Ahmed Abbas, a medical student in Khartoum, writes on the burden of rheumatic heart disease and what could be done to address it.

September 28 was world heart day. It is a date that I will remember for 2 reasons. Firstly, I promised myself on that day to start an exercise fitness program (the details of which I have yet to figure out!). Secondly and perhaps more importantly, it got me thinking about the many patients which I have encountered so far with cardiac problems.

It has always been sad for me to see patients in heart failure, but to see young patients in debilitating heart failure due to a preventable cause is even more difficult. Unfortunately this is an all too common sight at the medical wards of our university hospital in Khartoum, Sudan.  The culprit is almost always rheumatic heart disease (RHD) which according to Dr. Jonathon Carapetis, a paediatric infectious disease expert and prominent member of the World Heart Federation (WHF), is the “most solvable cardiac problem affecting the developing world today”. (1)

RHD is the most common form of acquired heart disease in young patients in the developing world. It is the most serious complication of rheumatic fever (RF), the disease which “licks the joints, but bites the heart” … to put it lightly.  RF in turn is caused by infection with Group A beta haemolytic streptococci.

According to conservative estimates, 15.6 million people suffer from RHD worldwide, with 470,000 new cases of RF reported and 233,000 deaths linked to RF or RHD each year. The real values are likely to be considerably higher. (2) RF used to be a major public health problem around the whole world, with entire hospitals in industrialized countries committed to the treatment and rehabilitation of patients with RF. (2) However, in the latter half of the 20^th century, the disease ceased to be of major concern and almost vanished from all wealthy countries. The decline in the prevalence of RF is mainly recognized as a result of improved living conditions such as less crowding and improved hygiene, which had led to decreased transmission of the Group A streptococci. (2,3) 

However RHD still remains a major cause of morbidity and mortality in developing countries, where widespread poverty is rampant. In addition to the human suffering involved, this vicious disease can also contribute to the crippling of a country’s economy. This is not only because of the medical and surgical costs of treatment, but also because it is a disease that primarily attacks young adults (the most economically active group of any country). (4)

It is difficult to come to terms with the fact that more than half a century after it has practically been eliminated from wealthy countries, “the most solvable cardiac problem” is still rife in developing countries. The unfortunate reality is that RHD has become a neglected disease. (5) RF, despite its devastating consequences, receives little attention when compared to HIV or malaria for example. This is not to say that money is not being spent on RHD. Indeed in countries stricken by RHD, the great majority of funds go towards surgical treatment of valvular lesions. (1) This is well exemplified by some countries in the Pacific which according to the WHF spend up to 15% of their total health budget sending RHD victims abroad for surgery. (5) Little attention is being directed towards prevention or research of RF and it seems that up till now efforts are not being aimed at the source of the problem, despite the benefits that this might yield. In Nigeria for example, it was estimated that the cost of treating one patient with rheumatic fever was comparable to the cost of preventing 5.4 cases. (3)

A recent article in the NEJM suggested that the steady decrease in publications concerning this disease is simply the result of the diminished importance that RF now has for the minority of the world’s population living in wealthy countries.  Does that probable suggestion mean that millions of patients in the developing world have been cheated of the potential progress that might have come about as a result of medical research? The article goes on to say that the only advances that have significantly impacted the management of RF in the past 50 years have taken place in the medical and surgical treatment of RHD. This treatment is generally palliative and is not within the reach of most affected patients. (2)

Developing countries meet many challenges in the fight against RHD, primarily due to a shortage of money and resources. (3,6) For example, accurate data on prevalence is essential for any campaign concerned with preventing and treating RF and RHD. The World Health Organization has recommended “secondary prophylaxis” as the most cost effective means of controlling RF and RHD. This entails the regular administration of antibiotics to patients with a previous history of RF/RHD to prevent Group A streptoccal pharyngitis and a recurrence of acute RF. Although this strategy of using antibiotics is inexpensive, (3) developing countries need to keep a registry of patients suffering from these diseases to ensure efficient prophylaxis. (1) A new vaccine that protects against rheumatic fever may be made available in the next 10 to 20 years, however the cost-effectiveness and practicality of such a vaccine in poor countries is being questioned. (2,3)

I think the key issue that is being overlooked when considering these approaches is poverty. RHD being a disease of poverty cannot be eradicated without eliminating the conditions in which the causative organism thrives and spreads amongst its victims. It is beyond the scope of this article to discuss methods of getting rid of poverty, however I do not believe that any programme aiming to control RF and RHD, whether local, national or international can be successful without addressing issues such as overcrowding and poor hygiene.

The theme for this year’s world heart day is “know your risk”; designed to help people better understand their personal risk for developing cardiovascular disease. Having assessed my own risk, I know that a little exercise is in order to start lowering it. That seems like a very feasible and simple task when compared to the challenges described above. Unfortunately for the population of most developing countries, their risk for acquiring rheumatic heart disease seems set to remain persistently high.

Ahmed Abbas, final (5^th) year medical student at the University of Medical Sciences and Technology, Khartoum, Sudan.
ahmedabbas08@hotmail.com

References

(1) http://www.theheart.org/article/746133.do Rheumatic heart disease: Not gone, but almost forgotten (accessed 28 September 2008)

(2) Carapetis JR. Rheumatic heart disease in developing countries. N Engl J Med. 2007 Aug 2;357(5):439-41.

(3) Rheumatic fever and rheumatic heart disease: report of a WHO expert consultation. World Health Organ Tech Rep Ser 2004;923

(4) Cilliers AM. Rheumatic fever and its management. BMJ. 2006 Dec 2;333(7579):1153-6.

(5) http://www.world-heart-federation.org/what-we-do/rheumatic-heart-disease (accessed 28 September 2008)

(6) J Mackay, G Mensah, Atlas of Heart Disease and Stroke.  2004 World Health Organization. Geneva

Kendra Wu writes about avian influenza in Hong Kong. 

Aquatic birds are the natural reservoirs of avian influenza (or “bird flu”).  While some bird species carry these viruses with no apparent signs of harm, other bird species, including domestic poultry, develop disease when infected. [1] Apart from being highly contagious among birds, a highly pathogenic subtype of avian influenza A/H5N1 was discovered to have leaped through species barriers to infect humans in 1997 causing 18 people to be infected resulting in six deaths. [2]  In fact, since 1997, there have been 385 human cases and 243 deaths reported around the world (as of 19 June 2008). [3]  Wet markets - where people trade live animals, fish, fruit and vegetables - were identified as one of the risk factors for H5N1 influenza. [4]

I am currently in Hong Kong, where the first fatal human case occurred.

