Dr. Keith Fowke and Dr. Mario Pinto with patient cohort at Nairobi research clinic.

Today, UM research in Kenya includes two major inter-related Rady Faculty of Health Sciences programs led by Keith Fowke, Department Head of Medical Microbiology and Infectious Diseases and James Blanchard, Executive Director of the Institute for Global Public Health. Responding to a need for public health advocacy from UM research partners in Kenya, Global Public Health programs expanded to Kenya in 2008 as an extension of successful projects originally started in India.

“Our programs in Kenya are a unique example of how laboratory-based researchers interested in molecules and cells are collaborating with researchers studying issues of stigmatization and together they make meaningful impacts for marginalized people,” said Keith Fowke.

As researchers began working with marginalized patient cohorts, increased need for community-based supports emerged, informing new programs developed by UM researchers Dr. Souradet Shaw Canada Research Chair (CRC) in Program Sciences & Global Public Health, Dr. Marissa Becker, Dr. Lisa Lazarus, Dr. Lisa Avery, Dr. Joshua Kimani, Dr. Larry Gelmon, Dr. Lyle McKinnon, Dr. Julie Lajoie, Dr. Leigh McClarty, Dr. Jason Kindrachuk CRC in Molecular Pathogenesis of Emerging and Re-Emerging Viruses and Dr. Rob Lorway, CRC in Global Intervention Politics and Social Transformation,. 

“When I first came to Kenya in 2009 there was a group of young men who were starting to attend clinics established for female sex workers, many of whom identified as gay and bisexual, which is criminalized in Kenya,” said Rob Lorway. “Some were young students, and some were older or married, but what was important is that they had a high HIV prevalence. They came to us because we provided safe spaces from Kenya’s public healthcare system that can be, at times, quite judgmental.”

A legacy of evidence-based support & patient directed research

Four decades ago in the early 1980s, after eradicating an outbreak of the sexually transmitted infection Chancroid in Manitoba, Dr. Allan Ronald was recruited to lead a similar program with the Department of Medical Microbiology at the University of Nairobi, Kenya. Dr. Francis Plummer, then an infectious disease fellow on Ronald’s team studying with a group of sex-workers, would gain global renown for the discovery of a link between the spread of sexually transmitted diseases and the emerging HIV/AIDS epidemic.

Among the patient cohort exposed to HIV/AIDS, Plummer and his team identified a group of women with a natural immunity to HIV-1, the virus that leads to AIDS. Over the following 17 years UM researchers, including Fowke, studied the immune system of these women leading to new approaches to HIV prevention. The women participating in the study had contributed to saving and improving the lives of tens of millions of people living with HIV around the world but continued to live a criminalized lifestyle at the fringes of society.

Dr Elizabeth Ngugi, a local public health nurse working with Plummer in managing the patient cohort in the 1980s and ‘90s, recognized the adversity these women and others like them endured each day. Through advocacy, a new patient-directed research model was developed to foreground the needs and voices of patients as fully recognized research partners, rather than research subjects.

Keith Fowke, who was a graduate student at UM labs in Kenya at that time, recalls of Dr. Ngugi, “she was a very direct and clear-thinking woman. Beginning in 1984, Dr. Ngugi developed a peer educator model to train sex workers and support them as informed and educated leaders within the community. Dr. Ngugi’s influence has been global and has resulted in a deep 40-year relationship with this community which has now evolved into the Sex Worker Outreach Program (SWOP) which has been adopted as a best-practice model by the World Health Organization, UN AIDS and countless others.”

Dr. Julie Lajoie (second from left), Dr. Mario Pinto, Joyce Adhiambo (pictured in SWOP t-shirt) and Dr. Keith Fowke pictured here.

Now in 2024, UM infectious disease research in Nairobi encompasses 10 SWOP clinics providing HIV prevention and care services to more than 30,000 female sex workers, about 9000 men who have sex with men and close to 1500 transgender individuals. Supported by Joshua Kimani and Larry Gelman who follows in the legacy left by Dr. Ngugi, some patient partners are now respected community organizers like Joyce Odhiambo with SWOP Ambassadors, who presented to EU Parliament in Brussels in 2018.

