An analysis on the positive effects of exercise on blood sugar levels in people with Type 2 diabetes mellitus (T2DM) shows that while all exercise helps, certain activities – and their timing – are especially beneficial. The study, published in The American Journal of Medicine, provides a comprehensive but straightforward summary of the benefits of exercise on controlling blood glucose levels in people with T2DM.
“The challenge with this is that most, if not all, people know exercise is good for them but they don’t know the best approach,” said Steven Malin, an associate professor in the Department of Kinesiology and Health at the Rutgers School of Arts and Sciences and an author of the study. “We targeted this issue by focusing on a few key parameters: the utility of aerobics versus weightlifting, the time of day that is optimal for exercise, whether to exercise before or after meals and whether we have to lose weight to get benefits or not.”
As part of the analysis, researchers sifted through dozens of studies and extracted common conclusions. Some of the key findings include:
Habitual aerobic exercise: increases the heart rate and the body’s use of oxygen helps manage blood glucose.
Resistance exercise: benefits insulin sensitivity in those with Type 2 diabetes.
Movement throughout the day by breaking up sitting time benefits blood glucose control and insulin levels.
Performing exercise later in the day can result in better control of blood sugar levels as well as improve insulin sensitivity.
“In short, any movement is good and more is generally better,” Malin said. “The combination of aerobic exercise and weightlifting is likely better than either alone. Exercise in the afternoon might work better than exercise in the morning for glucose control, and exercise after a meal may help slightly more than before a meal. And, you don’t have to lose weight to see the benefits of exercise. That is because exercise can lower body fat and increase muscle mass.”
While insulin resistance in T2DM is harmful, scientists believe increased insulin sensitivity is beneficial. High insulin sensitivity allows the cells of the body to use blood glucose more effectively, reducing blood sugar.
Malin researches insulin sensitivity and teaches kinesiology, the study of human movement. He and several other faculty members at Rutgers support the concept of “exercise as medicine.” The idea, which is supported by the American College of Sports Medicine and is increasingly being borne out by research, is that exercise can be considered a first-line therapy.
“I’m one of those individuals who subscribes to that notion, and in that way, I think of exercise as a drug,” Malin said.
Malin and colleagues authored the study to offer the medical community up-to-date practical advice for their patients.
“Together, this idea of exercise timing and type is important because it helps medical professionals more accurately recommend exercise prescriptions to combat high blood glucose,” Malin said.
Compared with white women, Black women have elevated risks of being diagnosed with advanced uterine cancer – also known as endometrial cancer – and of developing aggressive tumours. Researchers recently compared the incidence and trends for endometrial cancer, both overall and by subtype, between African descent women in Florida and women in the French Caribbean, specifically, the islands of Martinique and Guadeloupe. The findings are published by Wiley online in CANCER, a peer-reviewed journal of the American Cancer Society.
Endometrial cancer is classified as endometrioid or non-endometrioid (a more aggressive form) based on tumour cells’ appearance and genetic alterations. When Heidy N. Medina, PhD, MPH, of the University of Miami School of Medicine, and her colleagues analysed data on 34 789 endometrial cancer cases from Florida (US) and the French Caribbean from 2005–2018, they observed the following:
Caribbean Black women had the lowest rates for both endometrioid and non-endometrioid subtypes.
Non-endometrioid types were most common among US Black women (9.2 per 100 000), 2.6-times greater than the rate for US white women.
For endometrioid cancer, rates increased 1.8% yearly from 2005–2018 for US Black women and 1.2% for US white women, while no change was observed for Caribbean Black women.
For the more aggressive non-endometrioid cancers, rates increased among all women: 5.6% yearly among US Black women, 4.4% among Caribbean Black women, and 3.9% among US white women.
“This study informs the current scientific evidence about endometrial cancer risk among a diverse sample of African descent women, highlighting that within group differences matter among Black women,” said Dr Medina. “Our study suggests that these differences among Black women in different regions of the world are partly due to social factors associated with assigned race rather than purely African ancestry – related factors based on genetic origin.”
Dr Medina added that the study emphasises the need to not generalise results from Black women in the US to other African descent populations worldwide where limited data exist. “This signals the need for coordinated efforts around the world in identifying disparities, emphasising the importance of strong cancer surveillance systems and registries throughout different regions, and the necessity for there to be a greater priority among the global health community in allocating resources to improve data collection for cancer registries worldwide,” she said.
