By Elliot Davis

King’s College London
elliot.davis(a)kcl.ac.uk

In 2005, the World Health Organisation (WHO) estimated that three quarters of all HIV positive individuals in Malaysia contracted the virus through intravenous drug use. Described by the UN as a “concentrated epidemic”, the result was a country failing in its Millennium Development Goal of reversing the spread of HIV/AIDS. Since 2005, however, the Malaysian government has radically altered its approach to managing intravenous drug use in the country. Its previously tough stance has been softened, while needle exchange and methadone maintenance programmes have been piloted and are now starting to be rolled-out across the country. These schemes remain in their infancy, yet recent evidence suggests they are already starting to have a positive impact on HIV infection rates.

HIV and AIDS continue to represent a significant public health risk across South and South-east Asia. Recent estimates by the WHO suggest that there are now around 3.8 million children and adults living with HIV in the region. This means only sub-Saharan Africa has a greater burden of infection, with an estimated 22.4 million individuals being HIV positive [1].

In several South and South-east Asian countries, HIV prevalence rates exceed 1 per cent of the 15 to 49-year-old population. Cambodia (1.6 per cent), Thailand (1.4 per cent) and Burma (Myanmar, 1.3 per cent) are among those most severely affected [2]. In Malaysia, which is often lauded for the quality of its healthcare service, the HIV prevalence rate is much lower at 0.5 per cent. But while this figure is below that of even the United States (0.6 per cent), the country faces its own serious challenge. This is because three quarters of the estimated 69,000 HIV positive individuals living inMalaysia contracted the virus through intravenous drug use [2-3].

The extent of the problem was brought into sharp focus by a United Nations (UN) report in 2005. Reflecting on the country’s progress towards achieving its Millennium Development Goals (MDGs), the UN stated that: “Malaysia has achieved commendable successes towards all the MDGs except in halting and reversing the spread of HIV/AIDS” [4-5]. Branding the problem a “concentrated epidemic”, the report went on to point out that, although the general population was perceived to be at low risk, infection rates among high-risk groups – specifically intravenous drug users (IDUs), sex workers and prison inmates – were bordering on 20 per cent. This figure is forty times higher than the 0.5 per cent prevalence rate reported for the Malaysian population as a whole [2-5].

With its MDG of reversing the rise in HIV prevalence by 2015 under threat, the Malaysian government acted swiftly in a bid to stem the tide of rising infections, sparking a rapid and dramatic turnaround in the country’s previous drug policy.

Prior to 2005, Malaysia had exercised a zero tolerance approach when it came to drug use, declaring it “public enemy number one” and hailing 2003 as a “year of total war against drugs” [6-7].

This tough stance extended beyond mere rhetoric, with one of the government’s main aims being the creation of a drug free society by 2015 [7]. Previous attempts to introduce needle exchange schemes had been dismissed out of hand [6] and drug rehabilitation programmes were overseen not by the Ministry of Health but by the Internal Affairs Ministry, which had a wider remit for national security [8]. Capitalpunishment remained the maximum penalty for anyone convicted of trafficking [9]. Meanwhile, any individual recording a positive urine test for either opiate or cannabis use was likely to face a mandatory two year sentence in a government-run drug rehabilitation centre, followed by a further two years’ probation [6, 10].

To many commentators, this hard line stance resulted in a disjointed approach to not only HIV management but also to health policy in general. First and foremost, there was good evidence that the programmes in place simply didn’t work – with up to 90 per cent of those attending rehabilitation centres going on to relapse [7]. In addition, government policy marked a dangerous precedent in a country where various studies have suggested that up to 43.9 per cent and 89.9 per cent of IDUs are respectively HIV and hepatitis C positive [10-11].

Encouragingly, the evidence to date already suggests that the change in approach is starting to yield results. The Malaysian government has worked with a number of Non-Government Organisations (NGOs) to introduce harm reduction schemes, namely methadone maintenance and needle-exchange projects.

From an initial pilot scheme of three centres in 2006, the needle exchange programme had extended to cover eight of the country’s 13 states by 2008. In the same year, some 1.8 million needles were distributed to more than 12,000 users. Meanwhile, over 7,000 individuals are now registered with central government-run methadone clinics, with a further 10,000 people receiving opiate replacement therapy through private practices [6].

The introduction of methadone maintenance schemes, in particular, seems to have had a major knock-on effect in terms of health benefits. A number of studies from around the world have already suggested that individuals involved in these schemes are more compliant with anti-retroviral treatment (ART) regimens, resulting in improved healthcare outcomes [12-13]. By 2007, up to 25 per cent of Malaysian ART patients were IDUs, marking a sharp rise from the figure of 7 per cent reported in 2003 [6].

Although harm reduction programmes remain a relatively new invention in Malaysia, the progress made so far has been heralded as a step in the right direction. Research from UNICEF suggests that the number of new HIV infections occurring in the country each day has fallen from 17 to ten between 2004 and 2009. There has also been a noticeable drop in the number of these infections associated with intravenous drug use, from the previous 75 per cent to 57 per cent [14] (see Figure 1).

Figure 1: HIV infection rates in Malaysia [2, 14]

Yet there remain problems. A recent article in The Lancet pointed out that IDUs continue to drive the epidemic in Malaysia. Around 1.3 per cent of the population are believed to be IDUs. And although HIV testing is now almost universal amongst these individuals (at close to 100 per cent), just 5.1 per cent said they used a condom during their last sexual encounter. Less than 30 per cent, meanwhile, reported using sterile equipment [15].

