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.

(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.

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…)

Nicholas Gavin and Lara Bishay describe their visit to the Bomu Medical Centre

When HIV/AIDS emerged in the early 1980’s, its burden lay disproportionately with the poor. This generalization still stands today. While the pandemic has had its greatest impact in sub-Saharan Africa it has also scarred South East Asia, the South Bronx in New York, and Brixton London. These low income areas continue to bear the brunt of HIV/AIDS. This is an account of our visit to Mombasa, Kenya, before the recent violence. (more…)

 Rishi Rattan and Chris Curry discuss the medical and social impact of using microbicides to prevent HIV in low-income countries

Think of the birth control options you saw during reproductive health lectures.  Imagine if those gels, rings, diaphragms and cervical caps were able to reduce the risk of sexually transmitted HIV.  They’re effective, cheap, accessible and discreet.  The desire to have children with one’s sero-discordant partner, or the inability to negotiate condom use, would no longer mean exposing  oneself to HIV without protection.  These are concerns that many women face daily.  In sub-Saharan Africa, women make up the majority of those living with HIV; in some areas, they are three times more likely to be infected than men their age. (1) (more…)

Jonathan Currie, Laura Mason, Eleanor Southgate, Yolande Squire
Intercalating Medical Students International Health BSc, Centre for Child & Adolescent Health, University of Bristol, Bristol BS6 6JL, UK

The current HIV epidemic in South Africa stands as one of the most severe in the world. In 2005, 5.5 million people were living with HIV and 320 000 people died from HIV/AIDS, more than 875 lives per day ¹. Moreover, there are no signs of the epidemic reaching a plateau. Stark differences exist in the proportion of men and women affected; young women (aged 15-25 years) are approximately four times more likely to be infected than men.¹

(more…)

Dr. Joris Hemelaar
Final year graduate-entry medical student. Magdalen College, Oxford University. joris.hemelaar@medschool.ox.ac.uk

Last month a large-scale clinical trial of a candidate HIV vaccine started in South Africa.¹ The four-year study plans to enrol 3000 HIV-negative sexually active men and women at five sites throughout South Africa, making it the largest African HIV vaccine trial to date. In South Africa, the trial is called Phambili, which means “moving forward” in the Xhosa language.

(more…)