Dr Medina also stressed the importance of tracking the increasing rates of the deadlier non-endometrioid types of endometrial cancer and identifying risk factors associated with these malignancies.
Technical work on the discovery of new medicines is not commonly done in Africa, but Kelly Chibale, a professor in organic chemistry and founder of H3D at the University of Cape Town is changing this. PHOTO: Nasief Manie/Spotlight
Inside Professor Kelly Chibale’s office the bookshelves are packed with awards. On the walls, framed photographs include his class photo at Cambridge University in the United Kingdom, dated 1989.
Chibale is a professor of organic chemistry and founder of the pioneering Holistic Drug Discovery and Development Centre – H3D – at the University of Cape Town. While many important clinical trials have been conducted by Africans in Africa, the kind of drug discovery work that Chibale is doing is rare on the continent.
Chibale relays how he sees molecules everywhere – in hair, in clothes, in all of life around us. His animated voice fills the space as he speaks. “With organic chemistry, we are very visual. We look at chemical structures. If you give me a chemical structure, oh my goodness, my head starts racing about what I can do with it, or how I can change it to create new properties or new materials.”
H3D has 76 staff members investigating novel chemical compounds that could become new lifesaving medicines, with a focus on malaria, tuberculosis, and antibiotic-resistant microbial diseases.
Effectively a small biotech company embedded within the university, to date, H3D’s most notable discovery was a compound in 2012 which they named MMV390048, which had the potential to become a single-dose cure for malaria. Phase I clinical trials saw MMV390048 tested on human volunteers in South Africa and in Australia.
“In Australia, the testing model used is a volunteer infection study where human beings volunteer to be injected with the malaria parasite, which they know can be treated using available medicines,” says Chibale. “And then a section of those are given the experimental drug. And it worked beautifully there.”
‘Fail your way to success’
He adds, “People don’t realise this – there’s no medicine that will be given to people if it wasn’t tested on people first. Even me as an African. Oh man, I suffered from malaria as a child in Zambia many times. Thanks to our government then I’d be taken to a health facility and get malaria tablets, which I took and got well again. Otherwise, I would have died. Malaria kills very quickly. Now this is something I didn’t know then, something I took for granted. Only much later in life did I realise, goodness the medicine I took – someone somewhere invested in its research and development. And someone, somewhere, another human being, volunteered for that drug to be tested on them for my benefit.”
In 2017, the compound made it to Phase II clinical trials in patients with the disease, but further development was halted in 2020 when extensive further tests showed toxicity signals in rats – not rabbits though, Chibale says, adding that they had to err on the side of caution.
“In drug discovery, you have to kiss many frogs before you meet the prince,” he says. “Many drugs fail to progress. People focus on one product that makes it onto the market, right? But there are many failures that don’t even see the light of day. In this industry, you fail your way to success.”
H3D’s most notable discovery was a compound in 2012 which they named MMV390048, which had the potential to become a single-dose cure for malaria. PHOTO: Nasief Manie/Spotlight
Their work continues. In April last year at a function at Cape Town’s Vineyard Hotel, multinational pharmaceutical company Johnson & Johnson announced H3D as one of its three satellite centres for global health discovery. The other centres are in London and Singapore. At the time, Johnson & Johnson stated, “Driven by some of the leading researchers in Africa and discovery science, the satellite center [H3D] is focused on outpacing the rising threat of antimicrobial resistance by accelerating innovation against multidrug-resistance gram-negative bacteria.”
Seated at a boardroom table in his office, Chibale laughs deep from his belly. “We associate Johnson & Johnson with baby powder, but there’s much more…”
His left arm is in a sling following shoulder surgery – an injury stemming from lockdown when he slipped and fell while hiking on Table Mountain. “It happened just here, above the university,” he gestures, with his other arm.
Chibale and his wife Bertha live on the university’s campus, where he has served as warden of student residence Upper Campus Residence, formerly Smuts Hall, since 2015. Here he weathered the #rhodesmustfall and #feesmustfall protests, which saw students torch vehicles and police deploy stun grenades a stone’s throw away from his home.
Referring to his injured arm, he says at least his writing arm wasn’t hurt and that he can still type with one hand.
From a village in Zambia
Mentions of gratitude underpin the story of his journey, which starts in a village without electricity or running water in Zambia’s Mpika district. His father died when he was two months old. Laughing, he relays how hearing in his one ear is still impaired after being ambushed as a kid while stealing mangoes.