Current clinical programs funded by the President’s Emergency Plan for AIDS Relief (PEPFAR) deliver HIV care and prevention services. However, due to the criminal status of sex work and homosexuality in Kenya, the mere presence of HIV medications or even condoms could provoke harassment or police response.

Members of the patient cohort meet at a Nairobi health clinic.

“In Kenya 4% of the general population is infected with HIV, and in sex workers it’s about 28%,” said Fowke. “Despite these high risks, many women in our cohort choose not to take anti-HIV drugs to prevent infection because of the stigma resulting from their association with being used to treat HIV infection. We are working on providing new approaches to HIV prevention that would be acceptable to these women, including the anti-inflammatory drug, aspirin, which may prevent the immune cell HIV infects from entering the vaginal mucosal environment thereby preventing infection.”

Community empowerment through global public health research

Members of the male patient cohort meet with Dr. Keith Fowke and Dr. Mario Pinto.

“We’re talking about marginalized and stigmatized people, whose lives and livelihoods are criminalized,” said Lorway. “Within the first year of our program 12% of men who have sex with men who originally tested negative for HIV were testing positive. So, despite clinicians doing everything they could at the time – providing risk reduction counseling, supplying condoms and lubricant – HIV infection was growing among these men in our cohort.”

Tourism in Kenya has influenced hotspots where gay and bisexual men can congregate and celebrate themselves. By mapping these hotspots, the Global Public Health team have provided local clinicians and community organizations the ability to establish program catchments and generate their own accurate community health data to inform program coverage targets that guide the funding priorities of donors and the Government of Kenya. Furthermore, by providing training to community leaders so that they can cultivate their own research agenda, now community leaders are coming to Lorway and the team for support with their own investigations.

These expanding partnerships have paved the way for organizations like SWOP Ambassadors, who provides legal aid training and support to sex workers and engages with police to ensure that the right to access healthcare services is respected. The internationally-funded community based organization, HOYMAS (Health Options for Young Men on HIV, AIDS, and Sexually transmitted infections) has now established a clinic in Nairobi which guarantees non-discriminatory care and runs anti-stigma campaigns focused on sexual health and human rights advocacy.

“The shifting scope of Global Public Health research in Kenya is a strong sign of transformational success,” said Mario Pinto, Vice-President (Research and International). “The work of these dedicated researchers and clinicians to advance health as a human right has empowered these underserved communities, not just in self-advocacy, but as entrepreneurs and leaders in their field on the international stage. We know that when people of sexual minorities live free of harassment and stigmatization, they are more likely to access life-saving medical care and be their authentic selves.”

CFI-Funded laboratory provides much-needed sex worker outreach programs

Dr. Keith Fowke and Dr. Mario Pinto pictured with Dr. Julius Oyugi, Director of the University of Nairobi Institute for Tropical and Infectious Diseases

In Kenya, UM has partnered with the University of Nairobi to build a Canada Foundation for Innovation funded lab on their campus and has now developed 10 different SWOP clinics across the city as part of ongoing sex worker outreach programs. “When we first started this program, there wasn’t much medical research infrastructure in Kenya, now I’m supervising Kenyan PhD students doing cutting edge research projects without having to leave their country and we are able to hire all staff locally through with grants available to African institutions,” said Keith Fowke.

Decades of results in overcoming epidemics and securing international funding from partners including Bill & Melinda Gates Foundation and the Global Fund to Fight AIDS has helped to foster good relationships with government. health officials have signaled a willingness to collaborate on efforts to prevent an emerging epidemic of anal cancer among men who have sex with other men resulting from the sexually transmitted infection HPV.

“We have begun addressing an epidemic of cervical cancer resulting from HPV among female sex workers, but a different approach is needed to provide care for men who have sex with men,” said Lorway. “Hate speech almost constantly enters the political theatre during times of economic disruption like the COVID-19 pandemic, so it’s often about quiet negotiations with health official — which can be frustrating because of the urgent need for care. Working with our local partners we’ve established new provisions for anal health care for men who have sex with men. Although working in such a prohibitive political climate can be challenging, these partnerships provide the room we need to discretely develop programs without provoking a negative public reaction.”

