Category Archives: HIV/AIDS

What’s happening to Kenya’s first generation born HIV-positive?

On May 30, 2012 I posted an article under the title ‘What’s happening to Kenya’s first generation born HIV-positive? As Kenya observes 2015 World AIDS Day today this question remains as relevant as when it was put up.

To what extent are the issues facing that generation better defined and addressed today? Among the challenges earlier mentioned were the following: Emotional problems- especially coping with the late discovery that they are HIV positive; their care considering many of them are orphaned; fear of stigma which may interfere with their adherence to drugs, etc, etc.

Society forces me to live two lives, one of which – the one where I’m honest about my status – I have to keep completely secret from the other one. It’s partly because I have to live this life of shame and secrecy that I find it so hard to take my meds….I’m angry about the stigma in society that makes me have to lie about my status”.

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‘What if the HIV epidemic first manifested in poor countries?’

Japheth Mati

This week’s call by Doctors Peter Piot, David Heymann and Jeremy Farrar urging US authorities and WHO to make available for African Ebola patients, the same treatment already given to the two American missionaries, Dr Kent Brantly and Nancy Writebol, reminds me of the above question I raised in a blog I wrote in 2012.

In the article I compared the unprecedented brisk response to the HIV epidemic with the dilatory reaction to the so-called ‘neglected tropical diseases’. The contrast is regrettably dependent on who the patient is: the high profile wealthy and powerful versus the poor and powerless.

I believe it is because of the former that within less than a decade of the first AIDS case in San Fransisco, several drugs had received FDA approval. In other words, authorities were prepared to ‘bend rules’ in order to permit early availability of life-saving treatment.

Now Dr Piot and colleagues tell us that there are in fact several drugs and vaccines under study that could be used to combat the disease.

In a desperate situation such as in the West African countries, it is difficult to imagine what else makes the relevant authorities not ‘bend rules’ as they did previously, to avail experimental treatment where it is needed the most?

Medical practice changed for ever the moment AIDS arrived

Treatment Action Campaign activists in Cape Town South Africa, June 2012

 

The AIDS epidemic has changed practically every aspect of medical practice; from the way we view the disease, the accelerated global research to discover diagnostic tools, to unprecedented drug approval processes and speedy distribution and utilisation of new drugs. To date, manifestations of the AIDS virus are dealt with in practically all branches of medicine; unlike in the early years of the epidemic when cases were largely found in medical (internal medicine) wards, and even there they were isolated from the general patient population.

For example, the first AIDS cases admitted at the Kenyatta National Hospital were isolated in small dark cubicles in selected medical wards, often much against the wishes of the consultants in charge of the wards. No one physically touched the patients and medicines were placed on a stool and pushed inside the room by a nurse who stood clear of the door. Supposedly, the patient would reach the stool from his bed and collect not only the medicines, but also something to eat. When they died the corpse was placed in a black body-bag into which copious amounts of formalin would be poured. Relatives were not permitted to take the bodies for burial lest they spread the disease; the bodies had to be incinerated.

The AIDS virus has received the greatest attention of all time in medical history, more than any other pathogen; it has been as challenging to medical doctors, biomedical and social scientists, economists, theologians and philosophers alike, the pharmaceutical industry and drug regulatory authorities. Indeed, it is the combined effort of all these disparate groups and their quest to understand the disease that finally has shed some light at the end of the tunnel. As a result, today AIDS is not as perplexing as it once used to be. Within a span of under three decades HIV infection has changed from a death sentence to a chronic disease (at least where antiretroviral drugs-ARVs are readily available). This is unprecedented in medical history. For example, it took more than 400 years from the first recorded outbreak of syphilis in Europe (1494/1495) to identification of the causative organism, Treponema pallidum, in 1905 and discovery of the first effective treatment (Salvarsan) in 1910, before the wider availability of Penicillin in 1946. In contrast, the virus that is associated with AIDS was first identified by Montagnier et al. in France in 1983 and by Gallo et al. in the US in 1984, and within less than a decade, several drugs had already received FDA approval.

AIDS hit the world in 1981, first in California and New York in the United States. In 1982 the Centers for Disease Control (CDC) coined the term ‘acquired immunodeficiency syndrome’ (AIDS) and identified four “risk factors”: male homosexuality, intravenous drug use, Haitian origin, and hemophilia A. In 1983 a major outbreak of AIDS was reported among both men and women in central Africa, prompting the CDC to add female sexual partners of men with AIDS to its list of “risk groups”. Shortly afterwards, a history of blood transfusion and  female sex workers were added to the list, and before long the disease became a threat to all segments of society—though it still remains largely concentrated within the poorer and marginalised groups.

