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Canadian Efforts Supporting the Fight Against AIDS at Home and Abroad

by Francis Mandy

During the early 1990s, the mandate of the Canadian Federal HIV Immunology Laboratory, under my direction, was to ensure that the continuously developing cellular immunophenotyping related to clinical management of HIV disease was disseminated across Canada. Our role was to transfer flow cytometry-related biotechnology to laboratories designated to participate in antiretroviral therapy (ART) type of drug trials across Canada, and to provide a quality assessment program that was as good as the one provided by NHI’s ACTG program. This process included knowledge transfer to both clinicians and laboratory technologists across Canada. Because of the officially bilingual nature of Canada, one of the challenges was how to deliver effective didactic technical material and convert it into skills and knowledge for individuals who speak English or French but not both. Furthermore, for about 80 percent of our bilingual staff, English was an acquired language.

President Bill Clinton and me in New Delhi, India. I was working with his Foundation to introduce an external quality control programme for CD4 T-cell counting.

In the fall of 1995, Dr. John Fahey (University of California, Los Angeles) approached us to see if we would help to establish a pilot program to support quality assessment of immune status monitoring of individuals infected by HIV in resource limited countries. During the Vancouver AIDS Congress in 1996, we organized a meeting with representatives from NIH and other major agencies involved with CD4 T-cell enumeration. QASI, an international external quality assessment program (EQAP) for CD4 T-cells, was born. With the support of John Fahey, QASI was initially financed by the Fogarty International Center and it served about 75 laboratories in Brazil and Africa. The process of delivering technical assistance related to CD4 T-cell enumeration also began in 1996. Under my direction, QASI evolved into the largest CD4 EQAP, supporting public health laboratories in resource poor countries. All these labs at that time were struggling with HIV disease without adequate funding and of course without access to ART. Currently, QASI delivers an EQAP and quality management supporting software “LymphoSite” to about 500 laboratories in over 50 countries. This kind of success does not happen without funds. Currently, financial support comes from various organizations that are determined to fight AIDS in resource poor regions. These organizations include: the Clinton Foundation, Association of Public Health Labs (APHL), Centers for Disease Control and Prevention (CDC), Global AIDS Program (GAP), Doctors Without Borders (MSF), and, of course, the Public Health Agency of Canada (PHAC).

It is my firm belief that, to be effective, the trainer must know the trainee’s realities in the country of origin. Prior to “selling” QASI in Africa, I went to familiarized myself with some of the different laboratories which would eventually participate in QASI. Discovering the ubiquitous presence of graft, the precariousness of electrical and water supplies, even the peculiarity of regional vocabulary (the word ‘nightclub’ does not mean the same thing in Brazzaville as it does in Chicago!) are all essential to master the effective delivery of relevant biotechnology. We learned that face-to-face meetings are essential to establish effective initial and lasting communication and to understand regional realities to meet essential requirements that will remain sustainable over the course of the pandemic.

The Canadian experience gave our group some practical insight about how to adjust to deliver effective communications in Africa when English or French is not the mother tongue of the audience. Subsequently, we were able to harness effectively personal hands-on knowledge into action. Our presentations generally contain more animated self explanatory illustrations and less dry, didactic text. In Africa, we were able to focus almost immediately on biotechnology transfer workshops rather then how to communicate. Our early successes came in French West Africa where we had our first reconnaissance travels, but soon WHO offered financial and logistical support to expand our teams training skills to both English speaking Africa and to other regions including Asia.

The technology transfer expansion continues by hundreds of groups. I have given close to 200 lectures world wide, from Bobo-Dioulasso (Burkina Faso, West Africa) in French, Krosnoyarks (Central Siberia, Russia), in English with simultaneous interpretation, to Pécs, Hungary, in Hungarian. Some of our road-tested PowerPoint material is now part of the CDC/GAP’s African skills building package.

Senegal 2003 - flow cytometry skills and capacity building class

As our group began to deliver effective biotechnology-transfer workshops related to management of infectious immunology laboratories, institutions from many resource poor regions made requests with the help of CDC, to send young potential national leaders to our laboratory in Ottawa. During the past decade, dozens of individuals from Eastern Europe, South America, Russia, the West Indies, Africa, and Asia have been trained in Ottawa. During the past 15 years, we have contributed to the development of CD4 T-cell enumeration guidelines in the USA (NIH, CDC, CLSI) and Canada. In the past three years, our team has participated in the development of national guidelines documents with the governments of China, India, Morocco and Russia. Some of these national guidelines will be published in English early in 2008.

Zambia 2005 - flow cytometry skills and capacity building class

These long term altruistic investments are slowly paying back some dividends with profound national/international impact. Our most recent endeavor was also in response to the realities of Africa. After perceiving a need, we set about to develop a one year internship course for HIV immunology laboratory quality management. The curriculum was developed in Ottawa and will now be administered by our long time colleague, Michele Bergeron. The first scholarship has been awarded. The inaugural internship commenced in June 2007 with a student from Dakar, Senegal. The next objective is to find a suitable academic institutional home for this Infectious Immunology Laboratory Quality Management Course with emphases on practical aspects of affordable flow cytometry. The goal is to bring public health managers from resource limited regions who speak English or French (not necessarily with mother tongue capacity) to a recognized Northern Hemisphere academic center to obtain an internationally recognized diploma. There is an urgent need for this type of assistance. For example, an enormous amount of money has been mobilized to deliver ART first in urban and more recently in rural Africa. It is well understood that it is essential to monitor therapy diligently to be sure that patents get optimal drug benefits and the possible development of massive drug resistance to ART is avoided at any cost. It is also recognized that CD4 enumeration with affordable technologies is the most cost effective singular test for such purposes. Yet most African health ministries do not actively support efforts to monitor quality nor to regulate CD4 T-cell counting services. Generally, public health authorities with their meager revenues have a profound difficulty associating fiscal responsibility and delivering effective public health care programs.

Just recently, I was appointed as Director of Education Programs at ISAC. We all know that collegial cooperation can lead to remarkable synergistic outcomes. Please consider approaching me with ideas to build a healthier world with our remarkable and diverse expertise in biotechnology.