Local demands for live animals for fresh produce make wet markets popular and widespread in Hong Kong.  Presently, there are 64 wet markets [5] in the 18 community districts in Hong Kong averaging 3-4 wet markets per district.  However, wet markets also pose public health concerns from the perspective of zoonotic transmission.   

Interspecies transmission of influenza viruses involving species other than birds, such as pigs, [6] sea mammals, [7] and humans [8] have occurred sporadically.  This type of transmission often involves gene segments mutation, reassortments, or recombining of gene segments.  In 1957 and 1968, for instance, both of the influenza pandemics were caused by reassortments of gene segments from the avian and human influenza viruses. [9]  However, for the fatal human cases in Hong Kong, this was not the case.  For these patients, all genes of the H5N1 virus were of avian origin, indicating that the virus had not undergone genetic reassortment. [6]  Since it has been found that visiting a poultry market is a risk factor of infection, [6] direct contact of birds and poultry should be minimized to avoid cross-species transmission.  However, wet markets provide a favorable environment for close repeated contacts between humans and birds.

How so?  First of all, the animals at wet markets are kept alive and stay in very confined cages from days to weeks. [10]  If one of the birds becomes infected by avian influenza, the rest of them will become vulnerable to infection because of the packed and confined environment.  In addition, since the animals stay in their cages for a long period of time, and the highly pathogenic viruses can survive for long periods in the environment, [1] there is plenty of time to be infected.  Although stalls that sell live aquatic birds do not usually sell live poultry or red-meat animals, the stalls can be next to each other, which provides an environment for cross species transmissions.  Daily introduction of new animals also increases the chance of contact between infected and non-infected animals, which provides a favorable condition for disease epidemic.  Adding daily close human contacts make wet markets an important potential source of viral infection and transmission. 

Once the virus infects humans, H5N1 has the potential to cause severe illness with a high risk of death (the overall case fatality ratio (CFR) is 63% as of 19 June 2008). [2]  If this subtype becomes capable of efficient human-to-human transmission, a pandemic could break out in a highly dense urban community, such as Hong Kong, due to the general lack of immunity to this strain of virus among humans.

Hence, the city has put resources into educating the public and developing expertise and medical facilities to detect and control avian influenza, among other infectious diseases.  Aside from preventing viral transmission within Hong Kong, as a trading and financial hub, the city recognizes that a high volume of goods and travelers pass by Hong Kong daily.  Therefore, the city also puts in efforts to prevent various emerging and re-emerging infectious diseases from entering the city and transmitting to the rest of the world.  Based on the stories of how Hong Kong provided support for the discovery of the bacteria that caused the plague in 1894, identifying H5N1 as the cause of the human avian influenza cases in 1997 and isolating the coronavirus (CoV) that caused severe acute respiratory syndrome (SARS) in 2003 almost 110 years later, [11] this investment is necessary. 

Preventive Measures

The media in Hong Kong has been reporting new human or poultry cases of avian flu in China, Hong Kong, and sometimes in neighboring regions.  The local government also puts out television commercials regularly during prime time to remind the public of how they can protect themselves from bird flu.  For instance, they are discouraged from directly contacting live poultry or from blowing poultry aerosols during purchase (for health inspection).  During consumption, they are asked to thoroughly cook the meat.  In addition, they are also advised to pay attention to personal hygiene and to seek immediate medical attention when symptoms of influenza-like illness occur.  Hence, the local community should be rather well informed regarding the risk of this disease and how they may protect themselves from bird flu. 

Regulations were also been implemented after the fatal human cases in 1997 so that all aquatic birds, including ducks and geese, are not allowed to be sold live from retail markets.  Instead, they have to be sold chilled in the markets to minimize direct contact between live birds and humans.  With regard to poultry, chickens have not been banned from retail markets due to the opposition of poultry workers and the continuous demands for live poultry from the local community.  As a compromise, the local government asks a sample of each truckload of poultry entering the wet markets in Hong Kong (either locally or from China) to be screened for the level of avian flu immunity.  Despite these efforts, H5N1 of multiple new genotypes reappeared in retail markets in 2001. [12]  Subsequently, a monthly ‘clean day’ was introduced during which all markets are emptied and cleaned in order to minimize the chance of viral survival at wet markets.  Quail, which was newly recognized as a host susceptible to all subtypes of influenza and a potential intermediate host, was not allowed to be sold in the retail markets either.  Yet, H5N1 viruses reappeared in late 2002 and in early 2003.  In fact, in February 2003, the virus was transmitted to two humans resulting in one death. [2]  A second clean day every month was then introduced.  The Agriculture, Fisheries and Conservation Department (AFCD) also began to perform routine surveillance among wild birds, pet birds and poultry across the territory. [13] In addition, only designated farms may supply live poultry to the wet markets and these farms are asked to vaccinate their poultry.  Farms and private citizens have also since been banned from keeping domestic poultry without licenses.  Nevertheless, in June 2008, H5N1 virus was again detected in local retail live-poultry markets again. [14,15]

As a result, all poultry from the poultry stalls in affected markets were asked to be culled blindly in case there was any H5N1-infected poultry that was undetected.  Despite the steep economical cost, this practice is an attempt to eradicate the disease from the territory and has been used since 1997.  It has since become the gold standard and adopted by countries from around the world.

Discussion

The repeated appearance of the H5N1 virus in wet markets illustrates the difficulty of keeping the virus away from the wet markets.  Why is this?  While all aquatic birds, including ducks, geese, and quails, are banned to be sold live, chickens are exempted from the ban regulation and are allowed to be sold live at retail markets.  However, as long as chickens are alive, they pose a threat to shedding the virus, and presently these animals are allowed to be transported to retail markets which spread across 18 community districts in Hong Kong. 

The local government is relying on routine surveillance to identify infected chickens and stop them from entering Hong Kong.  Yet, we often struggle with identifying infected poultry unless it becomes very sick from virus infection or if it happens to be sampled during routine surveillance.  In a non-endemic area, finding a H5N1-infected chicken through routine surveillance is practically like finding a needle in a haystack.  Not finding a positive sample does not mean that the virus is not in the area. 

Asking all suppliers to vaccinate imported poultry would minimize the proportion of chickens susceptible to avian influenza from being imported to Hong Kong; however, poultry vaccines of good quality are not widely used in China. [16] Therefore, vaccinated chickens may or may not be protected as much as we would like. 

