager, Biocair
Witnesses to the Extraordinary, and What Motivates Our Heroes
COVID-19 is the new pathogenic kid on the block, and is proving to be a formidable adversary by forcing the hands of decision makers to exercise what some deem to be draconian measures in order to save lives.
Amidst the uncertainty of the near future and the disheartening circumstances we are faced with at home, in our communities, in the workplace, and in our countries, I think about what it is that gives our heroes at the frontlines like Azwi, and the brave yet often unseen heroes like Yunda, and many other individuals the support they need to do what they are called on to do.
Azwi is mother to two beautiful and bubbly toddlers, one who believes that her mother can transport the African big five [lion, leopard, rhinoceros, elephant, and water buffalo] on an aircraft. I recollect a video call of Azwi making such a promise while we were in Kigali. In the eyes of the young toddler, she believes her mother can do what few people can.
In Shanghai, 15 hours ahead of Seattle, the wind under Yunda’s wings can be seen in her children who support and stand alongside her as she steps forward to carry the baton to help end HIV and now, to curb COVID-19. To Yunda, her children are an inspiration and strength reminding her that her efforts over many hours are changing the lives of people.
Globally, COVID-19 continues to test more than just the strength of economies, the resilience of healthcare systems, our definition of freedom, and the going concerns of businesses – it is testing our humanity and benevolence. History is being written with these unrelenting efforts to face life threatening adversaries such as HIV/AIDS and COVID-19. We call each adversary by name and we recognize the impact of each. We also recognize what these adversaries do not have – our will and human spirit to overcome, as well as the need to protect future generations who are the spirit behind our struggle and the wind beneath our wings.
Aziel Gangerdine is the Director of Communications for the HVTN.