Africa

Global Health Partnerships in Southern Africa Put Infectious and Chronic Disease Innovation on the Map

Over the past two decades, SPH faculty in the Departments of Global Health and Epidemiology have collaborated with researchers, program implementers, and government officials in South Africa and Zambia to advance screening, prevention, and treatment for HIV, malaria, and other conditions.

Fifteen years ago, beginning treatment for HIV in South Africa was a long and burdensome process, requiring as many as half a dozen clinic visits before patients could finally receive their life-saving medication. This delay in care often meant that patients had weakened immune systems by the time they began taking a daily dose of pills. 

In 2016, a School of Public Health researcher led a pivotal randomized control trial to examine whether expediting this process could result in a better health outcome for people living with HIV. Published in PLOS Medicine, the “RapIT” study (Rapid Initiation of Treatment), found that initiating same-day antiretroviral therapy (ART) during patients’ first clinic visit could indeed improve their viral suppression. These findings later informed the July 2017 WHO recommendation for same-day initiation.

“RapIT was important because it indicated that same-day initiation of ART was both feasible and safe, and could effectively eliminate loss of patients from care in the period between testing positive and starting treatment, says Sydney Rosen, research professor of global health and principal investigator of the study. 

This work represents one of many research collaborations that SPH faculty have led or contributed to in southern Africa. Faculty have studied disease prevention, spread, and treatment in multiple countries across the region, with a sizable portion of research focusing on HIV treatment in South Africa and maternal and child health (including HIV), respiratory infections, and vector-borne diseases in Zambia.

20+ Years of Collaboration

For more than two decades, SPH has maintained a partnership with the Health Economics and Epidemiology Research Office (HE²RO) at the University of Witwatersrand (Wits University) in Johannesburg, South Africa. HE²RO was founded in 2003 by Rosen and Ian Sanne, a professor at Wits and a National Institutes of Health (NIH)-funded clinical trial researcher with a goal to understanding the economic and epidemiologic consequences  of HIV and TB, the outcomes of HIV and TB treatment, and the benefits and costs of interventions for these diseases. HE²RO is currently codirected by Rosen, Matthew Fox, professor of epidemiology and global health, and Lawrence Long, research associate professor of global health, with Sanne operating as division head and Jacqui Miot as division director. The team includes 78 staff in South Africa and several affiliate faculty members in the Department of Global Health (GH) in Boston, along with integral support from doctoral students. 

The researchers emphasize the collaborative nature of the partnership, where the South African team determines the research priorities and secures funding, informed by the needs of the government and public healthcare system, and the SPH faculty provide supporting epidemiologic, economic, and technical expertise.

“In our last five-year plan, the school emphasized a goal to establish global partners,” says Rosen. “It’s a really difficult thing to achieve, especially with no independent funding. But I think our ability to work with HE²RO over the past 20 years is as close to such a model as we’ve come.”

The partnership began at a pivotal time for HIV treatment in South Africa. After years of political denialism that HIV causes AIDS in the 2000s, the country’s HIV management efforts generated what is now the largest antiretroviral therapy (ART) program in the world, serving more than six million South Africans. Almost all of the eight million adults in the country living with HIV know their status. The South African government has led the large-scale provision of effective HIV treatment—transitioning from complex multi-pill regimens to well-tolerated, once-daily therapy—enabling people with HIV to live long, fulfilling lives.

But barriers to care continue to exist, including persistent stigma, difficulty getting to and from clinics for care or being able to skip work to do so (the country’s unemployment rate is more than 30 percent), and fear of side effects from the medication.

“When the roll-out for treatment first began, there was an assumption that if treatment would save your life, of course people would stay on it,” says Rosen. “But evidence started to accumulate that that wasn’t always the case. Over the years, we’ve built a body of work that addresses questions of how do you get people to stay in care and on treatment for their HIV? What happens if they drop out of care? And what are the best interventions to prevent that?”

One answer to the last question: establish trust with HIV patients. In a 2011 study in PLOS Medicine, Long led a major analysis that found that shifting HIV care from doctors in hospital-based ART clinics to nurses in primary care facilities was cost-effective, and a parallel paper published in AIDS by Alana Brennan, associate professor of global health and epidemiology, showed that this shift in care could decrease the burden on doctors and lead to equal or better treatment outcomes in resource-constrained areas. The model of care assessed in the study became the standard of care in South Africa and several other countries in the region.

