The initial results of the DREAMM project have been published in both Lancet HIV and Lancet Global Health. Now that the methodology has been proved to work, it’s only the start of an important process that the research team hope will soon lead to scale-up across other African countries. So why is this so urgently needed – and what needs to be done as a next step? We’ve interviewed two key players in the project for their insights into the wider context.
Dr Angela Loyse is Chief Investigator of the DREAMM project. Based in London, she’s an infectious diseases researcher and doctor, conducting large-scale trials in African countries focusing on HIV-related meningitis. Dr David Meya is a meningitis expert in the Infectious Diseases Institute at Makerere University who is working with Dr Loyse on next steps, including DREAMM 2.
Q: Why is this population of adults with HIV-linked meningitis conditions important to the future of sub-Saharan Africa?
Dr Meya: The HIV epidemic is hollowing out the fabric of society. In Africa alone, we have half a million people still dying of HIV-related conditions, typically men and women aged between 20-45. Those people are not only much-needed parents of children, and the offspring of the older generation; on a purely economic basis they are the most productive age group in the sub–Saharan African economy. If they can’t function, this will have a detrimental effect on life and economy in the region.
In addition, this population is adding to the burden of health care costs in countries across sub-Saharan Africa. Because they are being treated in hospital, when their meningitis is at an advanced stage, it’s more expensive than preventative measures. Although both approaches are needed, the balance is presently falling to hospital acute care, so greater investment in ensuring good hospital care is required for this group of patients.
Dr Loyse: Within often under-resourced and weak health systems, people living with HIV are generally just one or two steps from presenting to care seriously unwell. Opportunistic infections such as meningitis are quick to take hold and the consequences can be devastating. Those who are still dying from meningitis are often at the height of their economic productivity. They leave behind a huge hole in their communities that has yet to be adequately quantified on a societal or economic level.
Q: Why are people still getting these HIV-linked infections, given that antiretroviral therapies (ARTs) have been rolled out across Africa?
Dr Meya: There’s a notion that if people have their antiretroviral therapies everything will be fine – but that’s not the reality . Antiretrovirals work by stopping the virus replicating in the body, but they need to be taken every day. Not everyone will do that. Unfortunately, we know men are less good at taking their therapies than women, so typically the majority of people who show up in hospital with HIV related opportunistic infections are male.
In addition, antiretrovirals don’t stop people becoming infected in the first place. Sub-Saharan African countries don’t generally have good systems of screening or of contact tracing, and thus many people are not diagnosed. As their HIV develops, the problems come along, so that’s why hospitals get people presenting fairly late in the course of HIV, with serious infections that are suddenly taking hold. In Uganda, where I’m based, there are around 1.5 million people known to be living with HIV, however, it is difficult to estimate how many other people in the general population are unaware that they are infected.
HIV is a clinical problem but also remains a social issue. If people don’t know they are infected, they can’t take steps to prevent passing it on to others, or sharing drugs with someone who may or may not be infected. Social behaviour is a challenge to control. People do have more information now though, so things are improving in that regard.
Q: An important element of the DREAMM project is the diagnostic element; the training, and the medicines themselves. That’s expensive. Do you believe that all of this is realistically affordable, across African countries?
Dr Meya: African countries have to make a judgment on healthcare expenditure based on their GDP that is reflective of the value we, as Africans, place on our own lives. There are other organisations which could help fund tests and medicines such as PEPFAR, the Global Fund and Unitaid – but Africa needs to show it’s serious about leading the way.
With DREAMM, researchers have given them a way to progress in this particular set of infections that really works. Policymakers now want to know: ‘What resources are we talking about in terms of costs?’ and while we want to show them that, we need to also demonstrate the cost savings they’ll make by improving their healthcare systems.
Dr Loyse: Yes, as well as showing that our project’s health system strengthening could substantially reduce mortality from HIV-related meningitis, it also had a knock-on effect on the overall standard care in the public hospitals where it took place. A quarter of participants who had suspected meningitis actually did not have the condition, but their management was still sped up and improved.
The weak health systems that were successfully remedied within DREAMM within the field of meningitis affect the success of all programmes including paediatrics, Non-communicable Diseases and Neglected Tropical Diseases more broadly. Ultimately, we believe the DREAMM approach has the potential to be adapted to all these disease areas.
What, in your view, needs to happen next?
Dr Meya: There are several steps that are crucial now. Firstly, the scale up of the project is vital – that’s where we will understand that what might work in Malawi needs to be tweaked to work in Uganda, and again in Nigeria or Kenya.
Secondly, while publishing the study has been essential for credibility, we need to make sure that it’s disseminated to AIDS control programmes and Ministries of Health. These are the organisations who will enable training in the programme at a public hospital level, and it’s only with that training that it will be embedded into practice. It doesn’t matter if there is staff turnover – this is the necessary standard of care to reach.
Finally, publishing the cost effectiveness data will provide clarity on the resources that are needed, alongside effective modelling. So we can prove that, yes this is the initial cost – but we can also show health leaders the cost savings they will have if they implement this programme.
Dr Loyse: On top of the cost of tests and medicines, the actual cost of rolling out DREAMM is likely to be small as it consists mainly of time to train, mentor and build laboratory capacity over time. We need to rebuild a critical mass of healthcare leaders, front-line healthcare workers and laboratory technicians who will then train others so the investment will be finite; however we cannot avoid the initial cost of strengthening public hospitals and linkage to care if we are to meet The UN’s Sustainable Development Goals.
Dr Meya: The success of DREAMM is at present only partial and we need to continue to urgently build on what has been achieved. We’ll only really be able to talk about success when we see the impact it has had in three to five years’ time. Did the sites continue to run with the programme? Was it implemented in other countries? That will be the real test of success.