“This was a township,” he says. “So I’m climbing up a tree to steal mangoes and I was coming down. This gang, or well guys who were playful, had surrounded us. There were only about four of us, of who three managed to escape. And I was the only one left. Oh my goodness. And they took a big rock and smashed it to my ear. And then, when they saw me bleeding, they actually ran away. They were so scared of the damage they had done. Oh, that day! Anyway, so I went home and lied to my mother and said, no I went to school and tripped over a hole.”
During high school classes, thanks to an excellent teacher, he became fascinated with chemistry experiments. He went on to study organic chemistry at the University of Zambia, where he fell in love with the logical nature of organic molecules. “These things cannot be planned. I simply fell in love with organic chemistry, in the same way I fell in love with my wife Bertha,” he says.
From early on he realised education was a way out of poverty. “To get out of poverty, you either play sport or you follow education,” he says. “So I started applying for scholarships, writing letters to universities around the world. And I got rejected. I kept applying and kept on being rejected. But I didn’t give up. I kept applying.”
His first job was at Kafironda Explosives in the mining town Mufulira, on Zambia’s Copperbelt, where he made detonators, dynamite, and other explosives for use in Zambian mines. Laughing, he says this would come to haunt him later while applying for a visa to enter the United States. “There was a section on the form where you had to declare whether you’ve worked with explosives,” he says. “Of course, I said ‘yes’, and fortunately nothing happened.”
During two years at Kafironda, he continued applying for scholarships. “And I remember this,” he says. “It was January of 1989. I got a letter saying you have been shortlisted for a Cambridge Livingstone Trust Scholarship. Please present yourself for an interview on the 26th of January at the Anglo-American Corporation offices in Harare, Zimbabwe… So that was my first time out of Zambia. The first time to fly on an aeroplane.”
‘This was my turn’
Competition for the scholarship was tight, with shortlisted candidates from several African countries. “So in that year, there were six of us from Zambia, from different disciplines. I was the only scientist. And of course, I’d been failing all this time, getting rejected. But this was my turn. It was God’s appointed time for me. Actually, I was the only successful candidate.”
At Cambridge, without having completed an honours or master’s degree, Chibale enrolled for a PhD under the late organic chemist Professor Stuart Warren. “So Stuart, this amazing, incredible man, just gave me a chance. I mean there was such a gap between me and my colleagues who had all done their undergraduates at Cambridge. But in life, you can moan and complain about a disadvantage, or you can turn it into a challenge. I mean, the first three to six months were rough. Stuart would recommend to me that I sneak into first-year undergraduate classes to catch up. Stuart, he saw something in me that I didn’t even see in myself, and really gave me a chance.”
Chibale’s work at Warren’s lab, developing new synthetic methods for optically active molecules, helped secure his first post-doctoral position at the University of Liverpool, in the United Kingdom, after which he joined the Scripps Research Institute in La Jolla, California, funded through a Wellcome Trust International Prize Travelling Research Fellowship.
“That was another miracle,” he says. “I was eligible for this fellowship only because I had lived in England for three years, which was a minimum requirement. And the scholarship was so good, it even gave me an allowance for my family. I haven’t forgotten. It was 1 000 pounds per month. In those days, the pound was much stronger than the US dollar. So I went from rags to riches. In Liverpool, I was walking most of the time while in California, I actually had a car!”
Over the years, he was gaining insight into the pharmaceutical sector – the science but also the entrepreneurial side that pushes innovation, all the while longing to bring this knowledge to Africa. Peers suggested he consider South Africa, and particularly the University of Cape Town [UCT]. Around 1994, then UCT Department of Chemistry head, Professor James Bull actually made Chibale an offer to pursue postdoctoral research – which he declined. “Because I thought there was going to be a civil war in South Africa! I remember watching the release of Nelson Mandela on TV in England, quiet, just watching.”
Towards the end of 1995, inside a copy of the British scientific journal Nature, Chibale found an advertisement for a position as a lecturer in organic chemistry at UCT and applied. “It was a calling,” he says. The family moved to Cape Town.
Then in 2010 at UCT, with five post-doctoral staff, Chibale founded H3D. At the time his mentors included Dr Anthony Wood, former Pfizer senior vice-president, now head of GlaxoSmithKline’s Research and Development, who arranged for Chibale to have a four-month sabbatical with Pfizer in the United Kingdom to learn about the practicalities of innovative pharma. Thirteen years later, H3D has blossomed.
