Einstein in Africa: Researchers, Students Take on HIV and TB

The combination of HIV and tuberculosis packs a deadly one-two punch. As devastating as either disease is alone, together their effect can be catastrophic.

Through Einstein's Global Health Fellowship Program, students Liz Liu and Dorothy Shi went to South Africa, where they assisted with research projects addressing HIV and tuberculosis.A pair of Einstein students spent the summer helping researchers punch back.

Second-year students Liz Liu and Dorothy Shi completed internships at the KwaZulu-Natal Research Institute for Tuberculosis and HIV (K-RITH), in Durban, South Africa.

A collaboration of the University of KwaZulu-Natal and Howard Hughes Medical Institute, K-RITH brings together scientists throughout the world to conduct basic research into HIV, TB, and their co-infection. The institute was founded in 2009 by a team that included Dr. William Jacobs, an HHMI investigator – and professor of genetics and of microbiology & immunology at Einstein.

The location they chose is no accident.

South Africa is home to about 5.7 million people with HIV, more than any country in the world, according to K-RITH data. South Africa also has one of the highest rates of TB per capita. And each year, 250,000 HIV-infected people in South Africa develop active TB, accounting for about one-third of all the HIV/TB co-infections in the world.

Both HIV and TB are skilled at adapting to and resisting new treatments, compounding their danger.

In 2005, in the South African village of Tugela Ferry, an outbreak of an extensively drug-resistant form of TB produced results that seem like the stuff of science fiction. Fifty-three patients were admitted to the hospital with the disease. All but one died from it, including 44 who were known to be infected with HIV as well. On average, patients lived only 16 days after admission – far too short a time to even diagnose the TB.

The tragedy focused world attention on co-infection by the two diseases and how they might influence each other, and ultimately led to the formation of K-RITH.

Dr. Michelle Larsen, assistant professor of medicine and a member of Dr. Jacobs' lab, worked with the founding team and others to develop plans for the $40 million facility, located on the Nelson R. Mandela School of Medicine campus. K-RITH's eight labs – including highly secure spaces to handle dangerous pathogens – were designed to be a hub for investigations spanning diverse specialties.

Some local wildlife"Despite the population overlap between TB and HIV, research was really being done in siloes," Dr. Larsen said. "There was a need to focus on both diseases, in one place. And Durban was the place to focus on them."

By last summer, K-RITH had grown enough to consider sharing that focus with medical students. With the leadership of Dr. Jacobs and the support of Einstein dean Dr. Allen M. Spiegel and the Global Health Fellowship Program, a small internship program was created. Encouraged by Dr. Larsen, Ms. Liu and Ms. Shi applied – and were two of just 15 students accepted out of about 90 applicants from medical schools nationwide.

In Durban, Ms. Liu did bench work, helping to develop what may become a faster, more effective diagnostic tool for extensively drug-resistant TB. Ms. Shi joined a clinical team that collected and analyzed sputum, blood, and other specimens used by bench researchers, obtained from patients at neighboring hospitals.

"We had a unique view of the epidemic, working on research in the place where knowledge from that research is needed most," said Ms. Liu, who is taking part in Einstein's Student Opportunities for Academic Research Program (SOAR), with a concentration on global health, under the guidance of Dr. Larsen's colleague and fellow K-RITH researcher Dr. Max O'Donnell. "TB and HIV are so complex, there are so many questions that need to be answered. It can feel overwhelming at times. But I am so grateful I could be there."

Ms. Shi echoed those thoughts. "We were at the epicenter of the epidemic, seeing it day in and day out, learning day in and day out," she said. "Everything felt like a ‘first' to me. It was truly a great experience."

One factor that surprised both students was the language barrier that sometimes made communication difficult. Nearly all patients spoke Zulu; almost no doctors did, requiring nurses to serve as translators. The two Einstein students and the other interns were often at a loss for words, literally.

"These patients have to confront so many barriers," Ms. Shi said. "They often lack money. Getting to the hospital can be difficult. They have to take many medications according to complicated schedules, and when there's a language difference between them and their doctors, they can't ask questions directly."

Ms. Liu said, "How do you share information vital to treating a patient when you can barely communicate with them? Not only did this internship highlight how absolutely critical communication is to good medical practice, but it also taught me to be more mindful of differences between people and cultures. This experience really expanded my horizons."

Indeed, teaching students to deal with differences may be one of global health fellowship's greatest benefits.

"Being immersed in another system, in another culture, is disruptive. It forces you to ask questions," said Dr. Larsen. "That's important for any scientist."