In addition, according to the media, there might be birds and poultry entering Hong Kong via illegal channels, despite government efforts to stop them.  Therefore, we cannot be certain that all of the live chickens that are being sold at retail markets are free of avian flu viruses.

Aside from keeping infected birds and poultry from entering Hong Kong, the local government has also asked stall owners to empty and clean their stalls on two designated dates each month.  This regulation helps improve the sanitation of wet markets and minimize the chance of viral survival.  Based on the markets that the author has visited, stall owners have good compliance.  But, is two days per month enough?

New regulation

After the poultry outbreaks in June, the local government decided to require poultry stall owners to cull their live poultry and clean their stalls daily [17] in case any poultry was infected but undetected, so the virus would not be further transmitted.  The proposal was faced with opposition from the poultry industry because industry representatives argued that the source of infection was unknown, which meant that the viruses could have been from illegal imports.  They further argued that the government was killing the industry by “exaggerating the threat of avian influenza”.  Representatives warned that the new regulation would negatively affect Hong Kong’s fine reputation as a food haven. [18] 

Despite this, all three political parties opposed the veto from the poultry industry based on public health concerns, [18] which appeared to be the general consensus of the community as well.  Hence, the new regulation has been implemented since July 4. 

The future

High quality H5N1 poultry vaccines should, in principle, provide good protection to poultry for sale.  Unfortunately, some suppliers in China and the illegal imports are not using these vaccines, making their livestock susceptible to avian flu. Considering the uncertainty in identifying flu-infected poultry, keeping live animals away from the general population becomes the most desirable environment that Hong Kong, a highly dense megacity, should aim for.  H5N1 is not be the only avian flu virus that we are concerned about.  Other highly pathogenic subtypes of avian flu may become capable of leaping through species barriers.  In fact, other zoontic transmissions pose a threat too, like the severe acute respiratory syndrome (SARS) that was caused by the previously unrecognized coronavirus (SAR-CoV), which leaped from civet cats to humans. [19] As of today, animals that are found susceptible to H5N1 virus infection include aquatic birds, some species of wild birds, domestic poultry, [1] pigs, [6] palm civets, [20] tigers, [21] and cats. [22] 

Live-animal retail markets should be closed.  However, it takes significant political will to achieve this because such a policy would alter the public’s food consumption behavior and severely affect the livelihood of poultry workers, who are mostly people of advanced age and low education level.  In Hong Kong, for instance, live chickens are in demand due to food culture and religious rituals.  Despite successfully banning the sale of other types of live poultry and aquatic birds, live chickens are still being sold at retail wet markets.  Nevertheless, the local government would like to ultimately ban the sale of live chickens in retail areas some day.

However, when the general population can no longer purchase live chickens at wet markets, would the number of illegal imports increase?  If so, could these underground activities still be controlled?  Therefore, apart from closing live-animal retail, illegal imports would need to be controlled. 

Since our last pandemic in 1968, the global human population has almost doubled, [23] whereas the chicken population in China alone has multiplied 100 times to keep up with the demand. [24] When demand stays strong and poultry and humans continue to reside next to each other, the opportunity increases for zoonotic transmission.  

Kendra M Wu
Postgraduate student
London School of Hygiene & Tropical Medicine
kendra.m.wu@gmail.com
 

1. World Health Organization.  Avian influenza (”bird flu”) - fact sheet.  http://www.who.int/mediacentre/factsheets/avian_influenza/en/index.html

2. World Health Organization. H5N1 avian influenza: Timeline of major events. http://www.who.int/csr/disease/avian_influenza/Timeline_08_06_17.pdf

3. World Health Organization.  Cumulative Number of Confirmed Human Cases of Avian Influenza A/ (H5N1) Reported to WHO. http://www.who.int/csr/disease/avian_influenza/country/cases_table_2008_06_19/en/index.html

4. Mounts AW, Kwong H, Izurieta HS, et al.  Case-control of risk factors for avian influenza A (H5N1) disease, Hong Kong. Journal of Infectious Diseases. 1999; 180: 505-08.

5. The Government of the Hong Kong Special Administrative Region. Press Releases: SFH on measures to prevent avian influenza. http://www.info.gov.hk/gia/general/200806/28/P200806280150.htm

6. Shortridge KF, Gao P, Guan Y, Ito T, Kawaoka Y, Markwell D, et al. Interspecies transmission of influenza viruses: H5N1 virus and a Hong Kong SAR perspective. Veterinary Microbiology.  2000; 74(1): 141-147.

7. Horimoto T, Kawaoka Y. Pandemic Threat posted by avian influenza A viruses. Clinical Microbiology Reviews. 2001; 14(1): 129-149.

8. Claas CJ, Osterhaus DME, van Beek R, De Jong JC, Rimmelzwaan GF, Senne DA, et al. Human influenza A H5N1 virus related to a highly pathogenic avian influenza virus. The Lancet.  1998; 351(9101): 472-477.

9. Kawaoka Y, Krauss S, Webster RG. Avian-to-human transmission of the PB1 gene of influenza A virus in the 1957 and 1968 pandemics.  Journal of Virology. 1989; 63: 4603-08.

10. Fielding R, Lam WWT, Ho EYY, Lam TH, Hedley AJ, Leung GM. Avian Influenza Risk Perception, Hong Kong. Emerging Infectious Diseases.  2005; 11(5): 677-682.

11. Starling A, Ho FCS, Luke L, Tso SC, Yu ECL. Plague, SARS and the story of medicine in Hong Kong. Hong Kong: Hong Kong University Press. 2006.

12. Sims LD, Ellis TM, Liu KK, Dyrting K, Wong H, Peiris M, et al. Avian influenza in Hong Kong 1997-2002. Avian Diseases. 2003; 47: 832-838.

13. Food and Environmental Hygiene Department, The Government of the Hong Kong Special Administrative Region. Prevention of avian influenza. http://www.fehd.gov.hk/safefood_2/avian_flu/guide.html

14. The Government of the Hong Kong Special Administrative Region. Press Releases: Samples in Po On Road Market tested positive of H5N1. http://www.info.gov.hk/gia/general/200806/07/P200806070406.htm

15. The Government of the Hong Kong Special Administrative Region.  Press Releases: Three more markets found to have samples tested positive of H5N1 virus.  http://www.info.gov.hk/gia/general/200806/11/P200806110373.htm

16. Webster RG. Wet markets-a continuing source of severe acute respiratory syndrome and influenza?  Lancet. 2004; 363: 234-236.