Chibale says he is a Christian as well as a soccer and boxing fan. His wife Bertha runs a Cape Town catering business called Hearts and Tarts. They have three sons.
As the interview draws to a close, he looks up at his 1989 Cambridge class photo. “You won’t believe it,” he says. “Last year I visited my college at Cambridge with my wife and second son and they pulled out a copy of my handwritten scholarship application letter, written to them from Zambia all those years back.”
This precious relic of Chibale’s journey is not in his office. He keeps it on his desk at home.
Having only one or two alcoholic drinks per day does not protect against endocrine conditions such as obesity and type 2 diabetes, according to a new study published in the Journal of Clinical Endocrinology & Metabolism.
It is widely accepted that excessive alcohol consumption causes a wide range of health issues and is thus a major public health concern. Whether modest alcohol consumption has beneficial health effects remains controversial, however, due to the limited power of observational studies.
The researchers used mendelian randomisation (MR), which can help to mitigate biases due to confounding and reverse causation in observational studies, and evaluate the potential causal role of alcohol consumption.
“Some research has indicated that moderate drinkers may be less likely to develop obesity or diabetes compared to non-drinkers and heavy drinkers. However, our study shows that even light-to-moderate alcohol consumption (no more than one standard drink per day) does not protect against obesity and type 2 diabetes in the general population,” said Tianyuan Lu, PhD, from McGill University in Québec, Canada. “We confirmed that heavy drinking could lead to increased measures of obesity (body mass index, waist-to-hip ratio, fat mass, etc) as well as increased risk of type 2 diabetes.”
The researchers assessed self-reported alcohol intake data from 408 540 participants in the U.K. Biobank and found people who had more than 14 drinks per week had higher fat mass and a higher risk of obesity and type 2 diabetes. An extra drink per week was associated with an increased of 8% for diabetes risk and 10% for obesity risk.
These associations were stronger in women than in men. No data supported the association between moderate drinking and improved health outcomes in people drinking less than or equal to seven alcoholic beverages per week.
A woman with Systemic Lupus Erythematosus. Source: Wikimedia CC0
Recurrent bouts of systemic lupus erythematosus, marked by the body’s immune system attack of its own tissues, closely tracked with upticks in growth in the gut of a certain species of bacteria. New research from NYU Grossman School of Medicine shows that bacterial blooms of the gut bacterium Ruminococcus blautia gnavus occurred at the same time as disease flare-ups in five of 16 women with lupus of diverse racial backgrounds studied over a four-year period.
Systemic lupus erythematosus involves damaging inflammation, especially in the kidneys, but also in joints, skin, and blood vessels. Four of these study patients with R. gnavus blooms had severe cases of the most common and kidney-specific form of the disease, lupus nephritis, while one had a severe example of lupus involving inflammation in multiple joints.
Published in the Annals of Rheumatic Diseases, the team’s analysis of these lupus patients’ gut bacterial blooms identified 34 genes that already had established links to the bacterium’s growth in people with inflammation. While the specific causes of lupus remain unknown, many experts suspect that bacterial imbalances trigger inherited genetic factors responsible for the disease.
This study also investigated how tightly these patients’ immune system antibodies bonded to structures in the bacterial wall, much like they would an invading virus. These antibodies showed a strong affinity to specific bacterial lipoglycan molecules that are known triggers of inflammation. These lipoglycans were found to be common in R. gnavus strains in lupus patients but not in healthy people. Antibodies are a major cause of the body damage in this disease, and this diagnostic antibody response, the researchers say, highlights the important role played by R. gnavus in the autoimmune disease.
“Our findings provide the strongest evidence to date that silent growths of Ruminococcus blautia gnavus are tied to active serious renal disease in lupus patients,” said study lead investigator Doua Azzouz, PhD.
“Interestingly, our study also established this common bacterial link among a racially diverse group of females with varying forms of lupus,” said Azzouz, a postdoctoral researcher. Lupus is more common in women than in men, and the disease affects more Blacks, Hispanics, and Asians than Whites.
“Our goal is to use our growing understanding of the biological pathways that underpin the disease to develop new treatments that prevent or treat flares for all forms of lupus,” said study senior investigator and immunologist Gregg Silverman, MD.
“Such future treatments for lupus, especially lupus nephritis, could potentially decrease the use of drugs designed to dampen the immune system and instead promote the use of less-toxic antibacterial agents, probiotics or dietary regimens that prevent imbalances such as Ruminococcal blooms in the local gut bacterial population, or microbiome,” said Silverman.
