Two Michigan doctors - well known for their HIV/AIDS work here - have been taking part in the US effort to provide assistance to African nations. One is an infectious disease specialist, the other a Doctor of Religion.

Ironically, they are both called Jon and work with the federally funded Great Lakes to Tennessee Valley AIDS Education and Training Center (GLTV AETC). Jonathan Cohn, MD is an Assistant Professor of Medicine at Wayne State University and is Director of Medical Education for the GLTV AETC. Jon Lacey, Rel.D., is the director of the Michigan State University AIDS Education and Training Center (AETC), which provides training for medical professionals statewide.

Jon Lacey has trained clergy and healthcare providers in Botswana and Zimbabwe. In Swaziland and Mauritius he was invited to make international cooperative proposals for the sharing of HIV/AIDS knowledge to health care provider groups. "While I've had the support of (MDCH Director) Mr. Haveman for the enterprise, it's been largely self-financed, financed by faith based groups in the US in my service with the Council of Religious AIDS Networks, and to a smaller degree by a relationship with CDC (Centers for Disease Control and Prevention) and its subcontracts with my faith community through the Council," said Dr. Lacey.

Jonathan Cohn is part of a US government team that has traveled to Mozambique. A country about the size of California, Mozambique is one of the poorest in Africa. Dr. Cohn was asked to represent HRSA's (Health Resources Services Administration) AETC on the team. He knew the land, the people and the language from working there in the 80's.

His team was one piece of US government-funded activities in Mozambique. "Our part was about treatment and my part was about how to do the education component to support the treatment," said Dr. Cohn. "The formal project involved setting up a system to do primary care, including prophylaxis for opportunistic infections - not antiretrovirals at this point." Dr. Cohn said they would start setting this up by linking to sites where HIV testing would be offered.

The CDC had a separate contingent working on setting up HIV testing and surveillance in Mozambique. Before the CDC arrived, there was "virtually no HIV testing available" in the country. Blood donors were tested by the Ministry of Health. Red Cross does flood relief there, not blood collections, said Dr. Cohn. "When there are test kits left over from blood donors, doctors may use them on patients who they suspect (are infected)." Also, "blind sero-surveys are done in prenatal clinics for surveillance."

In Mozambique, where there are 400 doctors for a population of 18 million, nurses and mid-level nurse practitioners provide most primary care, said Dr. Cohn. "So our notion is to train nurses to do HIV primary care, with the main thrust being opportunistic infection prophylaxis and also treatment of common conditions and screening for more serious conditions."

The initial voluntary counseling and testing (VCT) sites will be located at hospitals or medical clinics or a freestanding center. Each of the VCT sites would follow common Ministry of Health protocols, but be financed by different donors, such as the French Government, Doctors Without Borders, People to People, and UNICEF.

Eventually they can build on this beginning structure of primary care at the counseling and testing sites, perhaps adding antivirals to prevent perinatal transmission. "We don't know if we offer these voluntary test sites, if anyone will walk through the door. On the other hand, if this were offered at prenatal clinics, it may be more widely embraced. In sub-Saharan Africa, fertility is very high. If you were targeting prenatal clinics, half the young adults would get tested in a few years." The manufacturer of nevirapine (VirammuneR) will provide it free for five years to nations with an organized program to reduce mother-to-child HIV transmission. Mozambique has not yet begun such a program, as it is still dealing with issues of VCT, fear and potential discrimination against persons with HIV/AIDS, logistics, and the limited resources of the public health care infrastructure.

Cost is a real barrier for this country for any HIV therapy. "Even at the reduced cost that companies are now willing to sell drugs at to developing countries, $600 - 1,000 a year for therapy, Mozambique could not possibly afford these - there would have to be donors buying these, " said Dr. Cohn.

Another part of the HRSA initiative is to try to develop support for Mozambique doctors who are writing both treatment guidelines for the country and an infectious diseases textbook to use in their medical school for use in their mid-level practitioner training.