Kenyan Aids activists in Nairobi take their campaign in support of the Global Fund to the streets. Photograph: Sidi Sarrow

Amongst the significant impacts of AIDS on the practice of medicine, three can be pointed out, namely, increased precautionary actions by health care workers, safer blood supply (for blood transfusion), and disease activism. Specifically, the AIDS epidemic has impacted on medical practice in the following ways:

Safer infection prevention practices: Today health care workers have to treat all cases as being potentially infectious, and have to observe standard guidelines on infection prevention- to guard against cross-infection between cases, as well as protecting themselves from being infected by their patients. Hospital hygiene and safe injection practices, previously neglected in much of the developing world, have become topics of global concern. There are written instructions on how to handle blood and other bodily fluids, including the use of sterile gloves when handling blood and other body fluids, double gloving during surgery and wearing of visors to protect eyes from splashed blood. Health care workers are trained on safe handling of used needles and surgical blades (sharps), and there is a total ban on re use of syringes and needles. Hospitals would normally maintain registers of needle prick (stick) occurrences and administration of post-exposure ARV prophylaxis (PEP), etc. is administered to the staff involved.

In most countries today blood for transfusion is safer than previously. There has been more careful screening of blood for transfusion- to include besides HIV and syphilis- hepatitis B, A and C, malaria and other pathogens depending on the technological capability of the lab. This has been facilitated by creation of regionalised blood transfusion centres with capability for safe storage of larger volumes, and in contact with hospitals in the catchments areas.

The major challenge in countries like Kenya is ensuring sustained flow of resources to enable supply of the essential items needed for the above. Among the complaints raised by nurses and doctors in recent months are the lack of basic supplies such as protective gear- gloves, gowns and disinfectants. We must guard against slipping back to the days when gloves, syringes and needles were reused- as late as in the early 1990s! Fear of contracting HIV infection may influence choice of career. There have been anecdotal reports that today medicine is no longer the first choice for ‘A’ students in Kenya. A 1988 survey of house officers in the US, 25 percent of all respondents reported that they would not continue to care for AIDS patients if given a choice, while another study in 1991 reported that half of all primary care providers would not treat AIDS patients if they could avoid it[i]. A more recent study shows there is reluctance on the part of some nursing students in some regions of the world to provide care for people with HIV/AIDS, and recommends that educational programmes based on research evidence must play a leading role in developing strategies to help nursing students understand and overcome such attitudes[ii]. However, many would believe things have changed a lot for the better since then.

Disease activism:  In no other disease has there been as much advocacy as in the case of AIDS. For example, the response to the continuing presence of the so-called neglected tropical diseases (NTDs) stands in sharp contrast to the unparalleled achievement in addressing the HIV epidemic. Yet these diseases continue to cause massive but hidden and silent suffering, and frequently kill, largely because the people affected or at risk have little political voice. On the other hand, as mentioned above, the first cases of AIDS reported in the US involved highly educated men, many from the upper echelons of the American society. They soon realized their plight and, through a strong well organized lobby movement, fought hard for public attention and support of the search for ‘cure’. Within less than a decade their advocacy started bearing fruit. Patients also became more active participants in the research and drug development, sometimes not just being study subjects but actively helping in design of clinical trials.

Disease activism has played a major role in quickened drug approval processes, which was almost unheard of before AIDS patients spoke up, and is now becoming common among a whole range of other illnesses, including breast cancer. Although the strongest AIDS activism in Africa has largely been concentrated in South Africa, organised groups of PLWHA in other countries are increasingly becoming vocal in demanding increased access to ARVs as well as to TB and Malaria treatment. One area of success for global disease activism is increased availability of low priced generic drugs

Spill-over effects of research: Funding for AIDS research has surpassed expenditures for any other disease. According to UNAIDS in 2008, an estimated US$15.6 billion was spent on HIV and AIDS compared to US$300 million in 1996. However, a 2010 UNAIDS report warned that flattening of global funding for HIV research may limit ability of researchers to move promising approaches forward, especially in search for a vaccine.

The extensive research connected with AIDS has spilled over into a greater understanding of other chronic diseases especially cancer. Sexually transmitted diseases research, prevention and treatment is another area that has received renewed attention since AIDS, as sexual and reproductive health gained renewed prominence. The frequency with which Tuberculosis occurs in HIV-infected persons has led [1]to a resurgence of interest in the diagnosis and treatment of this ancient disease, while advances in the treatment of HIV-associated Opportunistic Infections have benefited other immune-suppressed persons.

Scientific advances have resulted in the development of lifesaving, albeit not curative, treatment for HIV. By the end of 2009, more than 5 million persons in low- and middle-income countries were accessing Antiretroviral Therapy (ART), unimaginable just a few years before and made possible through the use of generic drugs, price reductions for brand-name drugs, and efforts of international donors through initiatives such as the US PEPFAR and the Global Fund. The increasing availability of highly effective ARVs have transformed the way doctors look at HIV infection, and so too has terminal care changed. What had previously been an emphasis on simply maintaining life is increasingly shifting to give greater weight on quality of life, comfort and individual productivity.

Research on the prevention of mother-to-child transmission of HIV has led to interventions with the potential to virtually eliminate HIV disease in children (i.e. HIV-free generation). This should have a bearing on doctors’ attitudes towards childbearing for those infected with HIV, including investigating them for infertility. Research has identified viable options for HIV prevention in intravenous drug users, such as opioid substitution therapy and needle/syringe exchange.

Diminishing stigma: There was a time when doctors that treated AIDS cases were stigmatized and shun by other colleagues and patients. Even Hospital administrations quietly tried to discourage doctors from taking too many AIDS patients because it affected their facilities’ bottom lines. Today this is generally the least of their concerns. Even Insurance companies have opened up to people living with HIV albeit at much higher premium.