17. The Government of the Hong Kong Special Administrative Region. Press Releases: Samples in Po On Road Market tested positive of H5N1. http://www.info.gov.hk/gia/general/200806/07/P200806070406.htm

18. Veto clearing live chickens daily.  Three political parties oppose.  Ming Pao News.  13 July 2008 (in Chinese).

19. Peiris JSM, Guan Y, Yuen KY. Severe acute respiratory syndrome. Nature Medicine. 2004; 10: S88-S97.

20. World Organization for Animal Health.  Avian influenza: H5N1 Timeline. http://www.oie.int/eng/info_ev/en_AI_factoids_H5N1_Timeline.htm

21. Thanawongnuwech R, Amonsin A, Tantilertcharoen R, Damrongwatanapokin S, Theamboonlers A, Payungporn S, et al.  Probable tiger-to-tiger transmission of avian influenza H5N1.  Emerging infectious diseases. 2006; 11(6): 976.

22. Kuiken T, Rimmelzwaan G, van Riel D, van Amerongen G, Baars M, Fouchier R, et al. Avian H5N1 influenza in cats. Science. 2004; 306(5694): 241.

23. United Nations, Department of Economic and Social Affairs, Population Division.  World population prospects: The 2006 revision, highlights, working paper No. ESA/P/WP.202. New York. 2007.

24. Guan Y.  Planetary discussion on Transmission, Pathogenesis, Immunity and the Control of Influenza. International Symposium of Area of Excellence on Influenza.  The University of Hong Kong, Hong Kong.  22 July 2008.

Itzhak Matthai asks why measles continues to kill hundreds of thousands of people despite the availability of a simple and cheap solution and despite a marked global improvement over the last few years.

Everyone knows about measles, but do we perhaps take it for granted, thinking it an unproblematic and easily avoidable issue? A disease most prevalent amongst young children between the ages of one to four, it is highly contagious - particularly in the four days before any sign of physical symptoms - and has been responsible for millions of deaths worldwide, mostly through the various complications it is liable to cause including hepatitis, conjunctivitis, encephalitis and severe respiratory infection (1).

Thank goodness, then, for the measles vaccine, which costs around GBP 0.17 including safe injection equipment and has been around for 40 years (2). Furthermore, the vaccine has been proven to be both safe and effective - so why does the disease continue to take lives even today across the whole world?

(more…)

Kush Patel reports on the violence that occurred in Kenya following the elections earlier this year.

For many years, Kenya has been considered as a refuge for people fleeing their own country because of domestic turmoil. However, on 29th December 2007, shouts emanated from an angry throng that had gathered on the streets. Marching determinedly towards them was a battalion of riot police. Within seconds, the rioters hurled stones at the police, who counterattacked using bullets and tear gas. In other parts of the country, youths clutching machetes and sticks launched themselves upon opposing tribes. Events such as these set the scene for a blood bath that has resulted in thousands of people injured, dead or homeless. Several camps for internally displaced people (IDP) were set up all over the country. Governmental and non-governmental organisations (NGOs) such as Merlin, Medecins sans frontiers (MSF), the Red Cross, AMREF and others, deployed teams to provide humanitarian aid.

Post-election violence in Kenya results in displacement

photo source: savethechildren.org/au

Trauma victims requiring medical attention overwhelmed the medical facilities. When particularly violent clashes broke out, trucks full of injured or dead people arrived at hospitals, which in-turn became so over-crowded that patients were being treated on the corridors. A system of triage was implemented at many institutions, thus helping to treat the most severe patients first. (2,3) Patients were being rushed in with broken bones, stab injuries, blunt trauma and burns. Doctors reported certain cases where patients had sustained machete wounds that resulted in near-amputations. (3) Flying surgical teams were put on high alert, responding to violence in inaccessible regions. (4) In the worst hit areas, temporary first-aid posts were setup that quickly stabilized victims, while waiting for transport to hospitals. Any person who was critical and needed specialist care was air-lifted to the closest hospital. (3) Many of the victims were (and some still are) mentally traumatized from witnessing the violence or having lost loved ones. These people were given psychosocial support by medical personnel. (2,3)

Cases of sexual violence increased dramatically. These incidents took place both within IDP camps and outside. This will probably result in increased incidence rates of sexually-transmitted diseases, including HIV infection. Counselling and screening for sexually-transmitted infections have commenced in certain areas. (4)

Many people have been displaced and gathered at temporary IDP camps. At these camps severe public health consequences can manifest amongst the IDPs.. Four main reasons behind this are that the population is displaced, food becomes scarce, health care diminishes and living conditions worsen. Studies have shown that mortality rates are usually highest immediately after the migration. (1) Apart from the acute emergencies, an increasingly large number of IDPs need to be accommodated. At each IDP camp, tents were pitched, food and water was provided, sanitation and lavatory facilities were set up and medical camps were established. (2-6) Other essential equipment such as bed nets, (6) cooking apparatus, (3) and clothing, (2,4) was provided to the IDPs. Most IDPs had left their homes without anything. For many, important documentation was lost. Therefore, the task of registering the IDPs and getting new identification cards for them was set into motion. In order to keep the IDPs busy and lessen their emotional stress, some were given responsibilities in the camps such as cleaning. (2) Some NGOs have setup tracing agencies that help reunite lost family members.(4) Planes and helicopters had to be employed to deliver medical and other essential supplies to ill-equipped areas.(3)

The most prevalent diseases amongst IDPs are diarrheal diseases, measles, acute respiratory infections, and malaria. Additionally, many people became malnourished because of the lack of food. This aggravates diseased states and worsens the patient’s prognosis.(1) At a single camp, 541 consultations were done mainly for respiratory tract infections.(3) Most of these patients were children and many had a poor prognosis. Factors that contribute to a high prevalence of respiratory tract infections are: over-crowding, poor ventilation, inadequate shelter, and prolonged exposure.(1)
The measles immunization was provided for children.(3) For those who survive the initial illness, it can lead to malnutrition and vitamin A deficiency. Previously, measles has accounted for high mortality rates amongst children in refugee camps. However, it is less of a threat now compared to before 1990.(1)

Diarrhoeal diseases are a common phenomenon in IDP camps. Factors that contribute to their high prevalence are unsanitary conditions and unsafe drinking water. Cholera and dysentery are the main problems. In some IDP camps, diarrhoeal epidemics had broken out. These were usually treated with oral rehydration salts. However, any serious cases of diarrhoea were referred to a hospital.(4)