“There was an initial belief that ART was so complex it would be difficult to deliver clinically, and that turned out to not necessarily be the case,” says Long. A native South African, Long served as a HE²RO director in Johannesburg (and local PI of the RaPIT study) and worked closely with the BU team before officially joining SPH in 2017. “Nurses are deeply embedded in primary healthcare in South Africa, and often have stronger relationships with the community, while interactions with doctors are relatively rare. We speculated that this might translate into greater trust, stronger support and, ultimately, better adherence to treatment.”

Tracking HIV Progression

Since 2004, South Africa has stored HIV and viral load testing data for millions of people in its National Health Laboratory Service (NHLS), a massive centralized database integrated into a public healthcare system that serves about 80 percent of citizens. 

But it was not until about a decade ago that these data were systematically linked at the patient level to track a patient’s disease progression over time. In 2014, researchers at the School of Public Health and HE²RO, in collaboration with the NHLS, developed and implemented a record-linkage algorithm to connect laboratory data to individual patients. 

The result was the creation of the NHLS National HIV Cohort—the first of its kind in any low- or middle-income country—that has enabled government officials and researchers to monitor the health status and program retention of people receiving ART to manage HIV, and this data has informed additional research, policies, and patient care.

“Unlike the US, South Africa only has one laboratory service that processes lab tests for all of the various districts throughout the country,” says Jacob Bor, associate professor of global health and epidemiology and a HE²RO affiliated faculty member. “We helped the NHLS to transform this giant database into a longitudinal cohort that tracks individuals as they progress through or drop out of HIV treatment programs, capturing data that showed when their viral load became suppressed or when their treatment was interrupted. We found that patients who had appeared to stop engaging with a facility’s treatment program had actually just switched to another clinic, and that wasn’t previously traceable.”

This insight was first detailed in a 2018 PLOS Medicine study Bor published with lead author Fox, coauthors Brennan and William MacLeod, research associate professor of global health, and senior authors from the NHLS.

“In this initial study, we sought to understand how much we were overestimating the number of people who stopped receiving HIV care, and it turns out that number was quite substantial,” says Fox, who worked at HE²RO in Johannesburg from 2008-2010.

The SPH team subsequently worked with NHLS and the South African HE²RO team to create national cohorts for tuberculosis, coled by Helen Jenkins, associate professor of biostatistics, as well as noncommunicable diseases, coled by Brennan.

US Funding Cuts

The Trump administration’s sweeping funding cuts to global health research over the last year have created uncertainty over the long-term stability of testing, prevention, and support services for HIV, TB, malaria, and other diseases throughout the region. The initial stop work order for all US foreign aid in early 2025, followed by the dissolution of the US Agency for International Development (USAID) and reduced funding for the US President’s Emergency Plan for AIDS Relief (PEPFAR), quickly halted clinical trials, prevented access to daily treatment, and forced the termination of staff across a number of programs.

South Africa and Zambia, in particular—both of which have HIV programs that are considered models of success—are navigating distinct and unique challenges due to this loss of aid. As an upper-middle-income country, more than 80 percent of South Africa’s HIV program budget is domestically funded and only 17 percent of this budget relied on US funding, but these funds supported key components of the HIV program. That support plummeted when the US slashed virtually all aid to South Africa in a 2025 executive order.

That loss of funding has also taken a serious toll on research. NIH had supported SPH and HE²RO’s work for the last decade, but has now frozen nearly all new grants to South Africa—including two grants among the SPH team—”which has jeopardized major investments in research infrastructure,” Bor says.

Last fall, the US approved $115 million in funding for a six-month period under its PEPFAR Bridge Plan, but that period ended on March 31. And in Zambia, negotiations to provide $1 billion in HIV funding to the US in exchange for access to Zambia’s vast minerals have stalled. 

“In South Africa, I think we were a good 10 years away from ending AIDS, and now we may not be,” says Gesine Meyer-Rath, a research professor of global health and principal researcher for HE²RO in Johannesburg. She has spent 15 years with colleagues building what she calls a “data to decision cycle”—developing data on the epidemiological impact, effectiveness, and optimal coverage targets of interventions, as well as cost-effectiveness and budget required—to directly inform policy at the national level. Just last year, she and HE²RO researchers analyzed the cost-effectiveness and optimal pricing of lenacapavir, a revolutionary six-month injectable HIV medication for both treatment and prevention, which has shown to be nearly 100-percent effective in preventing the transmission of HIV. The government considered these findings in its preparation for administering this drug, which is expected to be available for distribution in May.

Meyer-Rath recently published a study in the journal AIDS of the effects and cost of PEPFAR funding cuts in South Africa, finding that this loss of aid would result in up to 296,000 additional new HIV infections and 65,000 AIDS-related deaths between 2025 and 2028, and increase services-related costs by an additional $620,000 to $1.4 billion. A permanent discontinuation of PEPFAR-supported services could increase these totals to 2.1 million HIV infections and 712,000 AIDS-related deaths.