Typically, it has taken AIDS to bring the existence of marginalized groups such as sexual minorities to attention in low- and middle-income countries and to highlight their vulnerability and needs. They belong to what have been referred to as the ‘most at risk populations’ (MARPs), that include sex workers and their clients, men who have sex with men (MSM), and people who inject drugs (IDUs). It is recognised that failure to address these groups will compromise efforts towards reduction of new infections. As such it is unrealistic to operate as though they do not exist!

On the future: There is no better way of summarising the future of AIDS than to quote Dr Kevin M. De Cock, Director of the Center for Global Health at CDC in Atlanta: “Inevitably, the story of HIV/AIDS ‘could not be one of final victory. It could be only the record of what had to be done, and what assuredly would have to be done again in the never-ending fight against terror and its relentless onslaughts.’ An enduring frustration is that we will not know how the story of AIDS will finally end because the epidemic will outlast us. Yet the tide can be turned with principled pragmatism, adequate resources, trust in communities, and science as our guide”


[i] Infectious Disease News, June 2011, Infectious disease and the evolution of AIDS Thirty years since “patient zero,” how the world’s worst epidemic forever changed the specialty. http://www.healio.com/infectious-disease/hiv-aids/news/print/infectious-disease-news/%7BC1A89E60-E999-4FAB-A0FE-9DC54FD9AEED%7D/Infectious-disease-and-the-evolution-of-AIDS

[ii] Pickles D., King L. & Belani I. ( 2 0 0 9 ) Attitudes of nursing students towards caring for people with HIV/AIDS: thematic literature review. Journal of Advanced Nursing 65(11), 2262–2273. doi: 10.1111/j.1365-2648.2009.05128.x

 

What’s happening to Kenya’s first generation born HIV-positive?

Globally, there is a general lack of awareness of the health and social challenges that face the first generation of children born HIV positive; in fact, this has not been an issue of special focus. Yet the population of that group of people is not only increasing in numbers, it is also growing older. According to UNAIDS, of an estimated 390,000 children born with HIV in 2010 globally, 90 percent of them were born in 22 countries, of which 21 are in sub-Saharan Africa, the odd one out being India[1].

There is a lot of hope that with increasing access to improved PMTCT services especially the availability of the more effective antiretroviral regimen for pregnant women and their newborn babies, fewer children will be born HIV positive. Where highly active antiretroviral therapy (HAART) has been employed, the rate has reduced to below 5 percent. As a result, in 2011 UNAIDS and PEPFAR jointly launched the Global Plan towards the Elimination of New HIV Infections among Children by 2015 and Keeping Their Mothers Alive. The plan has a main focus on the 22 countries (see above).

Source: UNAIDS and PEPFAR bring together Health Ministers and partners to advance progress in ending new HIV infections in children

For many years there was a strongly held assumption that survival from birth to adolescence with HIV was so unlikely without treatment as to be negligible, and that HIV in late childhood was very unusual. The accepted view was that the majority would die before the age of five. However, there is now accumulating evidence that children born with HIV do survive into teens and adults. In Kenya, the oldest of these children are now approaching 30[2]. In Uganda it is estimated that as many as 150,000 children are already living with HIV right from childhood. In 2006, the oldest surviving of young people born with HIV in Uganda turned 23 years old, thanks to antiretroviral therapy[3]. That same year, The Aids Support Organization (Taso) had registered 4,696 ten to nineteen-year-olds living with HIV since infancy, while another 1100 young people were receiving care at the Mildmay Centre and Mulago Hospital.

A recent article by Amelia Hill[4] entitled Teenagers born with HIV tell of life under society’s radar, HIV-positive youngsters who were infected before or at birth reveal their secret lives, highlights some of the challenges faced by youngsters in the United Kingdom who were born HIV positive. These challenges include:

  • Coping with the discovery that they are HIV positive: Usually the doctors and the parents would have withheld the information until such time as it is considered “safe” to divulge the status to the child. One 18 year old describes how at nine years old a careless receptionist at his local hospital blurted his status, and his reaction to the shocking revelation: “I remember standing there, with my mother’s hand around mine, as these feelings of complete confusion and fear washed over me. I suddenly realised that the pills my mum had been giving me every day – that I had thought were sweeties – were medicine, after that day at the hospital, I would lock myself in the bathroom when my mum took them out of the cupboard. Or I’d pretend to swallow them, and then throw them away. I know I’m killing myself,” he says truthfully, but with studied nonchalance. Inconsistency in the taking of medicines has important implication to development of resistance to specific drugs by the virus.
  •  Fear of stigma: HIV-positive youngsters have expressed worry over being branded by the stigma that is attached to HIV in society. “Society forces me to live two lives, one of which – the one where I’m honest about my status – I have to keep completely secret from the other one. It’s partly because I have to live this life of shame and secrecy that I find it so hard to take my meds….I’m angry about the stigma in society that makes me have to lie about my status“. Some adolescents have admitted having considered killing themselves.