Compare these figures with the Ukraine, which is frequently cited as the country in the world with the most significant IDU-driven HIV epidemic, and the extent of the task still facing the Malaysian government becomes clear. Although only 27.6 per cent of Ukrainian IDUs had been tested for HIV in the past 12 months, over 80 per cent use sterile equipment and almost 60 per cent used a condom the last time they had sex [15-16].

The importance of these statistics cannot be over-stated. One recent survey of 526 IDUs not involved in drug treatment programmes across five cities in Peninsula Malaysia reported that 68.6 per cent of those questioned continued to share equipment and that 34 per cent were regularly involved in paid sex. Presciently, the study also identified the sharing of injecting equipment and having multiple sexual partners as the two most significant risk factors for HIV infection [11].

There have also been reports that, initially at least, local anti-drug legislation was slow to catch up with the new approach. Writing in 2007, one group of researchers reported that some pilot methadone maintenance and needle exchange projects had been raided by police with attendees beingarrested [7].

Though there is much work still to do in Malaysia, the results achieved so far do suggest that introducing simple measures like needle exchange programmes and methadone maintenance therapy can have a significant impact on HIV infection rates.

As a result of the initial success of these schemes there appears to be increasing goodwill towards them. Last year alone, the number of government-run health clinics operating needle exchange programmes increased from seven to 12, with RM43.1 million (£9.3 million) being invested in the scheme over a five-year programme. In the coming years, the president of the Malaysian AIDS Council has set a target of granting access to these schemes to a minimum of 60 per cent of IDUs [17].

Time will tell how successful these measures are long-term. However, it could well be that Malaysia emerges as a model of just how effective harm reduction measures can be in curbing the spread of HIV/AIDS in developing nations.

References

1. Joint United Nations Programme on HIV/AIDS and World Health Organisation (2009). AIDS epidemic update: December 2009. Geneva, UNAIDS.
2. United Nations Children’s Fund (2007). The state of the world’s children 2008. New York, UNICEF.
3. World Health Organisation (2007). Country cooperation strategy at a glance: Malaysia [online]. Available:http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_mys_en.pdf [accessed 30 March 2010].
4. United Nations Country Team: Malaysia (2005). Achieving the millennium development goals: successes and challenges. Kuala Lumpur, United Nations Development Programme.
5. United Nations General Assembly (2005). Monitoring the declaration of commitment of HIV/AIDS. New York, United Nations.
6. Kamarulzaman A. (2009). Impact of HIV prevention programs on drug users in Malaysia. Journal of Acquired Immune Deficiency Syndrome 52(S1):17-19.
7. Reid G, Kamarulzaman A, Sran SK. (2007). Malaysia and harm reduction: The challenges and responses. The International Journey of Drug Policy18(2): 136-140.
8. Scorzelli JF. (1992). Has Malaysia’s antidrug effort been effective? Journal of Substance Abuse Treatment 9(2): 171-176.
9. Mazlan M, Schottenfield RS, Chawarski MC. (2006). New challenges and opportunities in managing substance abuse in Malaysia. Drug and Alcohol Review 25(5): 473-478.
10. Chawarski MC, Mazlan M, Schottenfeld RS. (2006). Heroin dependence and HIV infection in Malaysia. Drug and Alcohol Dependence 82(S1): 39-42.
11. Vicknasingam B, Narayanan S, Navaratnam V. (2009). The relative risk of HIV among IDUs not in treatment in Malaysia. AIDS Care 21(8): 984-991.
12. Palepu A, Tyndall MW, Joy R, Kerr T, Wood E, Press N, Hogg RS, Montaner JS. (2006). Antiretroviral adherence and HIV treatment outcomes among HIV/HCV co-infected injection drug users: the role of methadone maintenance therapy. Drug and Alcohol Dependence 84(2): 188-194.
13. Roux P, Carrieri MP, Villes V, Dellamonica P, Poizot-Martin I, Ravaux I, Spire B; MANIF2000 cohort study group. (2008). The impact of methadone or buprenorphine treatment and ongoing injection on highly active antiretroviral therapy (HAART) adherence: evidence from the MANIF2000 cohort study. Addiction 103(11): 1828-1836.
14. United Nations Children’s Fund (2009). HIV and AIDS in Malaysia: Fact sheet. Kuala Lumpur, UNICEF Malaysia Communications.
15. Arasteh K, Jarlais DCD. (2008). Injecting drug use, HIV, and what to do about it. The Lancet 372: 1709-1710.
16. United Nations Regional Task Force on Injecting Drug Use and HIV/AIDS for Asia and the Pacific. (2009). Malaysia country advocacy brief: injecting drug use and HIV. Geneva, UNAIDS.
17. Edwards A. (2009). Needle syringe exchange programme injects hope. The Star, May 2009.

This article has been written as part of the partnership between The Lancet Student and Asian Medical Students’ Association International. The 30th Asian Medical Students’ Conference will be held next week in Taiwan on the theme of ‘Stigmatised Illnesses: To understand, to accept, and to change’. We look forward to hearing about the conference, look out for the conference blog and podcast next week! Alistair Hustig, the Secretary of Academcis – Asian Medical Students’ Association International, has written this fantastic article on the theme.