A primary concern now is reaching key populations that are more vulnerable to HIV acquisition. “Outreach to specific populations such as female sex workers, men who have sex with men or trans people is now completely gone,” she says. “Programs for adolescent girls and young women to receive healthcare beyond HIV services, as well as support for orphaned children—all underwritten by USAID—is also gone.” 

In spite of these challenges, GH faculty and staff continue to collaborate closely with colleagues at HE²RO, with about 20 joint research grants underway at any given time. Researchers from BU and HE²RO share responsibilities for these projects, which can be led by either institution with a subaward to the other. SPH faculty also help build HE²RO’s research capacity. Brooke Nichols, associate professor of global health, and a principal researcher in the Johannesburg office from 2016-2019 conducting cost-effective analyses of HIV service delivery, has helped several of HE²RO’s most promising researchers complete doctorates in public health-related disciplines.

Mother-to-Infant Transmission

SPH faculty have also led impactful HIV research in Zambia, with several studies focusing on child health. Over the last two decades, Zambia has made significant strides in child health due to reductions in HIV transmission, as well as improvements in malaria control.

Donald Thea, a professor of global health at SPH for more than 20 years before retiring in December 2024, led a major randomized control trial in the 2000s that addressed a longstanding dilemma for new mothers living with HIV in low-resource settings: breastfeed their newborn and risk spreading the virus to them, or feed their infants formula and raise their chances of developing, potentially lethal,diarrhea or other illnesses due to bacterial exposure. The Zambia Exclusive Breastfeeding Study took place during a period before antiretroviral therapy was widely available in the region, and HIV-positive mothers faced a high risk of transmitting the virus to their child during pregnancy, delivery, or breastfeeding.

Among several findings, the study showed that exclusive breastfeeding for the first six months followed by an immediate switch to formula—compared to a shorter period of breastfeeding and an earlier introduction of formula—could substantially lower this risk. Based on these findings, the WHO released new recommendations in 2006 for breastfeeding that urged women with HIV to breastfeed exclusively for six months “unless replacement feeding is acceptable, feasible,affordable, sustainable and safe,” a departure from prior recommendations that had directed women to discontinue breastfeeding as soon as possible. 

“We showed that, under the best of circumstances, we could reduce the vertical transmission rate to as low as four percent, compared to 20 percent in the absence of antiretrovirals or a C-section,” says Thea, adding that today’s global risk of mother-to-infant HIV transmission is as low as one percent. “It was a major affirmation of the importance of exclusive breastfeeding, as well as effective program policy.” 

ZEBS led to another major grant for Thea in 2018, which became the Zambia Infant Cohort Study. The study underscored the health benefits of ART for HIV-positive mothers by showing that antiretrovirals can largely reduce the risk of morbidity and mortality among children who were born to mothers with HIV, but who had not become infected themselves. 

Improving Malaria Screening and Treatment

In addition to HIV, malaria is also a serious and widespread health concern in Zambia, with nearly 10 million cases reported in 2024. Malaria and HIV coinfections are also common, as HIV can increase the risk of a severe malaria case, and malaria can increase HIV viral load and transmission.

Davidson Hamer, professor of global health and medicine at SPH and BU Chobanian & Avedesian School of Medicine, along with Thea and MacLeod, have produced pivotal studies on malaria transmission and treatment in Zambia since the early 2000s. In 2003, Zambia became just the second country in Africa, after South Africa, to administer artemisinin-based combination therapy for malaria treatment, following a series of sentinel site in vivo efficacy studies Hamer led showing near 100-percent effectiveness of artemether-lumefantrine, and very high failure rates of chloroquine and sulfadoxine-pyrimethamine, (known as Fansidar).

“We worked with the Zambia Ministry of Health and the National Malaria Control Centre, and got them to change their policy to make artemisinin-based combination therapy the recommended first-line treatment for malaria,” Hamer says. “By 2006, almost every country in sub-Saharan Africa had made that change.”

In 2007, Hamer led a notable JAMA study that found artemisinin-based combination therapy, an expensive antimalarial treatment, was being overprescribed in Zambia, even in the absence of confirmed diagnoses. Rapid diagnostic tests (RDTs) were administered to fewer than 30 percent of patients with fever symptoms, while 65 percent of patients with negative blood tests—and 35 percent of patients with negative RDTs—still received the antimalarial medication. Due in part to the findings in this study, Zambia updated its national guidelines or malaria training manuals to include specific recommendations on how healthcare workers should handle negative RDTs.