Kenya has a high prevalence of tuberculosis (TB) (7) and AIDS. (8) A lot of IDPs with TB or AIDS fled their homes without anything, including their anti-tuberculosis or antiretroviral drugs.(2,3,6) Adding to this, the number of patients attending HIV/AIDS clinics reduced dramatically.(3) This can have serious consequences on their health, as non-compliance results in the development of drug-resistance. Patients also become susceptible to opportunistic infections and their risk of morbidity and mortality increases.(8) One report mentioned a woman trapped at home, unable to gain access to a new dose of anti-retrovirals. As a result, when she was found by relief workers, an infection had set in and she had to be admitted to hospital.(9) Another hurdle with respect to anti-retrovirals is that many HIV patients were not getting adequate nutrition. This resulted in patients unable to tolerate their medication, further increasing non-compliance.(9) Patients with tuberculosis, face a similar scenario where drug-resistance develops.(4,7) The problem with this is that patients then require second-line drugs that are more expensive than first-line drugs.(4) Long-term effects of this may result in increased infection rates within the population. These 2 diseases were a major concern for the NGOs, who constantly held testing clinics, offered counselling and provided medication.(6,2,3) Thankfully this volatile situation has calmed down allowing people to piece together their lives. Medical attention has also improved in most areas. (6)

A correspondent from Merlin gave the following account of a typical day at an IDP camp:
The day usually starts off early, with a meeting discussing the day’s agenda. A clinic is setup wherever space is available (a vacant room or under a tree). Patients are then prioritized according to their level of urgency. Immunizations, HIV testing and counselling and treatment for minor illnesses are provided to those who need them. For those who require referrals to health centres or hospitals, transportation is arranged. Other team members conduct health education sessions for patients while they wait for their consultation.

Kush Patel
Imperial College London
kush.p.patel04@imperial.ac.uk

References
(1) Toole MJ, Waldman RJ. The public health aspects of complex emergencies and refugee situations. Annu.Rev.Public Health 1997;18:283-312.
(2) Kenya Red Cross operations update. http://www.kenyaredcross.org/highlights.php?newsid=61&subcat=1, 2008.
(3) Medecins sans frontiers. http://www.doctorswithoutborders.org/news/report.cfm?id=2470, 2008.
(4) International committee of the Red Cross. http://www.irinnews.org/Africa-Country.aspx?Country=KE, 2008.
(5) AMREF Kenya news and press releases. http://kenya.amref.org/index.asp?PageID=10, 2008.
(6) Merlin newsletters. http://www.merlin.org.uk/Where-we-work/Kenya.aspx, 2008.
(7) O’Boyle SJ, Power JJ, Ibrahim MY, Watson JP. Factors affecting patient compliance with anti-tuberculosis chemotherapy using the directly observed treatment, short-course strategy (DOTS). Int.J.Tuberc.Lung Dis. 2002 Apr;6(4):307-312.
(8) Frick PA, Gal P, Lane TW, Sewell PC. Antiretroviral medication compliance in patients with AIDS. AIDS Patient Care STDS 1998 Jun;12(6):463-470.
(9) BBC news on Kenya. http://news.bbc.co.uk/1/hi/in_depth/africa/2008/kenya/default.stm, 2008.

Fourth year medical student from the University of Edinburgh, Rachel Phillips reports on her experiences working for TAC in South Africa. 

Having spent the last four months working for South Africa’s biggest HIV non-governmental organisation, Treatment Action Campaign (TAC), I would like to share my glimpse of AIDS denialism, the havoc it causes and the energy involved in opposing it.     

“Does HIV cause AIDS? Can a virus cause a syndrome? How? It can’t, because a syndrome is a group of diseases resulting from acquired immune deficiency.” (1) 

Bizarre and harmful statements made by South Africa’s president Thabo Mbeki are, by now, notorious.  So too is Health Minister Dr Manto Tshabalala-Msimang, who only initiated South Africa’s antiretroviral (ARV) rollout in 2003 after TAC took her to the Constitutional court.  She continues to undermine ARVs whilst supporting the use of garlic, beetroot and pseudo scientific ‘cures’ for HIV.  

Disastrous leadership has led to fatal delays in the fight against HIV, which infects an estimated 5.6 million South Africans. (2)  This has drawn sharp criticism from UN Special Envoy for HIV/AIDS in Africa, Stephen Lewis who famously slammed South Africa at the Toronto International AIDS conference for being  ‘the only country in Africa whose government continues to propound theories more worthy of a lunatic fringe than of a concerned and compassionate state”.(3) Thus it was into a vacuum of political action that TAC emerged in 1998.  Led by activist Zackie Achmat - the first person in the world to go on a drug strike - TAC campaigns for the rights of people living with HIV, especially the right to access ARVs. (4)  During my placement with TAC they were helping to publicise South Africa’s first national strategic plan for HIV, which finally came out  - in 2007!  

Where has Mbeki’s denialism come from? That’s the big question of course, and several theories exist.   One thing is for certain; the influence of AIDS dissidents on the president.  Mbeki’s stance has lent credence to this otherwise eccentric mix of people, who operate internationally to refute either the very existence of HIV or its link to AIDS.(5)  Moreover, he has created widespread confusion in South Africa , providing fertile ground for those who profit from ignorance and desperation.   

Enter characters like Matthias Rath, a German entrepreneur who has been marketing his vitamin tablets as an AIDS cure in townships.  According to Rath, organisations like TAC, cynically push ‘toxic’ ARVs on behalf of the pharmaceutical industry.  Think I’m exaggerating? Check out Rath’s website or even worse his book ‘END AIDS: Break the chains of pharmaceutical colonialism’.  Actually, don’t bother.  It’s a nauseating 280-paged rant, which blames the pharmaceutical industry for World War Two and apartheid whilst comparing TAC members to Nazi storm troopers. His reasoning for this seems, sensibly, to be that both have a sort of uniform.  The storm troopers brown khaki, TAC their world famous ‘HIV Positive’ T shirts inspired, ironically, by the Danish King who wore the yellow star of David during WW2 in solidarity with Jews.  Rath’s flawed logic follows that because support for ARVs comes from countries that also export them, there is a  conspiracy to bind Africa to western drugs. It is important to clarify at this point that TAC  has an explicit and strict policy that refuses any funding from the pharmaceutical industry and has even been involved in legal action against pharmaceutical companies.  You might think that Rath’s claims are so ridiculous that they are not taken seriously but sadly the opposite is true.  Hence TAC’s extensive legal battle against him, which is currently drawing to a close, after over 2 years.  Rath is just one of many charlatans pedalling false AIDS cures.   