Two studies, one in Zimbabwe and the other in Uganda have specifically highlighted some of the issues facing adolescents and young adults who were born HIV positive in those countries. In Zimbabwe, a clinical study[5] has suggested that as many as one in four children may survive into adolescence without diagnosis or treatment. Of the children under HIV care in Zimbabwe during 2008, 42% were aged 10-19 years. This study has bust the long held assumptions that HIV in late childhood is very unusual, and that survival from birth to adolescence with HIV was so unlikely without treatment as to be negligible. Among the problems most commonly faced by adolescents were psychosocial issues and poor drug adherence (which is critical in keeping the ever-changing AIDS virus at bay).

The Population Council in Uganda[6]  has addressed reproductive health needs of adolescents born with HIV. It involved a sample of 732 adolescents aged 10-19 years. The study shows that these adolescents are most likely to be orphaned, hardly any of the teens and young adults born with HIV have both their parents alive, As such they are subject to the challenges that face orphans generally. They were also found to be at risk of entry into casual relationship, using no protection, and with persons whose HIV status they do not know. Most of them conceal their status to their partners. The study reports that as many as 61 percent of the sexually active adolescents surveyed said they did not use any protective method during their first time sex, and do not know the status of their current partner.

There are lots of similarities between the findings in the two Africa-based studies and the issues raised by their counterparts in the UK report. What these limited studies clearly reveal is the inadequacy of our knowledge regarding the social, psychosocial and health challenges faced by adolescents and youths born HIV positive and their guardians.

[1] UNAIDS and PEPFAR bring together Health Ministers and partners to advance progress in ending new HIV infections in children http://www.unaids.org/en/resources/presscentre/featurestories/2012/may/20120523whagp/

 [5] Rashida Ferrand,a Sara Lowe,b Barbra Whande,b et al., Survey of children accessing HIV services in a high prevalence setting: time for adolescents to count?Bull World Health Organ. 2010 June 1; 88(6): 428–434. Published online 2009 December 16. doi:  10.2471/BLT.09.066126

Do HIV infected women in Kenya have the guaranteed right to free choice contraception?

Government’s commitment to voluntary and free-choice family planning practices comes to question as Kenyan HIV infected women continue being coerced to use the IUCD. The Citizen TV on November 22, 2011 ran a story[1] about a widow in Mbita who has benefited from a fish farming venture supported by a grant from an American based non-governmental organisation. The sole qualification she needed to qualify for the grant was to be HIV positive and willing to be fitted with an intrauterine contraceptive device (IUCD). It is probable that this poor widow had no choice but to accept the condition- she needed help to support her family and, to that end, would take considerable risk. The question here is whether she had any choice in embarking on this method of family planning? Is it fair to assume she was in fact coerced to accept an IUCD by the grant of much needed cash?  What is the position of the Kenya Government on the matter?

Cash for contraception? Photo: Edgar Mwakaba/IRIN

According to Prof Peter Anyang’ Nyong’o, Minister for Medical Services, family planning practice should be voluntary[1]. Service providers must educate clients on the range of choices available, and let them choose that which suits them best. “But to flash money and say take this – no, that is not how to do it!” he added. However, it is not clear what the Minister has done to arrest the coercive practices.

Coerced sterilization of HIV-positive women came to light in 2007 when 13 cases were documented in Namibia[2]. Shortly afterwards there were reports of HIV-positive women in Kenya being paid money to accept long-term contraceptive methods, particularly IUCD[3]. These activities in Kenya (which include the case in point) are supported by Project Prevention, an American NGO founded in 1997 which also pays female drug users in the U.S. and UK to be sterilized. Whereas HIV-positive women do have a legitimate need for FP services, like every other woman they are entitled to exercise choice free of coercion or manipulation through incentives. Use of incentives and disincentives to pressure poor people to be sterilized was rejected at both the 1994 International Conference on Population and Development (ICPD) in Cairo, and the 1995 Fourth World Conference on Women in Beijing. In particular, the Beijing Platform for Action states clearly that “The human rights of women include their right to ….decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence”.

Coercion for sterilisation through incentives reached its peak in India during the rule of Prime Minister Indira Gandhi, with her government’s policy of sterilising (vasectomy) millions of Indian men who had fathered two or more children, being compensated with a transistor radio! This policy was ruthlessly and often illegally applied to the extent it came to symbolize the dangers of authoritarian rule[4]. It is notable that payment for sterilisation continues in India to this very day; for example, a medical college was recently reported to pay men that opt for non-scalpel vasectomy 1,100 Indian Rupees[5]. In Uttar Pradesh, to obtain a shotgun licence requires two people being sterilised; for a revolver licence, the price would be five. Wealthy farmers have managed to stock their armory through forcible sterilization of their poor farm hands![6]