‘Stamping out Mental Health Stigma’, NHS.

Stigma. This one word often represents the most crucial element effecting people living with a wide range of illnesses. It negatively impacts efforts to treat and prevent disease, and adversely affects individuals’ quality of life. Many illnesses have a high prevalence of stigma including mental illnesses, cancer, leprosy, and sexually transmitted diseases. However, the type of stigma varies with different conditions. This article highlights some causes and differences of stigma associated with mental health and HIV, as well as successful strategies of reducing its impact.

Definitions of stigma encompass social identity (deviance from what is normal), power discrepancies (that allow discrimination), and discrediting attributes that result in devaluation of people living with illnesses, such as those above (1,2,3). This often manifests itself in an external sense as discrimination, hatred, intolerance, rejection, and exclusion. However what is often under-recognised is the internal aspect of stigma. Internal manifestations can include self-loathing, shame, and self-blame, all of which are preyed upon when someone stigmatises (3,4). Stigmatisation can also extend to family, friends, and even to institutions and clinics which themselves perpetuate stigma. As a result anyone associating with patients, or visiting centres, can be dragged into the net of stigma.

People living with Mental Illness
People who have depression, schizophrenia, and other mental illnesses, commonly report stigma from both community and health professionals. Depression is a leading cause of disability effecting 121 million people worldwide (5). Schizophrenia affects millions of people. Of these, only 25% of those with depression, and 50% of those with schizophrenia who are in need of treatment are receiving appropriate therapy (5). These figures suggest that stigma, at least in part, may be having an affect on treatment of mental illness. The perception of depression as a weakness rather than an illness (6); or people with depression are dangerous, and ‘schizophrenics’ are violent (6,7) remains embedded in public opinion. These views are less shared with other common illnesses for example cardiovascular disease. Unlike mental illnesses, cardiovascular disease is less stigmatised at least in part because the aetiology, pathophysiology, and successful treatments are well known. The fear of the unknown may therefore contribute to stigma being ingrained in an illness. As a result people with the illness are afraid of disclosing to family and friends, and do not seek help where it would be of benefit (6). Health practitioners, even those in the field of mental health can also stigmatise through intensive use of language and labelling. Some are more empathic and understanding of the nature of the illnesses, but some practitioners continue to define their patient by their illness. The difference in language is powerful – a ‘schizophrenic’, whose behaviour defines them, versus a ‘person living with schizophrenia’, whose illness causes altered behaviour (7). This labelling may plague the patient as a ‘life sentence’ (7) reducing self-esteem, withdrawing social opportunities, and creating ongoing employment difficulties (8), ultimately ruining any chance of normality.

People living with HIV
It is estimated that around 33 million people worldwide are infected with HIV, with the majority in low- and middle-income countries (9). Of these, only 3 million were receiving appropriate anti-retroviral therapy as at December 2007 (9). Again one of the biggest issues preventing uptake is stigma. However, the stigma signature associated with people living with HIV is different to that explained for mental illness. Bos and colleauges (10) propose a model for stigmatisation of people living with HIV. They describe how perceived contagiousness (everyday contact, not just sex), perceived seriousness (life-threatening), personal responsibility (unsafe sex) and norm-violating behaviour (e.g. male-to-male sex, and intravenous drug use) contribute to increase fear and anger while decreasing pity for people living with the disease. Stigma also surrounds certain groups at increased risk, such as homosexuals, intravenous drug users, and sex-workers. This further stigmatises people living with HIV leading to amplified discrimination and negative social responses. As a result, people living with HIV have a decreased quality of life and are less likely to seek testing, treatment, and counselling, or disclose their status to potential support providers. This can result in advanced presentations with high viral loads, low CD4 counts, and opportunistic infections.

Strategies for Reducing Stigma
The need to address stigma is paramount in order to reduce prevalence and thus burden of illness (e.g. curbing the HIV epidemic), and increase treatment uptake. For mental illnesses, in particular depression, Barney and colleagues (6) suggest that blaming, avoiding, and labelling people living with mental illnesses must be addressed. Accurate knowledge and portrayals of survival and recovery, as well as the true risk to the community for these health conditions needs to be expressed by all means possible, especially the media.

Public disclosure of HIV status has been shown to have a beneficial impact to both the individual and the surrounding community (11). Individuals are often very scared and describe this as the most difficult and dangerous thing to do. Post-disclosure they feel empowered, released from a heavy secret, and less isolated and withdrawn, taking back control of their lives (11). To help facilitate this appropriate training and support needs to be given before disclosing to prepare for potential negative reactions from community members. However, public speaking regarding one’s positive living helps to make the community more aware and dispel myths around HIV, thus reducing stigma. This is echoed by studies involving public speaking by people living with HIV (11) and mental illness (12), which have shown improved attitudes among high school students to those living with the illness. Uniting all people with stigmatised illness would provide a voice that would be far too loud to ignore.

Access to relevant treatment that communities understand is effective and essential in any stigma reduction programme. The case of universal access to HIV therapy in Botswana (which has the 2nd highest prevalence), implemented in 2002, provides clear evidence of reducing stigma (13). Wolfe and colleagues (13) demonstrated pre- and post-implementation that only 31% of people had disclosed positive HIV status to family, and 5% to friends in 2001, compared with 90% and 55% respectively in 2004. Other examples of reduced stigmatising attitudes include an increase in the number of people that would care for a person living with HIV, accept them as a teacher and buy food from a shopkeeper with HIV.