Another example is Tina van der Maas.  In her propaganda video she heals a Zulu lady from the clutches of death by administrating natural remedies, all to the soundtrack of African drums.  So glad this Dutch woman is getting back to her African roots.   Kim Cools, is another denialist who operates a ‘clinic’ in Kwa Zulu Natal.  He came to my attention when he started systematically texting TAC members (he must have got their phone numbers off the internet) inviting them to leave TAC and join his own ‘Truth Action Campaign’.     

Not all the AIDS ‘cure’ charlatans are from abroad.  Mr Zeblon Gwala  an ex -lorry driver is currently doing great business selling ‘Ubhejane’  - a  brown liquid made according to a recipe revealed by his late grandfather in a dream and sold in plastic litre bottles. Gwala may have the best of intentions but he is not only cheating people out of serious money, his advice to stop ARVs is fatal. Then there is Freddie Isaacs, a self styled prophet who markets a beautifully named product ‘Comforters Healing Gift’, and the list goes on…   

Learning about these people and helping to lodge complaints with the Advertising Standards Authority and Medicines Control Council with TAC colleagues– all extremely well informed themselves- it was easy to forget the public confusion that surrounded us. But I never had to go far -  a simple morning jog would easily turn into a discussion with Xhosa guards over whether HIV existed and whether ARVs worked or not.  Opening a newspaper would reveal adverts for herbs that could increase my CD4 count.  I heard that in some parts of town minibuses smell of the garlic chewed by those misled by their Health Minister.  Apparently no section of society is immune to the confusion.  After four months on the topic I spent my last night in South Africa listening in astonishment to a white middle class university student who had just watched a popular You-tube video that convinced him that the ‘HIV myth’ is indeed a conspiracy. 

The battle for truth on HIV in South Africa is raging. Which is why its great to know that there are so many committed to answering AIDS denialists and providing the public with accurate information.  This includes those who promote a holistic approach to treating HIV and emphasise the importance of good nutrition in addition to ARVs.  TAC is currently involved in several complaints against pseudo-cures, trains members in treatment literacy, produces masses of educational leaflets and a regular magazine ‘Equal Treatment’ which disseminates up to date information in an accessible format for the public.  It was my privilege to witness this battlefront first hand and to meet some of those working hard for the side of truth.  

References 

1. Quote taken from an article on the AEGiS (AIDS Education Global Information System) website.  Harvey M.  How can a virus cause a syndrome? Asks Mbeki. I-clinic – September 21, 2000.  2.  Statistics from Actuarial Society of South Africa – extrapolated from the ASSA 2003 model.  3.  Lewis S.  Race Against Time.  UN Official Assails S.A. on its response to AIDS.  New York Times Aug 19 2006 

4.  Please see the Treatment Action Campaign website 

5. Nattrass N.  Mortal Combat:AIDS Denialism and the struggle for Antiretrovirals in South Africa.  University of Kwa Zulu Natal Press 2007

 For more information on AIDS denialism in South Africa please go to the excellent AIDSTruth website: AIDS truth 2007.  Answering AIDS denialists and AIDS lies. 

Rachel Phillips

4th year medical student

University of Edinburgh

rachelphil@gmail.com

Rachel Jones discusses a recent WHO report on multidrug resistant TB

A new report recently issued by the WHO (1) reports a growing global trend in multidrug resistant tuberculosis (MDR-TB). This trend is focused in India and China which are responsible for up to half of all global cases. (1) MDR-TB is defined as tuberculosis resistant to isoniazid and rifampicin, two first line drug therapies for TB. With this in mind, there are fewer therapies that are effective for treating multidrug resistant tuberculosis and these are not as effective as first line treatments. MDR-TB therefore carries higher mortality and morbidity rates than conventional strains. (more…)

Karl Pang takes a global look at what different countries are doing to combat this important clinical concern

Methicillin Resistant Staphylococcus aureus (MRSA) causes major morbidity and mortality. Once introduced into an institution it frequently becomes endemic, difficult to control, expensive to treat and often impossible to eradicate.

Staphylococcus aureus (S. aureus), a gram positive coccus is just one of a family of staphylococcal bacteria. 30% of healthy adults are colonized by S. aureus in their nose. (more…)

Three quarters of blindness in sub-Saharan Africa is due to five treatable or preventable conditions as Justin Sherwin explains

There is a disproportionate amount of blindness in Africa, which is home to 19.8% of the world’s blind but only 11.5% of the population. (1) In 2001, it was estimated that approximately 1% of the continent was blind, defined as bilateral visual acuity <3/60 in the better eye. (2) Precise estimates of the prevalence of blindness are difficult to generate, because such research requires large sample sizes, in order to achieve sufficient statistical power, and are expensive. A novel method, the rapid assessment of avoidable blindness (RAAB), is simple to administer, cost-effective, and has been successfully used in Kenya. (3)

There are many reasons for the importance in treating avoidable blindness. Firstly, the ability to see is a human right, and no one deserves to be needlessly blind. Most of Sub-Saharan Africa is afflicted with poverty, which is an independent risk factor for blindness and is also associated with reduced access to treatment. (4) In the absence of treatment, the cycle of poverty is perpetuated, and acts as a further barrier to socio-economic development. The World Health Organization (WHO) considers the alleviation of avoidable blindness as one of the most cost-effective health interventions. Globally, it is estimated that the VISION 2020 strategy can ultimately save more than $200 US billion.(5)

VISION 2020
Through the collaboration of the WHO and the International Association for the Prevention of Blindness (IAPB), the VISION 2020: The Right to Sight Initiative recognised that more than 75% of the blindness in Africa is due to one of 5 treatable and/or preventable conditions. (5) These five conditions comprised cataract, glaucoma, trachoma, onchocerciasis and childhood blindness. Ocular leprosy no longer constitutes a major problem in Africa, but the HIV infection has changed the ophthalmic landscape in some endemic areas, with the emergence of ocular associated manifestations of HIV/AIDS. Other target disease areas for VISION 2020 are low vision, diabetic retinopathy, refractive error and age-related macular degeneration, but a discussion on these is beyond the scope of the article. VISION 2020 is the global initiative for the elimination of avoidable blindness by the year 2020, and has an international membership of non-government organizations (NGO’s), professional organizations, eye care institutions and corporations. The overall objectives of VISION 2020 are to identify and educate individuals and organizations about the causes of preventable blindness within a particular country and to provide sufficient resources to prevention, treat and provide rehabilition to those in need. (5)