Proponents of coerced contraception are usually driven by the wish to create an HIV-free tomorrow by preventing birth of children infected by their mothers. It is known that in Africa before the advent of antiretroviral drugs up to 40 percent of children born to HIV infected mothers were also infected. However, in Kenya, there has been an increasing access to services for prevention of mother-to-child HIV transmission (PMTCT), most often offered at antenatal clinics and at delivery. According to the Kenya Service Provision Assessment Survey of 2010, 58% of all health facilities nationwide offered some component of PMTCT services, with 33% of these facilities providing all four components for the minimum PMTCT package (HIV testing with pre- and post-test counseling, ARV prophylaxis for mother and newborn, counseling on infant feeding, and FP counseling or referral). This is increasingly reducing the incidence of perinatal transmission as well as rates of mortality among infected children. Accumulated evidence to date shows that administration of antiretroviral therapy to the mother during pregnancy, labour and delivery, and then to the newborn, as well as delivery by Caesarean section for women with high viral loads, can reduce the rate of perinatal HIV transmission to well below 10 percent[7]. What this means is that despite the many challenges not addressed here, it is possible to dream of an HIV-free generation without having to resort to cruel acts of forced contraception for HIV infected persons. Indeed this was the view expressed by UNAIDS Executive Director Michel Sidibé, during a visit to a Millennium Villages Projects (MVP) in Kenya: “We have seen that it is possible to virtually eliminate infant HIV infections in high-income countries ….Now we must apply the knowledge and tools to create an AIDS-free generation in Africa and the rest of the world.”[8]


[1]Brett Davidson and Lydia Guterman. What’s Wrong with Paying Women to Use Long-Term Birth Control? February 21, 2011 http://blog.soros.org/2011/02/whats-wrong-with-paying-women-to-use-long-term-birth-control/ accessed October 22 2011

[3]Brett Davidson and Lydia Guterman. What’s Wrong with Paying Women to Use Long-Term Birth Control? February 21, 2011 http://blog.soros.org/2011/02/whats-wrong-with-paying-women-to-use-long-term-birth-control/ accessed October 22 2011

[4] “The World: The Issue that Inflamed India” Lawrence Malkin, TIME New Delhi Bureau Chief, Monday, Apr. 04, 1977

[5] Team to probe forced sterilisation charge Express News Service

http://www.indianexpress.com/news/team-to-probe-forced-sterilisation-

[6] Outrage at guns for sterilisation policy, Indian farmers given firearms licences as an incentive to curb population growth. Randeep Ramesh in Lakhimpur The Guardian, Monday 1 November 2004 23.56 GMT http://www.guardian.co.uk/world/2004/nov/01/india.randeepramesh

My considered view on the new Africa based study published in the Lancet linking hormonal contraception for women to increased HIV infection risk

A research report published in the Lancet on 4th October 2011 has provoked widespread fear throughout the world. This multicentre study involving in seven African countries: Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda and Zimbabwe, has shown increased risk of HIV infection to women who used hormonal contraceptives– particularly injectable methods like Depo Provera, as well as to male partners among discordant couples. The global concern is due to the fact that there are more than 140 million women worldwide using hormonal contraceptive methods. In most African countries, Kenya included, the injectable contraceptive is the most widely preferred method. The Kenya Demographic and Health Survey (2008-9) showed that more than a half (22%) of the 39% of Kenyan married women using a modern contraceptive method relied on Depo provera.

Three points are worth emphasizing. First, generally, hormonal contraceptives are safe and effective family planning methods that are central to initiatives to reduce unintended pregnancies, empower women, promote economic development, and improve maternal and child health.  Family planning has a key role to play in the attainment of Millennium Development Goals.

Second, there is no such thing as a contraceptive that is 100% safe and, in fact, contraceptive practice is associated with a variety of risks, depending on the method used. This is why family planning service providers have a responsibility to assess the risk to clients of developing method-associated complications (side effects), depending on the health history and the nature of the method chosen. It is important that all clients seeking family planning services should be assessed with regard to their risk of STIs including HIV/AIDS, remembering that all persons at risk of getting infected with an STI are also at risk of getting infected with HIV. It must be realized that HIV/ AIDS is largely a sexually transmitted disease.

The third point to emphasize is that whereas hormonal contraceptive methods are extremely effective in preventing pregnancy they do not prevent infection with STIs including HIV. On the other hand, proper and consistent use of condoms (male and female) is an effective way of preventing most STIs, including HIV. This is why family planning service providers should promote dual protection- the use of condoms for clients who are at risk of acquiring STIs even when they are using other methods of family planning methods.

In Kenya, the above points are emphasized in the Fourth (2009) Revised Edition of Family Planning Guidelines for Service Providers published by the Division of Reproductive Health, Ministry of Health, which is updated from time to time to incorporate evolving research evidence. It is guided by a WHO Scientific Working Group which periodically reviews the latest scientific information on safety of contraceptive methods, and makes recommendations on criteria for their use in different situations (WHO Medical Eligibility Criteria).

Hormonal contraception and HIV risk

A new study published in the Lancet suggests that use of hormonal contraception doubles HIV risk to the woman as well as to her discordant male partner. Read more 

What if the HIV epidemic first manifested in poor countries?

By Japheth Mati

The first WHO report on neglected tropical diseases[i] highlights the importance of a class of diseases which though medically diverse, are grouped together because all are strongly associated with poverty, all flourish in impoverished environments and all thrive best in tropical areas, where they tend to coexist. Most are ancient diseases that have plagued humanity for centuries. These diseases remain largely silent, as the people affected or at risk have little political voice. As a result, they have traditionally ranked low on national and international health agendas, allowing them to continue causing massive but hidden and silent suffering, and frequently kill, though not to the same extent as in the case of HIV and AIDS, tuberculosis or malaria.