Previous research by Silverman’s team showed that R. gnavus blooms weaken the gut wall barrier, prompting bacterial leakages that in turn trigger inflammatory and overactive immune responses.
The team plans to extend the research to other medical centre and also plans further experiments in mouse models of lupus to see how R. gnavus colonisation triggers lupus. Using mouse models, they also want see whether if R. gnavus blooms speed up or otherwise affect the severity of flares and inflammation.
The researchers say they also want to conduct experiments on various lipoglycan molecules from different R. gnavus strains to see if any particular part of the molecular structure is key to triggering inflammation or if other lipoglycans also prompt an immune response tied to lupus or other diseases of the gut, including Crohn’s.
For the study, researchers used stool and blood samples from lupus patients being treated at NYU Langone. All study participants were being closely monitored for disease flare-ups. Test results were compared with those of 22 female volunteers of similar age and racial background who did not have lupus and were otherwise healthy.
As an autoimmune disease, systemic lupus erythematosus can lead to widespread inflammation and long-term tissue damage in affected organs. According to researchers, about half of patients develop lupus nephritis, of whom one-quarter are likely to experience end-stage renal disease that may require regular blood dialysis and even kidney transplantation.
Researchers assisting microbiologists in Ukraine have found an extremely high level of bacterial resistance among the war-wounded patients treated in hospitals. The study, recently published in The Lancet Infectious Diseases, found resistance in many hospital-acquired infections stemming from damaged and overwhelmed healthcare infrastructure, with many samples resistant to the last-resort antibiotic colistin.
“I am quite thick-skinned and have witnessed numerous situations involving patients and bacteria. However, I must admit that I have never encountered bacteria as resistant as this before,” says Kristian Riesbeck, professor of Clinical Bacteriology at Lund University in Sweden.
There was never any doubt about helping out when Dr Oleksandr Nazarchuk, a microbiologist at a university in Vinnytsia, Ukraine, got in touch, says Kristian Riesbeck. Help was needed in Ukraine to assess the extent of antibiotic resistance in bacteria among severely injured patients in hospital.
In addition to all the human suffering caused by the war in Ukraine, another battle is being fought — an invisible war against resistant bacteria. This became evident when Kristian Riesbeck and his research colleagues analysed patient samples from seriously wounded patients, many of whom had burn injuries, in Ukraine. The patients had acquired infections while in hospital, primarily due to the overwhelmed wards and destroyed infrastructure.
Samples were collected from a total of 141 war victims, 133 adults who sustained injures during the war and eight infants diagnosed with pneumonia. These patients were admitted to three different hospitals in Ukraine, where they received emergency surgeries and intensive care to address their conditions.
“We observed that several the Gram-negative bacteria exhibited resistance to broad-spectrum antimicrobial agents, including newly developed enzyme-inhibiting antibiotics that are not yet available in the market. Moreover, nearly ten per cent of the samples contained bacteria that demonstrated resistance even to our ‘last-resort’ antibiotic, colistin. While we have encountered similar cases in India and China before, nothing compares to the extent of resistance observed in this study. As much as six per cent of all the samples contained bacteria resistant to every antibiotic we tested,” says Kristian Riesbeck.
He emphasizes that this clearly highlights the challenges posed by resistant bacteria in times of war. In particular, Kristian Riesbeck expresses concern regarding the resistance displayed by Klebsiella pneumoniae bacteria, as they have the potential to cause illness in individuals with a healthy and well-functioning immune system.
“This makes me very worried. It’s rare to encounter Klebsiella with such high levels of resistance, and it was not what we anticipated. While isolated cases have been documented in China, the magnitude of this situation surpasses anything we have seen before. While many countries are providing military aid and resources to Ukraine, it is equally crucial to assist them in addressing this ongoing situation. There is an evident risk of further spread of resistant bacteria, and this threatens the entire European region,” remarks Kristian Riesbeck.
An international team of researchers has developed a new method to deliver drugs into the inner ear, according to a new study in Science Translational Medicine. The discovery was possible by harnessing the natural flow of fluids in the brain and employing a little-understood backdoor into the cochlea. When combined to deliver a gene therapy that repairs inner ear hair cells, the researchers were able to restore hearing in deaf mice.
“These findings demonstrate that cerebrospinal fluid transport comprises an accessible route for gene delivery to the adult inner ear and may represent an important step towards using gene therapy to restore hearing in humans,” says lead author Barbara Canlon, professor at Karolinska Institutet.