Research impacts at home in Manitoba

Joyce Adhiambo (left) and Victoria Were (right)

“There is a presumption that access to care and sex worker support programs are less advanced in the global south. However, in Canada, by criminalizing the clients, we push sex works even further underground,” said Lorway. “Criminalizing sex work makes it extremely difficult to deliver health services. In this case we have something to learn from our work in Kenya about how to provide services to those who are hardest to reach.”

Leading the way in sex work advocacy in Manitoba is the Sex Workers of Winnipeg Action Coalition (SWWAC)  who are partnering with UM infectious disease expert Julie Lajoie, to facilitate an ongoing information exchange between the sex worker communities in Nairobi and Winnipeg. Two community leaders came to Winnipeg in 2022 to discuss their role as grant co-applicants and to share strategies on getting organized in the face of criminalization and public stigma.

“In Canada, we have a parallel issue of Missing and Murdered Indigenous Women, and tragically, there are commonalities in the experiences of marginalized people on both sides of the ocean,” said Keith Fowke. “In Manitoba we’re at least a decade behind African programs in HIV prevention approaches. There are more new cases of HIV in Manitoba this year than in epidemic of the 1980s and ‘90s, and it’s mainly among women in indigenous communities.  We need to adapt global best-practices to prevent infections in Manitoba.”

The Winnipeg-based community resource center Sunshine House is leading the way in Manitoba by offering HIV and sexually transmitted disease testing services and have held a Science + Supper, often featuring presentations from UM Faculty members.

“Programs like those offered at Sunshine House, SWWAC and SWOP Ambassadors are foundational,” said Lorway. “Something we as researchers can always work toward is the de-monopolization of science, to put the power to make change into the hands of those who most urgently need it.”

“This excellent showing by our faculty members and their partners in receiving this funding is a testament to the outstanding quality of research conducted at the University of Manitoba,” said Dr. Mario Pinto, UM’s vice-president (research and international). “I congratulate these research leaders, whose work continues to improve the quality of health and patient care here in Manitoba and around the world.”

Project: Anti-Thrombotic Therapy to Ameliorate Clinical Complications in Community Acquired Pneumonia (ATTACC-CAP)

Dr. Ryan Zarychanski and Dr. Sylvain Lother

Dr. Ryan Zarychanski, associate professor of internal medicine, Max Rady College of Medicine and senior scientist at CancerCare Manitoba, and his team received more than $3.9 million over five years.

Building on the knowledge the trial team gained while studying the blood thinner heparin in COVID-19 patients, the Manitoba-led team will conduct a large international adaptive randomized trial that will evaluate whether therapeutic-dose heparin reduces critical illness and mortality in hospitalized patients with non-COVID pneumonia.

“This is the first large international trial to be wholly managed by the University of Manitoba and will provide unique training opportunities to junior faculty like co-principal investigator Dr. Sylvain Lother,” said Zarychanski, UM Lyonel G. Israels Research Chair in Hematology. “It will also showcase UM’s clinical trial management and data coordination capacity at the George and Fay Yee Centre for Healthcare Innovation.”

Project: Regulation of Programmed Necrosis in the Heart

Dr. Lorrie Kirshenbaum

Dr. Lorrie Kirshenbaum, UM Canada Research Chair in molecular cardiology and professor of physiology & pathophysiology and pharmacology & therapeutics, Max Rady College of Medicine, and his team received $1.1 million over five years.

The study will focus on the role of mitochondrial-regulated cell death programs and how they integrate at the cellular level to cause heart failure. The study will look at the mechanisms underlying doxorubicin (a chemotherapy drug) cardiotoxicity. It will also explore the relationship between cell death and other cardiovascular diseases, such as heart attack, known to cause heart failure.

“The studies are highly innovative and clinically relevant, as many of the concepts and avenues of research have not been previously explored,” said Kirshenbaum, director of the Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre. “I am particularly excited about commencing this research and hopeful it will be translated into new drug discoveries that will reduce the incidence of heart failure and improve the quality of life of cancer patients and individuals following heart attack or other human diseases where cell death is known to play a major role.”

Project: Understanding the cellular mechanisms that drive clonal T cell expansion of the HIV reservoir

Dr. Thomas Murooka

Dr. Thomas Murooka, associate professor of immunology, Max Rady College of Medicine, and his team received more than $719,000 over five years.