The response to the continuing presence of the neglected tropical diseases (NTDs) in most countries in the Tropics stands in sharp contrast to the unparalleled achievement in addressing the HIV epidemic. The first case of AIDS was diagnosed in 1981. Two years later, in 1983 the HIV virus was identified, and in 1985 the FDA approved the first HIV antibody test, making it possible to diagnose the disease more precisely and to screen individuals (and blood) for the infection. In 1987 the FDA approved the first antiretroviral drug AZT (ziduvidine). Thus, despite remaining a serious global challenge, HIV had changed within a period of less than a decade from being essentially a fatal condition to become a chronic illness, thanks to the unprecedented global cooperation and commitment of massive resources for HIV research and development (R&D) activities.

Source:Working to overcome the global impact of neglected tropical diseases, First WHO report on neglected tropical diseases, 2010

Funding for Research & Development (R&D): HIV and AIDS versus NTDs

From the 1990s until 2009, funding for the HIV epidemic increased substantially[ii]. In 2008, an estimated $15.6 billion was spent on HIV and AIDS compared to $300 million in 1996. These funds mainly derived from donations from national governments, multilateral funding organisations, and private funding. In 2009 the United States of America was the largest donor in the world, accounting for more than half of disbursements to HIV R&D by governments. DFID is the world’s second biggest bilateral donor for HIV/AIDS.

On the other hand, R&D of drugs for NTDs has been very significantly under-funded. The first comprehensive survey of global spending on R&D for neglected diseases[iii], showed that in 2007, nearly 80% of the global investment into R&D of new medical products[iv] was consumed by three diseases- HIV/AIDS, TB, and malaria. Many NTDs, responsible for killing millions of people in developing countries, shared the remaining 20%; each received less than 5% of global funding. These diseases include Filariasis, Schistosomiasis, Onchocerciasis, Sleeping sickness, Leishmaniasis (kalar-azar), Chagas disease, Guinea-worm, Dengue, diarrhoeal illnesses, worm infestations, Pneumonia, Meningitis, Leprosy, Buruli ulcer, Trachoma, Rheumatic fever, Typhoid and Paratyphoid fever, and Rabies.

What is peculiar about the HIV epidemic?

AIDS as a disease entity was first reported in 1981 among homosexual men in the United States, and for some time the disease was considered peculiar to homosexuals, being variously labeled “the gay cancer”, “the gay plague” and “the gay-related immunodeficiency disease [GRID]”). These first cases involved highly educated men, many from the upper echelons of the American society. They soon realized their plight and, through a strong well organized lobby movement, fought hard for public attention and support of the search for ‘cure’. No wonder, within less than a decade, several drugs had already received FDA approval. Since then, HIV disease has engulfed the world, and the majority of the cases now live in developing countries. Nevertheless, it is possible that the conscience and momentum built up in those early years continue to play a significant role in sustaining international support for HIV activities.

What is peculiar about the neglected tropical diseases?

The nature of NTDs differs in several respects from HIV[v]. Generally, although these diseases affect the poor and marginalized populations living in rural and urban areas, they are almost exclusively limited to the tropics. These are people that cannot readily influence government decisions that affect their health, and often seem to have no constituency that speaks on their behalf. Also, unlike HIV, most NTDs generally do not spread widely, since their distribution is restricted by climate and its effect on the distribution of vectors and reservoir hosts; in most cases, there appears to be a low risk of transmission beyond the tropics. Consequently, not much is spoken about the impacts of the NTDs, nationally or internationally.

The neglected tropical diseases, also dubbed the ‘ancient companions of poverty’, have an enormous impact on individuals, families and communities in developing countries in terms of disease burden, quality of life, and loss of productivity aggravating poverty, as well as the high cost of long-term care. They constitute a serious obstacle to socioeconomic development and quality of life at all levels. WHO estimates that these diseases blight the lives of 1 billion people worldwide and threaten the health of millions more[vi]; they are a serious obstacle to the achievement of health-related Millennium Development Goals.

These diseases can, at relatively low cost, be controlled, prevented and possibly eliminated using effective and feasible solutions, such as the five strategic interventions recommended by WHO[vii].

What if the HIV epidemic first manifested in poor countries?

The answer to this philosophical question may never be known. However, going by the example of the dilatory international response to NTDs to date, it is worrying to imagine what the status of the HIV epidemic would be if it first manifested in poor countries.

[i] World Health Organization (2010) First WHO report on neglected tropical diseases 2010: working to overcome the global impact of neglected tropical diseases WHO, Geneva 

[iv] Total investment was about $US 2.5 billion.

[v] World Health Organization (2010) First WHO report on neglected tropical diseases 2010: working to overcome the global impact of neglected tropical diseases WHO, Geneva

[vi] World Health Organization (2010) First WHO report on neglected tropical diseases 2010: working to overcome the global impact of neglected tropical diseases WHO, Geneva

[vii] These are: preventive chemotherapy; intensified case management; vector control; the provision of safe water, sanitation and hygiene; and veterinary public health.

