Quarraisha Abdool Karim, Associate, scientific Director of the Centre for the AIDS Programme of Research in South Africa (CAPRISA)
“Building the ship as it sails”
Moderator: Tian Johnson
Complied by: Anna Matendawafa – with inputs from Wilfred Gurupira & Maaza Seyoum
Webinar Recordings & Supplementary Materials:
Date: 10 September 2020
Quarraisha Abdool Karim, (Ph.D.) is an NRF A1 rated scientist and infectious diseases epidemiologist. She is the Associate, scientific Director of the Centre for the AIDS Programme of Research in South Africa (CAPRISA). Professor in Clinical Epidemiology at Columbia University in New York and Pro-vice Chancellor for African Health, at the University of KwaZulu Natal. The recipient of multiple awards nationally and globally, Professor Abdool Karim, is currently a member of the Executive Group of the International Steering Committee for the COVID-19 Solidarity Trial and the Ministerial Advisory Committee for the COVID-19, in the Public Health group. Her research over the past 28 years has focused on HIV infection in adolescent girls and young women. This includes clinical trials from the early phase, through proof of concept and implementation of discoveries. Her landmark study, the Tenofovir gel CAPRISA 004 trial, demonstrated for the first time that antiretrovirals could prevent HIV infection. The research was highlighted by the journal Science as one of the top 10 scientific breakthroughs in 2010.Abdool Karim has over 200 peer-reviewed publications, edited several books, contributed several book chapters, including co-editing the 6th and 7th edition of the Oxford Textbook on Global Public Health. She has played a central role in building the science base in southern Africa through the Columbia University – Southern African Fogarty AIDS International Training and Research Programme that has trained over 600 scientists in Southern Africa. She holds Fellowships at the: National Academy of Medicine, The World Academy of Science, Royal Society of South Africa, Academy of Science of South Africa, and the African Academy of Science.Prof Abdool Karim’s scientific contributions in highlighting the vulnerability of young women, the need for women-initiated technologies, and integration of HIV prevention efforts into sexual reproductive health services have been recognized by more than 30 local and prestigious international awards including South Africa’s highest honour, the Order of Mapungubwe, from the President of South Africa.
QUESTION AND ANSWER
*This section contains a transcribed account of the Question and Answer Session with inputs provided in writing after the call to questions that were not addressed during the call.
So, a question here from Greer Shoeman from the SANAC Civil Society Forum has been the focus today, it has been very much focused on those currently infected or measures to prevent infection. The community of COVID survivors are growing any ideas on what we should be doing to better support This group to sustain health and wellness.
Yeah. With the testing challenges that we’ve had, I’m not just saying this because it’s so centrally important our response and a critical advocacy point. We’ve had a shortage of reagents and test kits. We’ve not been able to test anybody who needs to be tested. But there has been a prioritization of those who are ill. And I think what’s happening is that we understand better now there is a viremic stage. Then, there is an immune response that most of the individuals during the viremic phase don’t suffer severe disease and significantly, to require hospital admissions when you look at illness and hospitalizations. But it is that immune activation that is what’s driving admissions in hospitals and the severe illness and we seeing with time. As these cohorts grow, some people seem to be, and not everybody has this very accurate immune response. However, they call the cytokine storm that up comes up about three weeks after symptom presentation lands you in the Intensive Care Unit (ICU); some of those individuals develop this severe immune response. It’s like the body goes into overdrive. It does the right thing, which exposes the virus. It’s finding the virus immune activation and this very extreme manifestation and doing a perplexing challenge for us. And it leads to people being an ICU, somebody building very long, slow illness, and hard to recovery. Those individuals need much support because they are sometimes so severely ill as they are discharged from hospitals. And what we have to understand is that this is infectious. Just from droplets from being near people, so it’s like spreads in the air literally. And so, families and people around somebody who’s sick are at risk as well, and about 40 to 60% of individuals infected with COVID-19 are asymptomatic. So the kinds of messages that we can’t move away from is all the simple things we have right now. Which is the sanitizing, it’s about the social distancing; it’s about the mask-wearing, it’s about isolation, it’s about quarantine, it’s about understanding better the diversity of this epidemic. There is still a lot of stigma and discrimination, and I am a human agent. Every time I go to do my shopping, and even though the priority lanes for first responders and healthcare workers, you go with people to give you a wide berth and wait, but it’s the stigma. To me, first responders are supposed to be the heroes in keeping the shops open so you can do your shopping. They are the ones delivering the food that you order online. If you happen to be in that cost and category of living lifestyle, but the disrespect with which they are treated, if