The study aligns with emerging data that a distinct subset of T cells seems to harbour the majority of residual HIV. By understanding why some T cells contain virus and others don’t, it may lead to a more targeted approach to purge this HIV reservoir in T cells. Murooka and his team will use new imaging tools and animal models to identify, track and kill these rare, infected T cells, so that daily drug regimens are no longer required for people living with HIV.

“So far, the HIV cure field has used a sledgehammer approach to eliminate residual HIV infection, with limited success,” Murooka said. “We are developing a more targeted, immunological approach to specifically identify and destroy rare T cells that harbour HIV as a new approach to achieve HIV cure.”

Project: Mechanisms and consequences of senescent beta cell accumulation in Type 1 Diabetes

Dr. Peter Thompson

Dr. Peter Thompson, assistant professor of physiology & pathophysiology, Max Rady College of Medicine, and his team received more than $589,000 over five years.

Thompson’s recent research has discovered that beta cells are not entirely innocent in the process that leads to Type 1 diabetes and some of them may aid and abet the immune attack. In this study, he will explore the “nuts and bolts” of these sick beta cells to determine how and why they arise, and how they may be restored. The research will take him closer to establishing a new early clinical intervention to prevent Type 1 diabetes in people who are at risk.

“Our study is unique in that it is working from a completely different concept of how Type 1 diabetes occurs as compared with conventional wisdom,” Thompson said. “It has generally been assumed that Type 1 diabetes is just an autoimmune disease, where the beta cells are just targets of the immune attack and thus the vast majority of interventional efforts are aimed at restoring the immune system. Until recently, very little attention was paid to processes operating in beta cells that might contribute. So our work is operating from a different point of view – which is that some beta cells actually promote the immune attack, leading to Type 1 diabetes. This is a major paradigm shift in how we understand the disease with implications for developing new therapies and we are now poised to make exciting progress in this area.”

Project: Confronting Homophobia in Anal Health: Community-based Program Science and HPV among MSM in Nairobi, Kenya

Dr. Rob Lorway

Dr. Rob Lorway, UM Canada Research Chair in global intervention politics and social transformation and professor of community health sciences, Max Rady College of Medicine, and his team received more than $512,000 over three years.

Lorway’s project builds on the University of Manitoba’s extensive Kenyan-Canadian collaboration that has been studying sexually transmitted infections since the 1980s. His team will employ new community-based participatory strategies to identify the risk factors that underlie HPV-related anal diseases among gay, bisexual and other men who have sex with men in Kenya. Lorway aims to generate new scientific knowledge related to the clinical, social and epidemiological aspects of HPV infection to inform local sexual health services delivery.

“Although HPV immunization programs in Kenya tend to focus on cervical cancer among adolescent girls and young women, the evidence from this study will enable community health activists and their allied health care providers to advocate for the urgent need to expand immunization to include gay, bisexual and other men who have sex with men,” Lorway said.    

Project: Investigating the molecular and cellular abnormalities of the brain in Rett syndrome

Dr. Mojgan Rastegar

Dr. Mojgan Rastegar, professor of biochemistry & medical genetics, Max Rady College of Medicine, and her team received $100,000 over one year.

The study focuses on the molecular and cellular abnormalities of the brain in a neurodevelopmental disorder known as Rett syndrome. Rastegar and her team will perform side-by-side molecular and cellular research studies to determine the shared anomalies of the human and murine Rett syndrome brains. Her research will further include an investigation of rescue and recovery of the identified Rett syndrome-associated abnormalities, by the application of commonly used drugs in pre-clinical therapeutic studies in animal models of Rett syndrome. 

“Our research results from this project are expected to determine the extent of molecular and cellular damage in the brain of Rett syndrome patients and shared defects with animal models of this disease,” Rastegar said. “Our research may eventually lead to potential therapeutic solutions that are targeted towards commonly impaired characteristics of the brain in Rett syndrome. Our research results may also help to understand the unique characteristics of specific types of MeCP2 mutations for this complex and severe disease. MeCP2 is a protein that binds, reads and interprets genomic modifications.”

And the University of Manitoba is there.