In Mozambique and other developing countries, homecare for HIV is a primary source of care. There isn't room in the hospitals for everyone who is sick. "Most hospitals have mattresses on the floor and two people to a mattress," said Dr. Cohn. "People who are doing homecare don't like to think of it as something to keep people out of hospitals. They like to think of it as something proactive and useful."

There are also home visits provided by persons living with HIV/AIDS agencies. Around one of the major cities, Chimoio, there is a network of church organizations that does home care. They don't say it's about AIDS, noted Dr. Cohn, due to the stigma. "They help the family, do chores all on a volunteer basis. It's based on a program in Zimbabwe."

The Ministry of Health's original goal for the testing program was to have 22 sites opened by the end of 2001, an ambitious goal that they aren't close to reaching. When these sites are up and running, they will be matched with the primary care clinics. Dr. Cohn said he would like to return to train the personnel once the program has been set up.

"It's starting small with the hopes that it will expand in service and with the kind of services that can be provided as more resources become available," he said.

Jon Lacey has seen the diversity of Africa, culturally, socially, politically and economically, through his extensive travels to the continent. He said care resources vary widely. "I've trained with physicians and other providers in hospitals, but we've also trained leaders of First World peoples in very poor settings in the African deserts. Generally, with the exception of Botswana where the standard of care is quite high owing to recent focus and funding as the world's 'population center' (Botswana has the highest rate of infection recorded - 38.6%), resources and training are poor to non-existent.

"My travel and training of clergy and healthcare providers in Botswana and Zimbabwe has been as one committed to sharing knowledge and skills-building expertise with African health care partners….In Zimbabwe I have most recently worked with the Anglican Church and with Bishop Gaul Theological College and Domboshowa College (where ministers and priests are trained) and with Mashambanzou, an interfaith AIDS service organization that uses nutrition, counseling and peer education along with available medications for a small number of Zimbabwe's dying HIV/AIDS patients.

The International Red Cross, Red Crescent Societies recently adopted the Zimbabwean Red Cross' policy framework for tackling HIVAIDS issues, but Dr. Lacey said Mashambanzou is really the model in the country.

"The numbers of the dying defy our sensibilities - more than 2200 persons dying a month in the capitol city alone. Graves with numbers instead of names; mass graves; unclaimed bodies in the thousands each month at the morgues."

At an international conference in September, Botswana was recognized for reducing mother-to-child transmissions. Does Dr. Lacey think other countries he visited have the infrastructure to administer perinatal prophylaxis drugs even if they were offered free?

"In a word, 'no,'" he said. "AIDS has companions: malaria, poverty, and malnutrition, TB. Practically speaking, AIDS, because it's a relatively slower killer, is the least of the worries of many mothers whose babies may die more rapidly with dysentery, malaria, TB or malnutrition."

The long-term antiviral therapy for people living with HIV has even more obstacles. While the global debate and controversy over patent law and drug availability for developing nations has captured the media limelight for over a year, the reality of the issue can only be observed locally.

"With our experience about adherence and compliance as a background, using some of the medications that we have available does not even begin to make sense in Africa if we don't systematically attack some of the companion problems. Warfare is also a big issue in many countries, including Zimbabwe, which spends already scant resources at the tune of $1 million/day to wage war in neighboring Democratic Republic of Congo. As here, the problem of resistance is a huge issue. Medications used improperly are already leading to resistant strains of HIV."

In Africa, it will take both spiritual leaders as well as modern medicine men to overcome the great obstacles to stopping the AIDS pandemic.

Jon Cohn will be celebrating World AIDS Day in Mozambique, in the port city of Quelima on the Indian Ocean. It was here Dr. Cohn worked for 2 years in 1982. He will present a donation from the Southeast Michigan Chapter of the Association of Nurses in AIDS Care from their fall fundraiser.

Jon Lacey will be celebrating World AIDS Day with a faith-based service in Indianapolis, IN and will then leave for the International Conference on AIDS in Africa in Ougadougou, Burkina Faso and for training at the University of Ghana Medical School in Accra, Ghana.