they get sick and almost like vectors of disease, and yet be at the coalface whether it’s about food production and sales and manufacturing or whether it’s about healthcare provision. So being that stigma is something we know from HIV. And I am surprised it is still like that? I think part of it is a point I wanted to make about how we move communities from anxiety to agency. And I think it’s not just about sick people. But it’s about all of our communities that are vulnerable about how we impart knowledge. The excellent knowledge, knowledge that empowers, knowledge that addresses all this anti-science and anti-vaxxer stuff there to me are critically important. It doesn’t differentiate between those who are infected and not infected. It makes all of us accountable and responsible for understanding that none of us have immunity. Even if we have been infected, we don’t know; we are not separating those who are sick from not but dealing with it, giving communities more agency and enabling them through knowledge, resources, and other ways.As you know, an intervention is that some people say, well, overcrowding, somebody will say about your lack of access to water. So, it’s the same intersection of issues; we’ve been dealing with HIV. So not to separate HIV from COVID-19, not to separate non-communicable diseases from COVID-19, not to separate TB from COVID-19. And I think it’s an opportunity for us to take a more integrated approach. If you want to protect people from COVID-19, it’s not age, its age, and comorbidities. And so, obesity is common. So, don’t wait as we usually do for people to arrive at health facilities. How do we start to increase this? How do we understand within our communities? Who is more vulnerable than others? And what are the things we should all be doing to mitigate that, one, infections, and two the consequences of infections? Thanks.
So, Wilfred is asking, given all the work you have done in other studies that have been done. Would you say HIV prevention needs more operational research than clinical research to impact HIV incidence in South Africa significantly? And then if we could just take another one, Moreneka here is asking. South Africa has been a leader with biomedical HIV prevention research in Africa. Are there capacity building plans were in South Africa does a transfer capacity. So south wise in terms of Africa, that sharing and leveraging of all of the significant work that CAPRISA has done historically so if you could address those two questions.
Sure. So, it’s true that we have many tools already available to prevent HIV infection. And there’s a big gap between that evidence that we have in our ability to translate it to population-level impact. In fact, a lot of the UNAID new strategy that’s been developed is about how it’s innovating; it’s what you have, but barely means gaps. We need a vaccine, and we do need to cure, we do need to expand the prevention options, particularly for women. And you know, a lot of the new advances in PrEP delivery that are less user-dependent, are all weighing in towards same transgender women and men who have sex with men. We continue to lag behind young people; we still lag for women; we still lag for pregnant women. And so, you know, what we see is a disconnect between what is available and getting it to those who would benefit most. And that’s our key population, our most vulnerable, and don’t utilize our health service, service facilities traditionally and typically, and I think, again, this is where advocacy is essential. The second is that we need to continue finding new tools and technologies because they are crucial gaps. Whether you’re talking about injecting drug use, whether you’re talking about sexual transmission, or looking at Prevention of Mother to child transmission (PMTCT), there are gaps in knowledge. And we continue to see new infections where they are used spatially, in terms of venues, etc. It’s quite related to human rights violations, and jurisdictions have rights, either as individuals or in terms of HIV policies and practice.In terms of capacity building, you know, it’s something we always have; it’s one of the goals in CAPRISA. So, we’ve done that through the poverty program. There have been a whole lot of initiatives through the poverty program, AFRIhealth being one of those. And now with the establishment of the African CDC, and also through the African Academy of Science. They are numerous initiatives on training and capacity building south-south. And I can see CAPRISA, as I said, it is a priority and we, you know, as a self-funded organization, we can only do the training that we can with the available funds. We’ll establish relationships in Nigeria through Alaska Amico, then in Zambia, and Kenya. But these all take time, as we know, to build a critical mass. And I would argue, and as many people will tell you, there are so many clinical research sites in Africa. And my question is, why don’t we have more African lead clinical research sites? Why are we not innovating and collecting data, we’re collecting specimens, and we can query scientists. And that’s something I think advocates need to be challenging is, why do we have pieces of the US and Europe in Africa, planning these clinical research sites, and we don’t have Africans in Africans who are there, and these sites have been there for at least two if not more decades. And in a way, we can’t wait for things to happen. We also have to be architects of our destiny. And if people take the initiative, we will see change if we are going to wait, will be waiting for another couple of decades, if not centuries.