Cataract
Cataract is any opacity of the lens in the eye, and is the leading cause of blindness in the developing and developed world. (1) In Sub-Saharan Africa, the prevalence of bilateral blinding cataract is estimated at 0.5%. (2) Unfortunately, the incidence of cataract in the developing world far outweighs the numbers who are being treated surgically. (6) In Sub-Saharan Africa, the cataract surgical coverage (CSC), a measure of the distribution of cataract surgery to those awaiting surgery in a given time period, is poor. (7) In order to monitor the surgical output in a given community each year, the cataract surgical rate (CSR) is calculated. This is usually quoted in the number of operations performed per year, per million persons. In 1999, it was estimated that Africa had the lowest CSR in the world at 300 operations/ million/ year, with the highest CSR’s estimated to be in developed regions. (7)

At present, nearly all surgery performed uses the insertion of an artificial plastic lens following the lens removal, using either an intracapsular or extracapsular approach. Surgery using phaecoemulsion technology is now the gold standard for most cases of cataract surgery in the developed world, however, is rarely seen in Africa due to high cost and complexity required to use it. Access to the low-cost plastic intraocular lens device has improved dramatically due to the installation of lens factories in developing settings, including India and Eritrea. Treatment of cataract blindness is a priority of many eye care NGO’s because it is cheap, quick, effective and relatively simple. Before the widespread implementation of the intraocular lens, cataract surgery consisted of removing the cataract lens and wearing thick, plus powered glasses in order to deal with the resultant high hypermetropia (long-sightedness). Uncorrected or undercorrected aphakia (state when no lens is present within eye) continues to be a problem in some communities. ‘Couching,’ the unorthodox process of manually pushing the cataract lens into the posterior chamber of the eye, is common in some African communities, and can often result in serious ocular complications.

Barriers to ensuring that persons with vision-impairing cataract receive surgical care, include economic reasons, access to healthcare services, lack of knowledge about the surgery and psychological issues. Further efforts at reducing the surgical backlog should focus on training suitable personnel, improving existing healthcare services and creating new healthcare services, and increasing the availability of surgical equipment to areas in need.

Childhood blindness
The most common aetiology avoidable childhood blindness in Malawi has been shown to be corneal pathology due to Measles/ Vitamin A deficiency. (8) Some countries in Sub-Saharan Africa do not have such a problem with Vitamin A deficiency because of diets high in Vitamin A foodstuffs such as red bean oil. Other common causes of childhood blindness in Sub-Saharan Africa include ophthalmia neonatorum (due to chlyamydia or gonorrhoea infection), trauma, uncorrected refractive error, (congential or juvenile) glaucoma, trachoma, corneal scarring, cataract, trauma and genetic eye diseases. (7)

There are several mechanisms by which the burden of childhood blindness in Africa can be reduced. These include distribution of Vitamin A capsules at health clinics, measles vaccination, avoidance of harmful traditional medicine practices to prevent corneal disease, ocular prophylaxis to prevent neonatal conjunctivitis and the ‘SAFE’ strategy for trachoma eradication (see below), in addition to providing health education to parents.

Glaucoma
Glaucoma is a heterogeneous group of conditions characterised by a ‘cupped’ appearance of the optic nerve and a corresponding visual field deficit that is typically, but not always, associated with elevated intra-ocular pressure. It is the second most common cause of bilateral blindness worldwide of whom more than 10% of which are considered to be blind.(1) Genetic factors play an important role in the aetiology of the disease, and the prevalence of glaucoma worldwide is highest in those of African descent. (9)

Detection of disease is hampered by lack of sensitive visual field machines in poor and rural settings, and other necessary diagnostic equipment such as slit lamp biomicroscopes with tonometers to measure the intraocular prssure. Patients are often asymptomatic before significant visual loss has occurred, which constitutes a considerable problem in resource poor settings. It may be advantageous to provide opportunistic screening for glaucoma, such as during refractive testing or at the time of ocular surgery for cataract. It is preferable to diagnose glaucoma as early as possible, because early diagnosis is associated with better visual outcomes. Even so, not all persons respond to treatment. Treatment for glaucoma includes medical treatment with ocular hypotensive therapy, surgical treatment that is typically a drainage operation (trabeculectomy) or laser therapy. In Sub-Saharan Africa, the use of ocular hypotensive therapy is restricted due to economic reasons and difficulties with compliance. Surgery is restricted due to cost and lack of trained staff, and laser therapy is restricted due to lack of available facilities.

Trachoma
Trachoma is the world’s leading cause of infectious blindness and is caused by repeated conjunctival infection with Chlamydia trachomatis, and is still prevalent in many countries in Sub-Saharan Africa. Trachoma affects about 84 million people worldwide of whom about 8 million are visually impaired. (10) It is more common in women and children, and typically associated with poor sanitation and hygiene. The present classification of trachoma outlined by the WHO comprises five categories. These are Follicular Trachoma (TF), Intense inflammatory trachoma (TI), Trachomatous scarring (TS), Trachomatous Trichiasis (TT) and Corneal Opacity (CO). Active trachoma is defined as either TF and/or TI.

WHO and the IAPB launched the “SAFE” strategy for Trachoma elimination. This strategy involves Surgery for trichiasis (bilamellar tarsal rotation procedure), Antibiotics (single oral dose azithromycin and tetracycline eye ointment), Facial cleanliness and Environmental improvements (increasing availability/quality of water, decreasing overcrowding, reducing density of flies and improving latrine access). Environmental improvements and antibiotic coverage also assist in the reduction of other infectious diseases, such as Guinea worm. In a critical review on SAFE, the highest support for its use was found in the ‘S’ and ‘A’ components. (11)

However, only limited supplies of tetracycline ointment and azithromycin are available for trachoma eradication in some countries in Sub-Saharan Africa, and the backlog of trachoma surgery is high in some areas. Yet, even when mass antibiotic treatment is not available, environmental and sanitary improvements have led to a reduction in trachoma prevalence in Malawi. (12) Surgery for trichiasis is widely performed by auxiliary ophthalmic personnel. The success of the SAFE strategy relies on donations of Zithromax (azithromycin) from Pfizer, as well as support from government and NGO’s.