What are the prospects of Africa achieving universal access to HIV treatment?

Universal access to HIV treatment is one of the targets of Millennium Development Goal 6 (MDG6), the indicator for which is the proportion of the population with advanced HIV infection with access to antiretroviral drugs (ARVs). For Africa, achievement of this goal is a monumental task considering the sheer magnitude of the problem. In 2008 sub-Saharan Africa was home to just over 22 million of the world’s estimated 33.4 million people infected with HIV[i]. Almost every country in the region has suffered a generalized HIV epidemic, with the highest HIV prevalence rates existing in southern and eastern Africa. South Africa is reputed to harbour the greatest number of people living with HIV in the world (about 5.7 million).

In the past decade there has been a considerable increase in access to HIV treatment in resource-limited settings where antiretroviral medications were previously unavailable, rising 10-fold between 2003 and 2008[ii], thanks to global funding sources, especially the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund for AIDS, Tuberculosis and Malaria (GFATM). According to WHO and UNAIDS[iii], the coverage of ARV therapy in the sub-Saharan Africa, rose from 2% in 2003 to an estimated 44% of adults and children by December 2008. However, important access gaps still remain. In Kenya, for example, by 2009 only 290,000 persons that required ARV treatment were receiving it[iv], at a time when more than 1.4 million Kenyans were living with HIV[v]. In the sub-Saharan Africa, by end of 2008 only four countries (Botswana, Namibia, Rwanda and Senegal) had ARV coverage of 50% or more among adults and children who were eligible for the treatment and only six countries had achieved coverage of 50% or more of pregnant women for the prevention of mother-to-child transmission of HIV[vi].

The rapid expansion of treatment access is saving lives, improving quality of life, and contributing to the rejuvenation of households, communities and entire societies. As the number of people receiving ARVs increases, so does improvement in survival among people living with HIV. Evidence suggests that improved access to ARV therapy is helping to drive a decline in HIV related mortality[vii]. In Kenya, AIDS-related deaths have fallen by 29% since 2002[viii]. Paradoxically, this reduction in AIDS-related deaths translates into an increasing population of HIV infected persons at any given time. This implies there is a continuous increase in demand for HIV treatment. However, some data has suggested that ARV therapy may lower HIV transmission rate by as much as 90 percent[ix]. It is believed that improved access to ARVs may help to lower viral load both at the individual and community levels, this resulting in reduced incidence of new infections. Treatment coverage for children have remained lower than for adults[x] due to a number of reasons, among them: diagnosis of HIV in children is more difficult; HIV infection tends to progress faster to AIDS and death in children; and appropriate ARV treatment regimens for children are less accessible.

Challenges for scaling up of ARV treatment

Achievement of the goal of universal access to HIV treatment requires that the scope of coverage of HIV services is rapidly expanded. This in turn demands sustainable financing mechanisms, human resources, quality in service provision and use of services. It will be important to understand and address the key factors that limit the scope of coverage, and impede the demand for and utilization of HIV services, which include a weak, usually under-funded, health system, weak management and governance systems, especially with regard to procurement and distribution of needed resources- for counseling, testing, diagnosis and clinical management and monitoring of treatment, and referral systems. There is need for strengthened logistics systems, including capacity building, in order to enable adequate supply of HIV test kits and drugs at all levels as appropriate.

Acceptability of voluntary HIV testing is another challenge to the scale-up and effectiveness of HIV treatment. It is also a factor in late diagnosis and entry into ARV treatment programmes. In Kenya, as many as 4 out of 5 HIV-infected persons do not know their HIV status, while 63% that should be on treatment, do not know their status, and are therefore not on ARV therapy[xi]. Stigma and discrimination of HIV infected persons in most African countries remain important reasons for fear to come out for testing and declaring status.

A serious challenge is the sustainability of access to affordable drugs. Scaling up of HIV treatment faces the barriers to be created by the adoption of anti-counterfeits policies and laws[xii] that would block the production and importation of life-saving generic medicines, particularly ARVs.

Sustainability of funding of treatment programmes is a formidable challenge. As mentioned above the rapid increase in access to ARVs has largely been driven by PEPFER and Global Fund funding. However, since the Obama administration, there has been a stagnation of PEPFAR funding which, among other things, has discouraged enrolment of new patients into treatment programmes unless they are replacing others who have left or died. This, in turn, would allow PEPFAR funds to support treatment of an array of health issues, including those not directly related to HIV, and stabilize funding for a variety of health concerns[xiii]. This implies many countries will be forced to treat the very sick patients first, and will be hard put to implement the updated WHO standard which raises the cut-off point for commencing ARV treatment from a CD4 count of 200 to 350.

The lesson is clear: whilst advocacy for enhanced international assistance must continue, at the same time African governments must increase national contribution to the cost of health care including HIV treatment, and increasingly reduce over-reliance on foreign support for critical sectors such as health care. For example, it has been reported that foreign agencies pay for more than 90 percent of Uganda’s AIDS-treatment regimens (Uganda is certainly not alone in this category). As the East African[xiv] has put it “donors hold the power of life and death over people living with HIV in Uganda”. Funding from the Global Fund has also been unpredictable. In the wake of repeated corruption allegations, in 2009 the Fund approved just under 6 percent of Uganda’s request. Kenya also has frequently run into a collision with the Global Fund over accounting issues, which has resulted in delayed release of subsequent allocations[xv]. Only Malawi, dubbed the model of success in the sub-Saharan African fight against AIDS, stands alone in this respect- the country is said to have actually doubled its own health spending. African governments can learn a lesson from the trend in Latin America, Asia, and the Middle East, where most governments double their health budgets while receiving aid[xvi].