Prof Oliver Meth is asking in the context where information is continuously changing and being updated. What is your experience been? Or what is the essential information for communities to know without adding to the noise? Have you seen any specific examples of this kind of communication that takes science to communities and cuts through the noise, the misinformation, the anti-vaccine movement? Does an example stand out to you?
Yeah, so I think people, there’s a perception that everything is black and white. And we know everything as scientists, and the reality is that you know, and when we use COVID-19, as an example, is our knowledge is only provisional. When we first started to hear about COVID-19, it was described as a respiratory problem. Today we know it’s a head to toe problem. So, we may say is this a term, and a phrase I use when I’m teaching students about COVID- 19 is we are building the ship as it sails. And so, I think the more the public understands the scientific method, and how provisional technologies and, you know, you can have two schools of thought and action. So firstly, as an epidemiologist, I don’t just understand; I have to act. So, we have to work on provisional knowledge that we have, and some believe that you have to have every I doted, and every tick crossed before you act? Well, you have to balance saving lives with livelihoods and action. With traditional knowledge, you have to update yourself on what’s coming through and understand what’s going on. And even though the publication may say X, you have to understand it locally and see if WHO does the guideline, which is the guideline, do we just follow that right blindly because WHO said that? Or do we take local context into account? So that’s what I mean about empowerment and knowledge empowerment, so if you understand what scientific method is and what your goal is, what you’re trying to do, and the need to be, if knowledge is dynamic, epidemics are dynamic. And when you’re trying to deal with this very dynamic situation, at multiple levels, and at the same time, in you know, COVID is not like COVID-19 is not like HIV, you know, we’re here with HIV, we have this long asymptomatic period. And then we got time to do many things. And when people talk about warp speed, it’s serious. I mean, you get exposed to SARS COVID 2 within two days, you’ve got the viral replication, you’ve got signs and symptoms, within eight to 10 days, the viremia is over, your immune response is kicking in. If you do a PCR like 14 days later, you may get a false-positive result. So, the diagnostic tests are essential. Many of the focus of diagnostic tests has been on PCR identifying the virus; I’m arguing that the viremia is not causing many problems; identifying infections is part of the differential diagnosis and care. We have to better understand the immune response because that’s where we lose our lives, where the deaths occur, and so on. So, we don’t have antibody tests yet. And we do antibody tests in HIV, we know you develop antibodies, but the antibodies alone are not protective. And that’s why we have HIV infection progressing to AIDS. Do we have the same thing for COVID-19? I don’t know. And with time, we’re dealing with like a six-month-old epidemic, and one that’s come in blasted itself in, I don’t know how many countries across the globe, wreaked havoc, and then when you think you’ve seen the end of it, we now are seeing second waves. And not everybody has seen the second wave. Some people see second waves that are in the midst of the first wave. And then the severity of illness changing symptoms gives you some ideas. Science is complicated, it’s low, but you have to have the humility to know that you don’t have all the answers, and you have to be able to share what you know, with the understanding that this is provisional. In fact, I marked my documents as of the 2nd of September, or what is it now the 10th of September? This is what we know; based on what we know, this is what are we doing? Because a week from now, it’s going to be different. And when I come to you a week from now is what did you say? And this is what’s creating fodder for anti-vaxxer and anti-scientists is this is science. This is how it’s always been and particularly Health and Human Sciences. So that’s not too different. How do we get that scientific method out there? It enables people to differentiate between what is hogwash and what is should or factually correct, even as provisional.
Thanks for that. And I mean, I think we saw this as recently as yesterday with the Oxford Trial. It was just blowing up a fertile ground for anti-vaxxer. And they’ve certainly gone to town with that. And of course, the civil society perpetually under-resourced and underfunded is you know, trying to step into that space to do some kind of response. I know we have exactly five minutes more left with you. I’m going to ask you to answer one question in 60 seconds. And then, Ntando is asking, can you speak to us about what we need to know about the second wave? You already touched on it? But could you almost give us the headlines? What does this look like? How real is it? What is coming with the second wave?