Conclusion
Stigma and its consequences affect the course of illness for many millions of people worldwide. It provides an enormous barrier to all attempts to help people living with stigmatised illnesses. Stigma affects all, it endures, and it compromises survival and recovery of those most in need. We must strive to find new ways to abolish stigma, and thereby allow access to treatment and empowering positive living.

Alistair Hustig, hust0007@flinders.edu.au
Secretary of Academics – Asian Medical Students’ Association International
Australian Medical Students’ Association Councillor
Graduate Entry Medical Programme Year II – Flinders University, Adelaide, South Australia
Bachelor of Medical Science – Flinders University, Adelaide, South Australia

References
1. Joint United Nations Programme on HIV/AIDS (UNAIDS). Reducing HIV Stigma and Discrimination: a critical part of national AIDS programmes. [Online]. 2007 [accessed 20 June 2009]. http://data.unaids.org/pub/Report/2008/JC1521_stigmatisation_en.pdf.

2. Reidpath DD, Chan KY, Gifford SM, Allotey P. ‘He hath the French pox’: stigma, social value and social exclusion. Sociology of Health & Illness 2005; 27(4): pp. 468-489.

3. Courwright AM. Justice, Stigma, and the New Epidemiology of Health Disparities. Bioethics 2009; 23(2): pp. 90–96.

4. Cameron E. Witness to AIDS. Cape Town: Tafelberg Publishers Limited; 2005.

5. World Health Organization. Mental Health: Disorders Management. [Online]. 2009 [accessed: 21 June 2009]. www.who.int/mental_health/management/en/.

6. Barney LJ, Griffiths KM, Christensen H, Jorm AF. Exploring the nature of stigmatising beliefs about depression and help-seeking: Implications for reducing stigma. BMC Public Health 2009; 9(61).

7. Flanagan EH, Miller R, Davidson L. ‘‘Unfortunately, We Treat the Chart:’’ Sources of Stigma in Mental Health Settings. The Psychiatric Quarterly 2009; 80: pp. 55-64.

8. Corrigan P. How Stigma Interferes with Mental Health Care. American Psychologist 2004; 59(7): pp. 614-625.

9. Joint United Nations Programme on HIV/AIDS (UNAIDS). Report on the global HIV/AIDS epidemic. [Online]. 2008 [accessed 20 June 2009]. http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp

10. Bos AER, Schaalma HP, Pryor JB. Reducing AIDS-related stigma in developing countries: The importance of theory- and evidence-based interventions. Psychology, Health & Medicine 2008; 13(4): pp. 450-460.

11. Paxton S. The paradox of public HIV disclosure. AIDS Care 2002; 14(4): pp. 559-567.

12. Spagnolo AB, Murphy AA, Librera LA. Reducing Stigma by Meeting and Learning from People with Mental Illness. Psychiatric Rehabilitation Journal 2008; 31(3): pp. 186-193.

13. Wolfe WR, Weiser SD, Leiter K, Steward WT, Percy-de Korte F, Phaladze N, Iacopino V, Heisler M. The Impact of Universal Access to Antiretroviral Therapy on HIV Stigma in Botswana. American Journal of Public Health, 2008; 98(10): pp. 1865-71.

 Viren Kaul  and Vishala Mishra discuss the need for changes in the social understanding of HIV/AIDS in India in order to effectively combat the epidemic.

An anesthesiologist returned home one day. And unlike most other days, she was disturbed and in anguish. Talking to her son sometime later that evening she let out her pent up emotions -pain, annoyance, hurt and disappointment- words wouldn’t come out of her mouth and it was clear that she had had a harrowing experience that day. She worked at a typical Indian governmental health set-up with a decent- sized patient load. On being constantly prodded by her son, the incoherent stream of words began to flow. It was as though she was reliving the entire experience, which weighed heavily on her mind.

She told her son of a woman who had come to the hospital triage with a threatened abortion. As the doctors hastened to shift her to the OT, the attendant gave a history of multiple pregnancy losses in the past. The present pregnancy, seven months along, was precious to the woman, who was childless, and the attendant begged the doctors to save the child. Shortly, as the doctors gloved up, an on-the-spot HIV test came back positive the woman was found to be HIV positive by a rapid test. As the doctors managed to stall the abortion and put her on treatment, the focus shifted to how she had acquired the infection.

A married woman of eight years, the patient was interrogated in detail for any means by which she might have acquired the deadly virus. With all known routes of transmission ruled out and the lady pledging to not having been unfaithful, the spot light fell on the obvious source: her husband. On being summoned to attend the HIV counseling service the next day, the husband, on much cajoling, revealed that he had had the virus for more than a few months and knew this. He told the counselors that he worked at a call center and had a night shift, and that the job and the mounting pressure on him had taken its toll and he had turned to engaging in multiple unprotected  sexual encounters at work. Most disappointing of this tale was the fact that the man was an engineering graduate from a well known engineering college in India. And with this the counselors realized that the reckless man had managed to knowingly endanger three lives – that of his “faithful” wife, their unborn child’s and not the least his own.