Dr. Marissa Becker [MD/99] is an associate professor in the department of community health sciences and the department of medical microbiology and infectious diseases within the Rady Faculty of Health Sciences. She is also director of technical collaboration for the Institute for Global Public Health (IGPH).

In Delhi, her role with IGPH supports UM projects in India.

Dr. Marissa Becker

UM has been working in India since the early 2000s, beginning with work on HIV prevention and care led by Drs. James Blanchard and Stephen Moses. Since then, the work has expanded to maternal and child health, nutrition, family planning, and health systems strengthening, as well as work on infectious disease surveillance and tuberculosis.

Becker notes: “We currently work in Delhi, Madhya Pradesh, Karnataka, and Uttar Pradesh. Our biggest program is in Uttar Pradesh in partnership with India Health Action Trust, where we work with the local government to run a Technical Support Unit (TSU) on maternal and child health. We support the government in achieving its health goals in the areas of maternal, newborn and child health, nutrition, family planning and health system strengthening.”

The UM TSU team, funded by the Bill and Melinda Gates Foundation, is large, with about 1,200 people, mostly local residents, providing technical support for programs at the state level and local community level. They work with frontline workers, health care providers, health systems, data, and they design and implement surveys.

Becker explains: “The TSU team is headed by Dr. Vasanth Kumar who has an appointment with UM community health sciences, as do many of our senior core team members from India.

In addition to the team in India, we have a number of UM faculty who support the work, including Drs. Stephen Moses, Maryanne Crockett, Rob Lorway, Shiva Halli, Lisa Avery, Ties Boerma, and BM Ramesh. Dr. James Blanchard is lead of the TSU team in Uttar Pradesh. A number of our postdoctoral students and other graduate students are also engaged.”

When the pandemic hit India a year ago, UM researchers were asked by the government of Uttar Pradesh to help provide support in dealing with the pandemic. They created and implemented a multi-pronged strategy using data for decision making and helped establish a very comprehensive COVID-19 surveillance system for the state. In addition, they provided training and support to front line workers in the community around prevention measures and community surveillance. Further, they supported forecasting for strategic planning of equipment and supplies and helped in conducting COVID seroprevalence studies.

With the tidal wave of COVID cases today, the UM team is working with the government to help address the very serious and very dire oxygen shortages.

Becker says: “The situation here is very difficult- and the health system in many areas across the country is overwhelmed- the impact is immense. The health care facilities are full and many have insufficient equipment and supplies. Families are really struggling. On top of their trying to cope with loved ones that are sick, many are incurring significant financial costs — catastrophic out of pocket expenses.”

She explains that the vaccination program in India started out strong but unfortunately the total proportion of the population immunized was still very low when this latest wave hit.

“I fear that the country will have a difficult time in catching up quickly enough to address this current wave,” she says. “In the meantime, other prevention measures have been put back in place with lockdowns in many states across the country. We are also now seeing many countries step up with support now, but I’m worried about the shift to more cases in the rural areas and also to neighbouring countries in the region in which we are seeing increases in cases — and these countries are also facing shortages of vaccines.”

Becker admits that the pandemic is affecting her personally to some extent.

“Many of our team members and their families have been affected,” she says sadly. “Many friends and colleagues are trying desperately to help their loved ones find a bed, find medicines, to provide care to them. You can hear people’s frustrations, grief and exhaustion when you speak with them.”

Becker believes that the UM community should be proud of the UM response in India. “Not only has our team played an active role in addressing the pandemic, but it has also tried to help the state of Uttar Pradesh ensure that many of the consequences of the pandemic, such as interrupted health care services, have been mitigated. We have worked very hard to ensure the quick and safe return of full services for ensuring maternal and child health.”

Finally, Becker appeals to all of us in taking the situation seriously.

“Sitting here in Delhi now, I want to convey that this is a global emergency and we need to treat it as such — with upmost speed in rolling out vaccination programs, and ensure access to all- within our own country, but also globally,” she explains. “We must learn from this pandemic in effort to prevent and better address future epidemics, and mitigate their very significant consequences, including the tremendous health,  social and financial impacts.”

She adds: “As academics, we need to keep making sure we are using science and appropriate data to inform our response to the pandemic. It’s so critical right now. I think our projects here demonstrate the use of data for decision making.”