Onchocerciasis
Onchocerciasis, commonly known as ‘river blindness’ is disease caused by infection with the microfilariae Onchocerca volvulus that is transmitted via the vector Simulium yahense, a black fly. Globally, there are 37 million people affected, with majority in West, Central or East Africa, and approximately 300000 are blind from disease. (13) Apart from ocular pathology, infection with the microfilariae may also cause skin conditions and other systemic illnesses. Successful treatment of onchocerciasis lies with the administration of a once-a-year dose of the drug ivermectin, which is currently being provided at no cost to all those with this infection from Merck. However, there is emerging evidence that there may be some resistance to the side-effects of this potent drug. (14) Thus, the search for a second-line drug should be key to future management strategies. Also, efforts are underway to reduce the number of blackfly breeding sites through the spraying of larvae with chemicals. Unfortunately, a significant barrier to progress in the fight against onchocerciasis in West Africa has been political and civil unrest that has led to delayed access to treatment.

Tackling the problem
Important principles inherent to VISION 2020 include cost-effective disease prevention, management and rehabilitation interventions, infrastructure (human resources, healhcare facilities, technology, equipment) and funding. (5) These principles should be integrated into existing national healthcare systems and sustainable, equitable and of a high standard. World Sight Day, occuring annually on the second Thursday in October, ensures that members of VISION 2020 raise the profile of blindness as an important international public health issue. Expatriat British ophthalmologist Nick Metcalfe, performed an African continental record of 111 cataract surgeries on World Sight Day in 2006. Such feats give a glimmer of hope for the future of blindness eradication in Sub-Saharan Africa.

Sub-Saharan Africa has a decreased ratio of specialist ophthalmic staff compared to other developing settings, and of course, the developed world. (6) Furthermore, ophthalmologists undertake many different roles including program managers, research scientists and teacher. (2) In order to deal with the gross inadequacy of specialist ophthalmologists, auxiliary ophthalmic staff are crucial team members. For example, Kenya has cataract surgeons who are trained primarily in the treatment of cataract, and who do not have formal medical school training. Ophthalmic nurses, most of whom are able to perform surgery for trachoma, are numerous in Ghana and other countries. Furthermore, in Malawi, the presence of ophthalmic medical assistants has reduced the workload of specialist ophthalmologists, by assisting with cataract surgery. Refractionists are trained specifically in reducing the burden of refractive error associated visual impairment, a role that is partly supplied by optometrists in developed settings.

Conclusion
More than 10 years remains before the year 2020. Whilst the framework for successful blindness eradication of avoidable blindness in Sub-Saharan Africa has been paved, the widespread successful implementation of VISION 2020: The Right to Sight is far from complete. Considerable progress needs to be made before we can live in a world in which no one is needlessly blind.

Justin C Sherwin
Faculty of Medicine, Nursing and Health Sciences
Monash University VIC 3800
Australia
justinsherwin@hotmail.com

(1) Resnikoff S, Pascolini D, Etya’ale D, Kocur I, Pararajasegaram R, Pokharel GP, et al. Global data on visual impairment in the year 2002. Bull World Health Organ. 2004 Nov;82(11):844-51.

(2) Lewallen S, Courtright P. Blindness in Africa: present situation and future needs. Br J Ophthalmol. 2001 Aug;85(8):897-903.

(3) Mathenge W, Kuper H, Limburg H, Polack S, Onyango O, Nyaga G, et al. Rapid assessment of avoidable blindness in Nakuru district, Kenya. Ophthalmology. 2007 Mar;114(3):599-605.

(4). Cook NJ, Rogers NK. Blindness and poverty go hand in hand. Acta Ophthalmol Scand. 1996 Apr;74(2):204-6.

(5) http://www.v2020.org/

(6) Foster A. Who will operate on Africa’s 3 million curably blind people? Lancet. 1991 May 25;337(8752):1267-9.

(7) Gilbert C, Foster A. Childhood blindness in the context of VISION 2020–the right to sight. Bull World Health Organ. 2001;79(3):227-32.

(8) Gilbert CE, Wood M, Waddel K, Foster A. Causes of childhood blindness in east Africa: results in 491 pupils attending 17 schools for the blind in Malawi, Kenya and Uganda. Ophthalmic Epidemiol. 1995 Jun;2(2):77-84.

(9) Wormald RP, Basauri E, Wright LA, Evans JR. The African Caribbean Eye Survey: risk factors for glaucoma in a sample of African Caribbean people living in London. Eye. 1994;8 ( Pt 3):315-20.

(10) WHO. Report of the 2nd Global Scientific Meeting on Trachoma. Geneva: WHO:2003. 2003; 2003.

(11) Ng WT, Versace P. Ocular association of HIV infection in the era of highly active antiretroviral therapy and the global perspective. Clin Experiment Ophthalmol. 2005 Jun;33(3):317-29.

(12) Hoechsmann A, Metcalfe N, Kanjaloti S, Godia H, Mtambo O, Chipeta T, et al. Reduction of trachoma in the absence of antibiotic treatment: evidence from a population-based survey in Malawi. Ophthalmic Epidemiol. 2001 Jul;8(2-3):145-53.

(13) Burnham G. Onchocerciasis. Lancet. 1998 May 2;351(9112):1341-6.

(14) Osei-Atweneboana MY, Eng JK, Boakye DA, Gyapong JO, Prichard RK. Prevalence and intensity of Onchocerca volvulus infection and efficacy of ivermectin in endemic communities in Ghana: a two-phase epidemiological study. Lancet. 2007 Jun 16;369(9578):2021-9.

 Farah Apoo compares the management of TB in these two countries

Tuberculosis (TB) remains the most infectious disease worldwide despite the availability of effective vaccines and drugs treatments. In 2005, WHO estimated the number of notifications was still increasing globally especially in South-east Asia and Africa. (1) The slow progress in TB control transpires from inadequate and poorly managed TB treatment. The long duration of treatment, use of multiple drugs with adverse effects and non-compliance all further complicate the management of TB in patients.

(more…)

David Ansari is currently on a Fullbright scholarship in Senegal and here he takes an indepth look at the influence of religion on HIV/AIDS

In a country where less than 2% (1)(2)(3)(4)  of the general population is living with HIV, a statistic that has heralded Senegal as a model country in terms of avoiding the AIDS epidemic, how are people living with HIV/AIDS (PLWHA) perceived?  What is the root of these perceptions, and how can the situation for patients be improved if such perceptions are harmful?  Studies conducted in South Africa and Haiti found that stigma and discrimination have been purported to be less pervasive in areas where antiretroviral medications are more available (5)(6)(7), as is the case in Senegal. Yet a study done in Mali found that stigma experienced by PLWHA may be higher in low prevalence settings and people may be at a higher risk of discrimination if they choose to disclose their serostatus (8).  Perhaps the association of HIV as a deadly illness is not so much the root of HIV-related stigma as is the equation with sexual promiscuity, sin and immorality (5)(9).       (more…)