India currently has had many awareness and education campaigns to raise the knowledge levels of HIV amongst its population. The government has even established the National AIDS Research Institute to deal with all aspects to HIV spread and treatment in India, including the social initiatives in this regard. The amount of health budget allocated to HIV related issues is also phenomenal. So the question arises – why is it that with both general and specific programmes targeted at high risk groups, unprecedented use of mass media, and the huge setup of Anti-Retroviral Treatment centers and Voluntary Counseling and Treatment Centers, do we have such unfortunate cases coming up? Many, like the anesthetist, blame a basic lack of morals as the reason to the increasing prevalence of HIV pandemic in India. However, is this the only answer?

Before we attempt to answer the question, here are a few facts -– A recent study by Dr. B. L. Nagda on AIDS awareness in an Indian slum attempted to shed light on some of these questions. The study revealed that a large number of people are not aware of how HIV/AIDS is transmitted. Large numbers of women are unaware of the risk of mother- to-child transmission. In addition, the very low proportion of respondents receiving information from a health worker or teacher points to a serious deficiency in HIV education. These facts have been highlighted in a study – Awareness about AIDS in slum dwellers of Udaipur district in India. (1)

Clearly, as can be seen from the case study, education, per-se is insufficient, for, the HIV infection rate has remained stubbornly high, despite the massive efforts taken by the government and NGOs. Experience over years has pointed to a well established fact that indicated that the public needs not only information, but also need to be enlightened about the social, economic, emotional and mental burden the disease carries besides its 100% fatality rate. They need to understand the fact that dealing with the virus has responsibilities and this is possible only when such information is part of the general programme.

What can also be safely inferred from the above discussion is that with the change in the dynamics of AIDS pandemic, and the changing social fabric; people’s need for information has also changed. Maybe, a strategy based on empowering people to be able to negotiate safer sex with their partners, and attempting to revamp the societal perceptions of sexuality, and urgently addressing the gender imbalances prevalent will serve to bridge the now deep chasm between “hearing slogans” and “effecting a positive behavioral change”. People need to be involved in the education process- and explore actively what the newly gained knowledge- in terms of the socio-economic, and emotional ramifications of the disease- means for them on a personal level.

Educational programmes have to be restructured to convey mixed messages- while on the one hand the grave risks and dangers of transmissibility of HIV by casual sexual contact or sharing of needles needs to be emphasized, on the other hand the insignificant risk of being infected by the virus through breathing “contaminated air”, “or touching the sweaty hands of an infected patient” has to be equally strongly and reassuringly emphasized.

The solution, therefore, does not lie in only distributing condoms, setting up counseling and drug-dispensing units, putting ads in the mass media, making policies, setting up help groups and other such initiatives, but in a very basic method – and arguably the only effective method – bringing about life-style change amongst people.

That would mean, for example, not only encouraging high-risk groups like truck drivers to use condoms and make use of the HAART drugs available, but finding out why in the first place they engage in such activities. Reaching out to the most basic level from where such high risk tendencies arise is the surest way of making certain that people utilize all the services that the governments and the NGOs are providing. In the absence of such pre-service utilization behavior priming, any well-intentioned effort will not have their desired or potential result.

Sadly, the attention given to anticipating the long-term consequences of a health policy decisions is inversely proportional to the perceived short-term urgency of the situation in which the decisions are made.

The change in people’s thinking patterns needs to be initiated at the grass roots level. The social pressures, work pressures, domestic problems, and economical issues need to be addressed as a priority before people can accept the measures being doled out now. The initiatives need to be specific to the situations of the public. This would include such initiatives as a support system for everyone that from students in colleges to call center workers to truck drivers to prostitutes. The initiative should be able to answer the basic fault with the situation that causes people to behave in a manner makes them adopt risky behavior. At a more detailed aspect, in order for these initiatives to be adopted and to bring about a life-style change in high risk groups, the ever important and menacing problems in developing countries will need to be tackled beforehand. Unemployment and the resulting poor socio-economic status, poor living conditions, population explosion, social evils (such as child marriage, dowry system, gender inequality), poor social support for single women, ineffective legal measures, illiteracy and poverty are only a few to name. It is obvious that the unfortunately mammoth proportions of the HIV pandemic are in no means independent of these problems.

Also, treatment of HIV will cost dearly to the society in the long run. This is expected to skew the ratio of health resources distribution in a developing country, already burdened by other diseases, with a greater priority for preventive health programmes, including programmes for AIDS, as well as immunization, nutrition. This should be with a specific emphasis on other primary health care programmes only with this can we expect to actually benefit the society from the HIV oriented programmes. In isolation, the HIV related programmes will only fail and that would be disastrous.

As much as the solution lies in medication and provision of facilities, the pandemic will only ever be truly defeated if we address the problems faced since time immemorial, since it is there that the true cure lies.

“What the mind does not know, the eyes won’t see,” is what the anesthetist told her son at the end. Maybe all that was on her mind when she said that was “Will the present efforts defeat HIV?” Or maybe all that she meant to say was that untill we eradicate the basic problems affecting people, we won’t be able to hinder the march of HIV for much longer.

Viren Kaul is a final year medical student at the Karnataka Institute of Medical Sciences in India.

Vishala Mishra is a second year, medical student at the Madras Medical College in India.