Yeah. So Ntando, that’s a great question. I’m not sure I can do 60 seconds justice to it. But let me try. So, you know what, we are still continuing to see new infections in South Africa, not as much as we did a little while ago. But we now in level two, and the public is interpreting level two, it’s time to party. And so, I walk around, and I see no social distancing. I see large gatherings; I see no mass wearing that’s the recipe for the second wave, the second wave is in each of our hands. And if we don’t do the UBUNTU, I am because of others, and I am doing this NPI, for me and for people that are near and dear around me, whether they work colleagues, or whether my family and other loved ones and friends. Is as simple as that. And if we do it together, that combination of things that we do that we have signs and symptoms, we’re not exposing others to it, which is where barrier protection comes in. We can do it; we can litigate it, but we pretend level two means goodbye COVID-19. Then we are just sticking our heads in the sand, and it’s the right grounds for the virus’s rapid speed. Now we’ve had COVID-19 spread differently in the country; we don’t understand completely why Western Cape and Eastern Cape and Gauteng now KZN, and not very big epidemics in other provinces. Those places are likely to be places if we’re going to see a second wave coming that we need to be monitoring in terms of hotspots and outbreaks. And this is where my bargain comes in about who gets tested. Where are we testing, why are we testing, and if we continue to only focus on those who are being admitted to hospitals, if we only do by testing for the virus and not for antibodies, and we pretend that if you’ve been infected, we got herd immunity? We don’t even know that. So, let’s keep our eye on the ball and keep vigilant and use what we know in terms of handwashing, social distance, and mask-wearing?
Absolutely. I don’t think we have a lot more time to address the rest of the questions. But we will get these questions to you and your team and hopefully get some answers to them. Always really asking essential questions about stigma. Yvette wants to speak about the responsibility of research. Veronica addressing stigma and the boldness of CAPRISA, its vision, and work. So, thank you again, Prof Abdool Karim. It’s always a pleasure speaking; we hope this is the first lesson from today’s call because we certainly need to spend more time with you to flesh out some of these issues. And so, thank you again for making time and always being available to engage. We appreciate it, and we wish you all the best in your work.
Thanks, Tian. And I think that my last parting comment is that we have to work together with science and advocacy as advocates. And I think it’s imperative that as advocates, you do not feel disempowered because the voices of the public you know, I read the book by the judge, I’m blanking McQueen, it’s Moseneke it’s called All Rise. And it’s not about all rise, because the judge has entered the room. It is about citizens’ power, which I think we continuously don’t have answers to.I happen to be a scientist, but I’m also a citizen. And I feel a lot of the time we underestimate our power; we saw it with HIV. We saw it with treatment access, and when new things come along, we forget that. I think instead of the silos, if you pull up, you know, talking about gender-based violence talking about COVID talking about HIV, talking about TB, talking about non-communicable diseases, we got to start joining the dots because the underlying issues are the same. The vulnerabilities that drive all of this are the same. It is a structural issue. It is about the inequities. It’s about the two tiers that we have of those who have and who do not. So, the more we bring that development context into what we’re doing, and the more we know that it’s not about the resources, because as long as we believe in and we have oxygen there, we can make a difference without money. And it’s all pooled voices and energies that will take us to realize an aspiration that I don’t think needs just to be an aspiration that can be realized. And thanks again, Tian, and thanks, everyone.
FOLLOW UP QUESTIONS AFTER THE CALLIn the few re-infection cases you have recorded, is this suggestive that the immunity conferred by SARS-CoV-2 is truly short?
The two-peer reviewed reported cases have raised more questions than answers as the person in Hong Kong presented with no signs and symptoms, but the person from Nevada had more severe illness than the first episode. Questions being asked include: how common is re-infection? What are the implications for disease presentation; what does this mean for correlates of protection and its implications for vaccines? We don’t have answers to these questions, but hopefully, as we start to study those individuals who have been infected and monitor new infections in these individuals, we will begin to get answers to these questions
Are there post-recovery health measures for COVID survivors to prevent re-infection?