The number of people worldwide predicted to have mild to complete hearing loss is expected to grow to around 2.5 billion by mid-century. The primary cause is the death or loss of function of hair cells found in the cochlea – which relay sounds to the brain – due to mutations of critical genes, aging, noise exposure, and other factors.
While hair cells do not naturally regenerate in humans and other mammals, gene therapies have shown promise and in separate studies have successfully repaired the function of hair cells in neo-natal and very young mice.
“However, as both mice and humans age, the cochlea, already a delicate structure, becomes enclosed in the temporal bone. At this point, any effort to reach the cochlea and deliver gene therapy via surgery risks damaging this sensitive area and altering hearing,” says Barbara Canlon.
In the new study, the researchers describe a little-understood passage into the cochlea called the cochlear aqueduct. The cochlear aqueduct is a thin boney channel no larger than several strands of hair.
Channel for spinal fluid
A new study shows that the cochlear aqueduct acts as a conduit between the cerebrospinal fluid found in the inner ear and the rest of the brain.
Scientists are developing a clearer picture of the mechanics of the glymphatic system, the brain’s unique process of removing waste. Because the glymphatic system pumps cerebrospinal fluid deep into brain tissue to wash away toxic proteins, researchers have been eyeing it as a potential new way to deliver drugs into the brain, a major challenge in developing drugs for neurological disorders.
The new study represented an opportunity to put the drug delivery potential of the glymphatic system to the test, while at the same time targeting a previously unreachable part of the auditory system.
Employing several imagining and modeling technologies, the researchers were able to develop a detailed portrait of how fluid from other parts of the brain flows through the cochlear aqueduct and into the inner ear.
The team then injected an adeno-associated virus into the cisterna magna, a large reservoir of cerebrospinal fluid found at the base of the skull.
The virus found its way into the inner ear via the cochlear aqueduct and delivered a gene therapy that expresses a protein called vesicular glutamate transporter-3, which enables the hair cells to transmit signals and rescue hearing in adult deaf mice.
“This new delivery route into the ear may not only serve the advancement of auditory research but also prove useful when translated to humans with progressive genetic-mediated hearing loss,” says Barbara Canlon.
June is Men’s Health Month and while the focus is mostly on men’s attitudes about their health, it is also worth reflecting on the health sector’s attitudes toward men.
We hear many stereotypes about men and health, but how many of those are actually true?
A few years ago representatives of The Mpilo Project spoke to more than 2 000 men in KwaZulu-Natal and Mpumalanga to understand why many find it hard to engage with HIV testing and treatment. We uncovered several myths and misperceptions in the process.
One common myth is that men are stubborn and apathetic about HIV – that they aren’t listening and don’t care. While many men may indeed wear a mask of indifference, HIV leaves many of them feeling paralysed by fear and anxiety. This is why we need a health service delivery approach rooted in encouragement and reassurance, not scolding and pressure.
Another common misconception is that men are mainly just workers who need practical solutions like convenient clinic hours and quick service. The reality is that men are complex human beings who face social and emotional barriers as well as practical ones. We need solutions that address both practical and psychosocial barriers.
There is also a view that sources of support are available and that men just fail to access them, perhaps because “they don’t really want support”. In fact, many men are hungry for support but see no sources that feel safe or relatable. They experience counselling as scripted, one-directional, overly technical, and often judgmental. The key is to give men the right sources of support and to speak empathetically to their individual issues and concerns.
Finally, there is a view that healthcare providers are helping men by taking proactive approaches like provider-initiated testing and tracking-tracing. But these often leave men feeling hunted and ambushed by the health system. We need proactive approaches that leave men feeling like they still have control over their own lives and decisions and help them develop their own internal motivation to start and stay on treatment.
These and other misconceptions can lead healthcare providers to conclude that men are simply difficult if not impossible to reach. But once we understand their barriers, that picture changes dramatically.
The 11th SA AIDS Conference concluded last week and in one of the plenary sessions we had the opportunity to respond to the question: “Strategies for reaching men—are we seeing a return on investment?”
The short answer is yes!
Since 2017, the percentage of men with HIV in South Africa who know their status has increased from 78% to 94%, nearly on par with women. We can attribute that in part to approaches like HIV self-testing that have made it quick, easy, and private for men to learn their status.
We’ve also seen good progress on viral suppression, which has increased from 82% to 93%, again comparable to the rate among women – proof that men on treatment are fully capable of being adherent.