A 2010 PLOS Medicine study, led by Hamer and Kojo Yeboah-Antwi, former research associate professor of global health, and coauthored by MacLeod and Thea, found that Zambian community health workers could play a significant role in effectively treating both malaria and pneumonia among children by providing early and appropriate pneumonia treatment to children with nonsevere cases, as well as malaria treatment to children after they test positive for the disease with an RDT.

“This work led to a gradual acceptance and use of malaria rapid diagnostic tests in Zambia at the community level, but also in a lot of other countries that were having similar problems,” Hamer said. These results contributed to the evidence base that led UNICEF and WHO to advocate for integrated community case management of malaria, pneumonia, and diarrhea as an equity-based strategy for countries in sub-Saharan Africa. 

Neonatal Infections and Mortality

The researchers have also published studies on other child illnesses, including pertussis and respiratory syncytial virus (RSV). 

“Infant and child mortality rates have really declined over the past 25 years, which is good news,” says MacLeod. “But as these rates decrease, remaining infant deaths often occur in the earlier stages of childhood, when children are more vulnerable to other infections.” 

In 2016, Hamer led another landmark RCT called the Zambia Chlorhexidine Application Trial (ZamCAT), which found that an antiseptic wash used for umbilical cord care did not reduce neonatal mortality in Southern Province, Zambia—despite previous studies showing that this wash was effective in reducing neonatal deaths in south Asia.

“The goal of this study was to compare 4% chlorhexidine applications to the cord right after delivery through the time the cord dropped, versus dry cord care, to see what impact it would have on neonatal mortality and cord infections,” said Hamer, who led this work with Katherine Semrau, former assistant professor of global health, and with coauthors MacLeod and Thea. The study involved nearly 37,000 live births. Because the wash proved to be ineffective at reducing mortality in Zambia, the authors discouraged global implementation of this practice.

Another major project, the Zambia Pertussis RSV Infant Mortality Estimation (ZPRIME) study, was conducted among infants at a morgue in Lusaka, Zambia between 2020-2022. This study was led by Christopher Gill, former professor of global health and currently a senior program officer at The Gates Foundation, ZPRIME was the largest post-mortem RSV surveillance study of its kind and the first to directly measure RSV infant deaths in the community, rather than rely on modeling estimates. MacLeod, Thea, and Rachel Pieciak, research associate in the Department of Global Health, also contributed to this work. One study from the project, published in Pediatrics, found that over 80 percent of infants who died in the community had delays in seeking or receiving care. A second paper, published in The Lancet Global Health, found that RSV was contributing to a substantial portion of infant deaths, as the virus was present in nearly 1 in 10 of all deceased infants who died in the hospital or in the community. Similarly, a separate study published in eLife by Gill, MacLeod, Thea, and Pieciak also showed that asymptomatic Bordetella pertussis infections (the bacteria responsible for whooping cough) were much more common in Zambian children than previously known.

Tools for Scientific Writing

Many SPH faculty working in southern Africa are seasoned researchers with decades of experience, but one faculty member is leading an initiative called Rethé that aims to increase the representation of early-career African researchers in scientific publishing. 

Elaine Nsoesie, associate professor of global health, collaborates with the University of Pretoria in South Africa, as well as local institutions in Tanzania, Nigeria, Sierra Leone, and Kenya to provide scientific writing training, tools, and mentorship to graduate students and junior faculty.

Funded by an SPH Practice Innovation Award, Nsoesie initially launched Rethé in 2019, offering a combination of in-person and virtual webinars and workshops on scientific writing and a range of related topics, such as research ethics and plagiarism. 

The second iteration, which launched in 2024, places more focus on the actual development of papers, where participants can view a series of YouTube videos on their own time before attending the workshops. 

“I’ve wanted to do this for a long time,” says Nsoesie, who is also a founding faculty member of the Boston University Center for Computing and Data Sciences. Her research focuses on applying data science methods such as machine learning and artificial intelligence, as well as data from nontraditional sources, such as social media, to address major global health issues. A native of Cameroon, she says she’s always wanted to see more Africans publishing papers. “I love to write, and I wanted to share that with other people.”

A core part of the initiative is a nine-month fellowship program in collaboration with Data Science Africa, a non-profit providing training in data science, machine learning and Artificial Intelligence in Africa. The fellowship includes cohorts of 20+ participants who focus on researching and writing about women’s health issues. 

“The fellows have worked on a broad range of issues around women’s health, from alopecia to cancer to maternal mortality,” Nsoesie says. The main goal is for the fellows to publish at least one paper during the course of the fellowship or afterwards—and a few fellows have already had papers accepted to journals, she says.