The key message that I think we can provide is continuing with NPI practices – applies to infected and uninfected persons – protect you and others around you – the vaccine in our hands! Not everyone who gets infected gets sick during viremia. More admissions we think are about two-three weeks later due to immune activation. Not everyone hospitalized has a prolonged recovery – again, very early days, about seven months into the pandemic, we are learning from each country epidemic – no two epidemics have been alike.
Something we are struggling with is the“stigma” and how it’s driving GPs to keep on telling people“it’s flu “ and go home to measure symptoms. Should we prioritize“oxygen level“testing? To “ catch those who are currently being missed and end up very ill in a day or two?”
Fear vs. stigma – two different things, I think. I have seen repeatedly the benefit of an oximeter and regular monitoring – I think it costs about R600 but is probably the best investment because as soon as your saturation levels start to drop to below 92%, it falls quite rapidly (within hours) and is an excellent trigger to get to a health facility for oxygenation and care
I would like to hear what is the responsibility of the researchers when engaging with the media? We have seen recent headlines such as“poverty has saved us” and the continually changing news headlines citing Prof Slims Abdool Karim’s remarks about schools reopening. What is the final word on children and COVID19?(To be clear, we are not asking you to speak or account for Slim but would like your viewpoint on this)
I think this is an excellent question, and several of us are grappling with. With increasing evidence-based decision-making/ science-informed, scientists have a huge responsibility to state the truth about what we know or don’t. I have learned from Covid-19 humility as there is more we don’t know than we know. Sometimes, I worry when “experts” provide opinions as fact and are so enamored with being on TV or radio or other outlets and start talking about issues outside their areas of expertise. As scientists, we have freedoms and responsibilities, and I would add humility to recognize and acknowledge what you know and what you don’t. Do we feed into media headlines or stay with what we know?We don’t know why Africa has seen a less severe epidemic; we don’t understand why the Western Cape saw an earlier epidemic than Gauteng or KZN; we don’t know how many people were infected and asymptomatic; we don’t know if we will have a second surge and when this will happen; we don’t know if antibodies offer protection or not…..We know that a few children get severe Covid-19 infection – why and how many don’t know. If it were more common, we would have seen more hospital admissions than we have. The school issue is the same as opening up the economy – how do we live with the virus and mitigate risk – the “new normal” of balancing saving lives with livelihoods. We have so many disparities, and depriving kids school attendance will exacerbate this as those who can afford it have connectivity and can do eLearning, etc.; human social interactions are essential for children; the importance of the meal in school is under-estimated; when parents go to work who looks after their children – not talking here about a middle class where there are stay at home mums but the majority of our households that are single, women-headed households.
Can you speak about your motivation to do the work you do – not HIV or anything scientific- what drives Quarraisha to wake up each morning and do what you do? The privilege and opportunity to do something meaningful.Where do you see yourself in 10 years?
Researching whatever health issue is impacting us in South Africa. Epidemiologists focus on populations and social justice through our action
What is your hope for South African women?
That the war on South African women ends soon and that everyone has the opportunity to contribute to their full potential in South Africa and on the continent
What would you say is the biggest lesson steering a research institute as CAPRISA has taught you?
The importance of focus and careful prioritization to make a meaningful difference – generating new knowledge is a slow process
What is CAPRISA’s most significant current challenge in undertaking its work?
Still trying to answer the two questions we set out to ask at inception in 2002
Where do you want to see CAPRISA in 10 years?
Having made more progress on our two priority questions; new leadership; addressing any emerging priority health challenges
A substantive majority of South African’s swear by traditional medicine. What work is CAPRISA doing currently on indigenous knowledge systems?
CAPRISA cannot do everything. In HIV-TB, we identified our two priority areas based on magnitude, severity, and significance. Dedicated centres and units are working on Indigenous Knowledge System (IKS)
What are your thoughts on traditional medicines in the public health response and system?
A crucial part of the health-seeking behavior of the majority of the population. Unfortunately, practitioners and products are not sufficiently regulated, e.g., in Ghana, China, or India. Hence, providers and products tend to range from genuine to charlatans and don’t have the same consistency and manufacturing oversight. Traditional Medicines should be subjected to the same rigorous evaluation as allopathic products before being prescribed for any specific indication