Yet only 70% of men who know they have HIV are currently on treatment – hardly any increase at all from 68% in 2017.
Given the progress we’ve seen in men testing for HIV and achieving viral suppression, the persistent gap in men on treatment suggests that something is wrong – not with men but with the HIV treatment services and support we are offering them.
The good news
The good news is that we know much more than we did a few years ago about what works. Here are three examples.
The MINA campaign aims to reach men with “the new HIV story” by featuring stories from real men living a healthy, happy life with HIV on social media, television, radio, billboards, etc. The campaign also helps men feel more welcome in the clinic, using signage and materials to send the signal to men that “this is your space too”. MINA-supported districts and facilities have seen strong growth in testing and linkage, as well as modest improvement in retention in care.
The Coach Mpilo model employs men who are thriving with HIV as coaches of men at risk of non-initiation or disengagement. Coaches provide a safe, relatable source of support and serve as living proof that HIV is not the end of the road. Piloted in 2020 and currently implemented in 18 districts, the model is achieving 97% linkage to care and 94% retention.
The B-OK bead bottles are a simple visual tool for helping people to understand the benefits of HIV treatment and viral suppression and, more importantly, to build the motivation to start and stay on treatment. Red beads are HIV; black beads are healthy cells. A mixed bottle represents most people upon diagnosis. A red bottle represents the virus multiplying uncontrolled in the absence of treatment. A black bottle with one red bead represents viral suppression achieved through treatment adherence. In an evaluation of the tool, understanding of how HIV treatment works increased from 12.5% to 92.5%.
Men are not indifferent about their health and they are not inherently poor health-seekers. If many of them are avoiding healthcare services, let’s consider that it may be because they are not getting what they need from these services.
We have seen that men do engage when we in the public health sector meet them where they are rather than where we want them to be; when we speak to their needs and priorities rather than ours; when we give them the right sources of support rather than one-size-fits-all, and when we help them build understanding and motivation rather than simply instructing.
When we invest, we see returns. Let’s keep investing in scaling what works.
*Malone is the Project Director of The Mpilo Project, PSI.
A new study of a brain region called the rostro-medial prefrontal could potentially advance diagnosis and therapies for Borderline Personality Disorder (BPD). Published in the journal Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, the research revealed that the rostro-medial prefrontal specifically becomes more active when people are rejected by others at greater rates. However, individuals with BPD – characterised by interpersonal sensitivity to rejection and emotional instability – do not display rostro-medial prefrontal cortex activity when rejected.
The brain reacts with rostro-medial prefrontal activity to rejection as if there is something “wrong” in the environment. This brain activity may activate an attempt to try to restore and maintain close social ties to survive and thrive. This region of the brain also is activated when humans try to understand other peoples’ behaviour in light of their mental and emotional state.
“Inactivity in the rostro-medial prefrontal cortex during rejection may explain why those with BPD are more sensitive and more distressed by rejection. Understanding why individuals with this debilitating and high risk disorder experience emotional distress to rejection goes awry will help us develop more targeted therapies for BPD,” said psychologist Eric A. Fertuck, associate professor at City College of New York.
On the significance of the study, Fertuck noted that while previous findings in this area have been mixed, “what we’ve done is improve the specificity and resolution of our rejection assessment, which improves on prior studies.”
Research continues with several investigations underway examining the role of social rejection in different mental health problems including post-traumatic stress disorder, depression, and social anxiety.
A massive and much-anticipated phase 3 trial of an experimental tuberculosis (TB) vaccine is set to proceed after funding for it has been secured from two large philanthropies. Wellcome and the Bill & Melinda Gates Foundation (BMGF) Wednesday announced they’d be investing a combined $550 million into the trial – around $150 million from Wellcome and the remaining from the Bill & Melinda Gates Medical Research Institute, a nonprofit subsidiary of the BMGF.
The vaccine, called M72/AS01E or just M72, made headlines in September 2018 when it was found to offer 54% protection against pulmonary TB disease in a phase 2B trial. That trial, of around 3 300 people, was conducted in South Africa, Zambia, and Kenya. Final results from that study were published in the New England Journal of Medicine in 2019 – efficacy in these final results was down to around 50%.
Medicines and vaccines are typically only brought to market once safety and efficacy have been confirmed in a large phase 3 trial. In this case, the phase 3 trial is set to have around eight times as many participants as the phase 2B trial.