Without enhanced international assistance and strong commitment by African governments to immediately increase budgetary allocations to the health sector, including for the purchase of ARVs, achievement of universal access to HIV treatment will remain an illusion. It is the hope that the resolution at the recent African Union Summit in Kampala, 19 to 27 July 2010, committing African leaders to invest more in ‘community health workers’ and to meet the Abuja target of investing up to 15% of government expenditure to health, will not simply gather dust like others in the past decade.

Another challenge, not frequently verbalized in medical circles, is ensuring access to appropriate diets for people entering HIV treatment programmes. Addressing the nutritional needs of such people has not been adequately prioritized within HIV and AIDS prevention, care and mitigation programmes that are currently underway in many sub-Saharan African countries. This is despite the knowledge that HIV infection, food and nutrition are closely linked, and cumulative evidence suggests that bolstering the nutrition of HIV infected persons can sustain them in active productive life, delay the onset of AIDS and permit longer survival. Malnutrition, an endemic problem in many parts of the region, is known to exacerbate the effects of HIV by further weakening the immune system, and contributing to poor tolerance to, as well as effectiveness of ARVs[xvii].

Among the major concerns voiced by groups of people living with HIV in five African countries visited by the writer[xviii], was food shortage, especially balanced diet that they are regularly advised to take while on treatment with ARVs[xix]. For example, one person in Zambia complained that he had been instructed to eat five meals a day while on treatment; this at a time when he could barely get one meal per day! The result is that many simply did not take their drugs.

Adequate nutrition improves the effectiveness of HIV treatment and sustains quality of life. In view of this, nutritional assistance should be an important component of HIV treatment programmes. This may be in the form of nutritional assessment, counseling, and increasing access to food, either provided directly, or through social protection programmes such as cash transfers, or facilitated income generation activities. In the long run, mitigation of the impacts of HIV and AIDS should include interventions that focus on increasing access to food and improved diets for HIV infected persons, for example, through measures that enhance household incomes, and improved agricultural productivity.

Related link

Food insecurity a serious threat to achieving universal access to HIV treatment in Kenya-millennium development goal Target 6B


[i] Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO) AIDS epidemic update: November 2009.

[ii] World Health Organization, United Nations Children’s Fund, UNAIDS (2009). Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Geneva, World Health Organization.

[iii] Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO) AIDS epidemic update: November 2009.

[iv] Dr Ibrahim Mohamed Scale up of access to ART in Kenya National Aids Control Program; Ministry of Medical Services Kenya, November, 2009

[v] National AIDS and STI Control Programme, Ministry of Health, Kenya. July 2008. Kenya AIDS Indicator Survey 2007: Preliminary Report. Nairobi, Kenya.)

[vi] Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO) AIDS epidemic update: November 2009.

[vii] Jahn A et al. (2008). Population-level effect of HIV on adult mortality and early evidence of reversal after introduction of antiretroviral therapy in Malawi. Lancet, 371:1603–1611; Mermin J et al. (2008). Mortality in HIV-infected Ugandan adults receiving antiretroviral treatment and survival of their HIV-uninfected children: a prospective cohort study. Lancet, 371:752–759.

[viii] National AIDS Control Council, National AIDS/STI Control Programme. Sentinel surveillance of HIV and AIDS in Kenya 2006. Nairobi, National AIDS Control Council, National AIDS/STI Control Programme, 2007.

[ix] Attia S et al. (2009). Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis. AIDS, 23:1397–1404.

[x] UNAIDS (2008). Report on the global AIDS epidemic. Geneva, UNAIDS.

[xi] National AIDS and STI Control Programme, Ministry of Health, Kenya. July 2008. Kenya AIDS Indicator Survey 2007: Preliminary Report. Nairobi, Kenya.)

[xii] These include the Anti-Counterfeit Act of 2008 in Kenya, the Counterfeit Goods Bill in Uganda and the EAC Anti-Counterfeits Bill

[xiv] Esther Nakkazi Uganda: ARV Shortage Sets in As Aids Funding Falls East African 3 August 2009: http://allafrica.com/stories/200908031372.html

[xv] Gatonye Gathura and David Njagi Kenya: Row With Global Fund on Cards Daily Nation On The Web 5 October 2009: http://allafrica.com/stories/200910051673.html

[xviii] During 2006/7 the writer had the privilege of interacting with groups of PLWHA in Kenya, Tanzania, Uganda, Zambia and Zimbabwe, whilst a consultant to Heifer International of Little Rock, Arkansas, USA.

[xix] Japheth Mati (2010) Food insecurity a serious threat to achieving universal access to HIV treatment in Kenya (Millennium Development Goal Target 6B) http://blog.marsgroupkenya.org/?tag=africa-health-info

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