REFERENCES:

1. Nagda BL. Awareness about HIV/AIDS among Slums dwellers of Udaipur District. Population Research Centres, Ministry of Health and Family Welfare, India. http://72.14.235.132/search?q=cache:TDTu04htHAgJ:prcs-mohfw.nic.in/writereaddata/research/546.doc+Prasada+Rao+J.R+et+al.+(2004),+‘India’s+response+to+the+AIDS+epidemic’,+The+Lancet,+vol.+364,+no.+9442,+October

Background information from

• Woolley, P (1993) Promoting sexual health in general practice , British Journal of Sexual Medicine November/December: 4-5

• UNAIDS and WHO (1999) AIDS Epidemic Update: December 1999. Geneva: Joint United Nations Programme on AIDS and World Health Organization.

• Godley, M.J. (1993) the management of sexually transmitted diseases in pregnancy. Medicine International 21(3):74-81

• The Lancet (2003) ‘Spreading the word about HIV/AIDS in India’, Vol.361, May 3

• Panda S. (2002), ‘The HIV/AIDS epidemic in India: an overview’, in Panda S., Chatterjee A. and Abdul-Quader A.S. (Eds.), ‘The epidemic and the response in India’, p.20

• Prasada Rao J.V.R et al. (2004), ‘India’s response to the AIDS epidemic’, The Lancet, vol. 364, no. 9442, October 9-15 2004

Mr Kapil Sugand and Dr Alexander James Hills express their views about the need for altruism within students in relation to the development of a HIV vaccination.

While numerous infections have plagued mankind for millennia, the HIV outbreak emerged less than three decades ago. However in this time, HIV has evolved from a small epidemic to one of the most devastating pandemics in modern history. In doing so, it has managed to gain attention from governments, global media, and the general public on a scale that no other disease has seen before.

Over 35 million people are currently living with HIV/AIDS and approximately 7,000 additional individuals are infected each day worldwide (1).  While HIV has become a manageable condition in the developed world, it is still decimating developing countries.  In developing nations, still striving for basic access to water, equality and freedom, access to essential HIV treatment is definitely lacking.  Firstly, the high cost of HIV ‘Highly Active Anti-Retroviral Treatment’ is a key reason why less than 10% of people with HIV have access to antiretroviral therapy (2).  Secondly, even in those receiving treatment, HAART is unable to fully eradicate latent HIV-1.  Thirdly, the other issues associated with HAART treatment include the threat of drug resistance and adherence problems to name a few.

A large proportion of medical students enter medical school with a sense of a ‘greater calling’ and the intent of leaving behind a legacy.  However, such a quality tends to gradually fade away during the progression in medical school after being sidelined by responsibilities, studies and relationships.   Often the more motivated students invest their electives in basic missionary work on the African, Asian and South American continents with the hope of helping reduce the burden of HIV/AIDS.   Unfortunately, most of these students are restricted from helping effectively by their lack of experience, and leave their elective feeling that their overall impact in tackling HIV was minimal.  

So how can we as medical students combat HIV/AIDS?  If going abroad has limited value, how can we contribute to the advancement of HIV treatment in our own home countries? We have a controversial suggestion…

To circumvent the problems with drug treatment, one of the major internationally-recognised Millennium Development Goals is to find an HIV vaccine (3).  In an attempt to meet this goal over thirty HIV vaccination trials are currently in development (4).  However, many of these HIV trials have their progress slowed by the lack of control subjects. With the help of altruistic volunteers, researchers would be one step closer to developing this necessary ‘magic bullet’ in the eradication of HIV. This is where students, for instance, could make all the difference. Even if a vaccine does not turn out to be a definitive cure due to the adaptability of the virus, it could be a valuable tool in turning the tide of this pandemic.

Presently there are more opportunities to get involved in research and clinical trials than ever before. Despite a small increase in the risk of contracting HIV in control subjects, through consequential unsafe sexual practice, the side effects from these vaccination trials are few. More importantly, the HIV Vaccine Trials Network (5) informs prospective volunteers that there is no risk of contracting HIV from such vaccines. It is important to be critical of this guidance as the Washington Post (6) have reported that the clinical trial using Merck & Co. vaccines may have led to increased rate of HIV infection in vaccinated test subjects.   Especially considering the potential problems of getting a career-damaging false positive HIV test result, and the fact that medical students are especially vulnerable to coercion and manipulation into joining trials this is a commitment not to be taken lightly (7).

We feel, for once, that medical students have the power to influence history. As Nelson Mandela once said ‘We must use time wisely and forever realize that the time is always ripe to do right’. Making HIV history is certainly feasible; making it a reality is up to us. If ever in doubt about the benefits of helping out with HIV research, just ask yourself these following questions: If not here, then where? If not now, then when? If not you, then who?

Kapil Sugand is a medical student at Imperial College School of Medicine, London, UK

ks704@imperial.ac.uk   

Dr Alexander James Hills is currently working at Charing Cross Hospital, London, UK

ajh502@imperial.ac.uk  

References:

(1) Need for a Vaccine, IAVI – International AIDS Vaccine Initiative [homepage on the Internet]. Unknown. 2008 [Cited 29/08/2008] Available from: http://www.thelancetstudent.com/wp-admin/www.iavi.org/viewpage.cfm?aid=7

(2) Global Citizen Corps: HIV/AIDS, Mercy Corps, [homepage on the Internet]. New York, USA. 2008 [Cited 29/08/2008]. Available from http://www.thelancetstudent.com/wp-admin/www.globalcitizencorps.org/issues.htm?page=issues_hivaids

(3) United Nations Millennium Development Goals [homepage on the Internet]. New York, USA. 2000-2008. [Cited 29/08/2008]. Available from http://www.thelancetstudent.com/wp-admin/www.un.org/millenniumgoals/

(4) England R. The writing is on the wall for UNAIDS. BMJ 2008 May 10;336(7652):1072.