26 000 study participants
“Conducted in collaboration with an international consortium of TB clinical investigators, the trial will enrol approximately 26 000 people, including people living with HIV and without TB infection, at more than 50 trial sites in Africa and Southeast Asia,” Wellcome and BMGF said in a statement announcing the trial.
They said the trial will “assess the candidate vaccine’s efficacy at preventing progression from latent TB infection to pulmonary TB”. In an online media conference on Wednesday Trevor Mundel, President for Global Health at BMGF, clarified that while most study participants will be people with latent TB infection, 4 000 people without TB infection would also be recruited. This is because establishing evidence of the vaccine’s safety in people without latent TB infection will be important if the vaccine is to be rolled out in areas with high background rates of TB without first having to test everyone for latent infection. “You’d want to be comfortable with vaccinating everyone in the community,” he said, “So we need to have that safety data in the uninfected as well in order to be able to have that usage, which will be the easiest way to use the vaccine at the end of the day.”
Mundel said that the study is scheduled to start early in 2024 and that it is expected to last for four to six years. Exactly how long the study will take will depend largely on how long it takes for 150 study participants to develop active TB – the number required for the study to have sufficient statistical power. By comparison, recruitment for the phase 2B trial started in 2014 and the first findings from that study were published in 2018.
According to the statement, additional details about the trial design and participants will be announced in the coming months.
Given that the phase 2B trial was partially conducted in South Africa and the country has substantial TB clinical trial capacity, it is almost certain that some of the 50 trial sites will be in South Africa – although know specific trial sites have yet been announced.
As pointed out in the statement, the only TB vaccine in use today, bacille Calmette-Guerin (BCG), was first given to people in 1921. It helps protect babies and young children against severe systemic forms of TB but offers limited protection against pulmonary TB among adolescents and adults. If the findings from the phase 3 trial of M72 are positive, m72 will become the first new TB vaccine in over a hundred years to be proven safe and effective.
According to the most recent figures from the World Health Organization (WHO), around 304 000 people fell ill with TB in South Africa in 2021. While TB rates are declining, they are declining relatively slowly and according to the most recent WHO World TB Report, a major technological breakthrough such as a new vaccine will be needed if ambitious TB control targets are to be met.
Announcement welcomed
“We’ve waited a long time for this study, so are happy to see the Bill & Melinda Gates Foundation and Wellcome taking up this important task,” said Patrick Agbassi, chair of the Global TB Community Advisory Board, in a comment included in the Wellcome/BMGF statement. “The question now becomes how we can enroll 26 000 people most quickly and ensure that all populations at risk of TB will ultimately be able to benefit from access to what could be the first new TB vaccine in over 100 years. A robust community engagement programme will be key, as will taking on studying this vaccine in younger adolescents, pregnant women, people with prior history of TB, and other key groups often underrepresented or left out entirely of TB trials and the benefits of scientific progress.”
Mark Harrington, executive director of New York-based advocacy organisation Treatment Action Group (TAG) said, “TAG welcomes this historic investment in TB vaccine development by Wellcome and the Bill & Melinda Gates Foundation. A Phase III clinical trial of the M72/AS01E TB vaccine candidate is a long-awaited milestone. We hope this funding commitment sparks governments and other funders to substantially increase investments in the TB vaccine pipeline, which contains a number of promising candidates in addition to M72/AS01E but faces a dire financial shortfall.”
“This Phase III trial,” Harrington said, “will take several years to complete. We encourage the Gates Foundation, Wellcome, GSK, country governments, and other partners to use this time to lay the groundwork for eventual vaccine adoption by ensuring the availability, affordability, and acceptability of M72/AS01E should it prove safe and effective.”
Initial development of M72 was driven by the pharmaceutical company GSK with support from several governments, philanthropies, and research organisations. The vaccine contains the M72 recombinant fusion protein, which the Wellcome/BMGF statement explains is derived from two Mycobacterium tuberculosis antigens (Mtb32A and Mtb39A) combined with the GSK proprietary Adjuvant System AS01E. According to the statement, GSK will continue to provide the adjuvant for the vaccine’s further development and potential launch.
NOTES: (1) The BMGF is mentioned in this article. Spotlight receives funding from the BMGF, but is editorially independent – an independence that the editors guard jealously. Spotlight is a member of the South African Press Council. (2) A representative of the Global TB Community Advisory Board is quoted in this article. Spotlight editor Marcus Low was previously a member of the Global TB Community Advisory Board.