(5) HIV Vaccine Trials Network [homepage on the Internet]. Washington, USA. Unknown. [Cited 31/08/2008]. Available from: www.hvtn.org/community/hvad.html

(6) Timberg C, Warning Is Sent to AIDS Vaccine Volunteers. Washington Post, 2007 Oct 25; A20. Available from: www.washingtonpost.com/wp-dyn/content/article/2007/10/24/AR2007102402514_pf.html

(7) Christakis N. Do medical student research subjects need special protection? IRB 1985 May-Jun;7(3):1-4.

Rebecca Bartlein writes about her concerns with the reauthorization bill for PEPFAR in relation to its ability to prevent the transmission of HIV/AIDS.

Federally funded reproductive health education curriculum in the United States has changed dramatically in the past decade with the passage of Title V, Section 510 of the Personal Responsibility and Work Opportunity Reconciliation Act in 1998 (1).  Title V, Section 510 authorized $50 million annually from the federal government for abstinence-only sex education programs in public schools across the country (2).  Currently the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, commonly known as the reauthorization bill for PEPFAR (the U.S. President’s Emergency Plan for AIDS Relief (3)) is making its way through congress.  However I am personally angered to see that not only has the Bush Administration let ideological considerations supersede public health and ethical concerns in our own health education system but is continuing to export this ideology as one of the strings attached to PEPFAR aid money. Currently, PEPFAR allocates a third of its funds for abstinence-only sex education as a means to prevent HIV, and encourages youth education about condoms only when emphasizing the failure rate of these prophylaxes. Although the language in the current reauthorization act is not as specific, little change in programming will occur unless PEPFAR has specific stipulations for including comprehensive reproductive health education for young people.

The evidence that the abstinence-only educational model is not appropriate has been presented in many studies in the U.S. (4).  Studies have been done to evaluate how closely the sexuality education curriculum in Title V programs follows what parents/taxpayers want and expect in terms of sexuality education for their children. One such study by researchers at the University of North Carolina – Chapel Hill showed that 89% of parents across North Carolina supported comprehensive sexuality education and more than 90% of respondents felt that parents and public health professionals should determine sexuality education content, not politicians (5).   This study surveyed 1306 parents across the state of North Carolina, where there are mandated abstinence-only sex education programs. Additionally, multiple studies have shown that abstinence-only sexuality education is not effective at lowering rates of teenage pregnancy or STI/HIV infection (6)(7).  In fact, the official evaluation commissioned by U.S. Congress showed no difference in sexual behaviors between youth who had access to the abstinence-only program and a control group that had no access to any sexuality education program (8).  These findings do not bode well for the reputation of abstinence-only education, and yet, the administration refuses to acknowledge its failed policy and continues to push its ideological product in the face of solid facts. 

So now, countries that are faced with the HIV pandemic and who are looking to the international community for support and funding are forced to accept the strict ABC (A – Abstinence, B – Be Faithful, C – Correct and Consistent use of Condoms where appropriate) approach to HIV prevention in order to receive PEPFAR aid. Unfortunately, twice the amount of emphasis is put on the A and B of the program, which reach over 41 million, than on the C goal, which is only directed to reach 16 million (9).  In PEPFAR programs, condoms are only promoted to those considered “high risk” such as sex workers, truck drivers, discordant couples, etc. despite the fact that in most PEPFAR countries the epidemic is generalized throughout the population (10).  PEPFAR funds may not be used to promote or distribute condoms to youth or in school settings, and abstinence and faithfulness are the only methods discussed with youth in order to prevent disease and unwanted pregnancies. In fact, PEPFAR implementing agencies are discouraged to educate youth about condoms at all unless it is to emphasize their failure rates and often this manifests in messages that condoms are not reliable enough to make them worth using or that they often have holes in them (10).  The result is that people have less accurate information about condoms, which would lead them to use them less, but results in no change in sexual behaviors.

Despite strong scientific evidence that an abstinence-only approach to sexuality education does not lead to the desired results of lower STI/HIV infection rates and fewer early unplanned pregnancies, the U.S. continues to export this intervention through its PEPFAR requirements. While programs should be tailored to fit the cultural and epidemiological specificities of the populations that they aim to reach, in no situation should ideology supersede scientific findings. If the United States wants to protect its reputation as a leader in the fight against the HIV epidemic, it needs to start basing policy decisions on clear and rigorous bodies of medical and scientific evidence. All young people, no matter where they are, “need accurate, positive and comprehensive information about safer sex and condoms because they are already sexually active or will be in the future.”(10).  With its dissemination of billions of dollars, the federal government must begin to support comprehensive programs and education that will actively lower the risk of youth developing STIs, HIV and unwanted pregnancies – by taking into account the realities of youth’s behaviors and culture both at home and abroad.

Rebecca Bartlein is a MPH Candidate studying within the Department of Global Health at the University of Washington

bartlein@u.washington.edu

(1) “Title V, Section 510 Abstinence Education Program has allocated $50 million annually for programs that teach abstinence from sexual activity outside of marriage as the expected standard for school-age children.” C. Trenholm, B. Devaney, K. Fortson, L. Quay, J. Wheeler, M. Clark. Impacts of Four Title V, Section 510 Abstinence Education Programs Final Report April 2007. Mathematica Policy Research, Inc.

(2) Abstinence-only education for youth is defined as a program that: 1) Has as its exclusive purpose teaching the social, psychological, and health gains to be realized by abstaining from sexual activity; 2) Teaches abstinence from sexual activity outside marriage as the expected standard for all school-age children; 3) Teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems; 4) Teaches that a mutually faithful monogamous relationship in the context of marriage is the expected standard of sexual activity; 5) Teaches that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects; 6) Teaches that bearing children out of wedlock is likely to have harmful consequences for the child, the child’s parents, and society; 7) Teaches young people how to reject sexual advances and how alcohol and drug use increase vulnerability to sexual advances, and 8 ) Teaches the importance of attaining self-sufficiency before engaging in sexual activity. C. Trenholm et al.

(3) Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008.

(4) Ethics, Ideology, and Reproductive Health Policy in the United States. Andrzej Kulczycki. Studies in Family Planning Vol. 38 Number 4 p. 333-351. December 2007.

(5) “We defined comprehensive sexuality education as education that includes a discussion of how to use and talk about contraception with partners.” K. Ito, Z. Gizlice, J. Owen-O’Dowd, E. Foust, P. Leone, W. Miller. Parent Opinion of Sexuality Education in a State with Mandated Abstinence Education: Does Policy Match Parental Preference? Journal of Adolescent Health. 2006 Apr 28; 39(5): 634-641

(6) The Content of Federally Funded Abstinence-Only Education Programs. Prepared for Rep. Henry A. Waxman. United States Committee on Government Reform – Minority Staff Special Investigation Unit, December 2004. Permanent URL:  http://oversight.house.gov/documents/20041201102153-50247.pdf

(7) Pamela K. Kohler, R.N., M.P.H., Lisa E. Manhart, Ph.D., and William E. Lafferty, M.D. Abstinence-Only and Comprehensive Sex Education and the Initiation of Sexual Activity and Teen Pregnancy. Journal of Adolescent Health. 2008 Aug; 42: 344-351.

(8) C. Trenholm et al.

(9) Accountability: Report on PEPFAR Partnerships for Prevention, Treatment and Care. Permanent URL: http://www.pepfar.gov/press/fourth_annual_report/99832.htm.

(10) G. Gordon, V. Mwale. Preventing HIV with Young People: A Case Study from Zambia. Reproductive Health Matters. 2006; 14 (28): 68-79.

Shawn Ellis writes on the role for male circumicision in reducing transmission of HIV. 

Male circumcision is the partial or entire removal of the foreskin (prepuce) from the penis (1). It is a common procedure throughout the world and is usually performed due to religious, social, cultural or medical reasons. 30% of men globally are circumcised and the procedure has a low complication rate of 0.2 – 0.6% (1). Recently, the practice has received interest as a potential means of limiting the spread of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs); however, this has raised concerns about the ethics of promoting male circumcision as a preventive measure and whether or not it would undermine current efforts to educate people about HIV prevention and sexual health. (more…)

Heather Zimba writes the epidemiology of HIV/AIDS in China and the government response to its spread. 

It is estimated by the Chinese Ministry of Health, UNAIDS and WHO that in 2007 there were between 550,000 and 850,000 HIV/AIDS positive cases and 80,000 to 90,000 AIDS patients in China. (1) However, due to under-reporting as well as inaccurate reporting by Chinese officials, the actual number of persons testing positive with HIV/AIDS is unclear. (2) Historically HIV/AIDS was most prevalent in intravenous drug users, commercial sex workers, blood donors, migrant workers and men having sex with men (3) with the main means of transmission being though contact with contaminated blood products and the sharing of needles by injecting drug users. (1) Furthermore, the epidemic was primarily isolated to western and southern providences. (4) Currently, however, HIV/AIDS has been reported among the general population in all 31 Chinese providences and autonomous regions (3) and a major means of transmission is now through sexual contact. (1) Given that in China many people continue to participate in high risk sexual behavior; there is a large migrant population, (5) the use of condoms is low among commercial sex workers (6), and there is a general lack of knowledge about HIV/AIDS, the potential for the rapid spread of HIV/AIDS is a real threat. As a result, there is a clear need for the Chinese government to take an active and aggressive role in combating HIV/AIDS. (more…)

Christian Ramers writes on the disparity between research advances in HIV treatment and what treatment is actually available.

In a recent keynote speech at the 48^th annual meeting of the Infectious Diseases Society of America, Dr. Kevin DeCock, HIV/AIDS director at WHO noted, “paradoxically, [anti-retroviral] drugs are most available where the diseases are the least prevalent.”  Referring to the stark differences in the variety and availability of highly active anti-retroviral therapy (HAART) in the developed and the developing world, DeCock alluded to the great paradox of the AIDS epidemic, that despite amassing substantial knowledge in treatment and care, it has yet to be thoroughly implemented in the populations which need it the most.  (more…)

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

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.

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