Tag Archives: malaria

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

 

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A malaria survivor reflects on World Malaria Day

Wednesday the 25th April 2012 was World Malaria Day and as I joined others on that day in reflecting on the disease I could not fail to appreciate how much the malady has impacted on my life. It is particularly sad to read the statistic in the World Malaria Report 2011 thatin 2010 an estimated 655,000 people died from malaria–most of them African children”. And although the same Report states that malaria mortality rates have fallen by33% in the WHO African Region, in Africa one child still dies every minute from the disease, accounting for around 90% of all malaria mortality worldwide.

Image Source, K4Health’s POPLINE Database

I am a malaria survivor, I suppose many times over, but I particularly remember my experiences as a little boy growing up during the Second World War in a place called Itoloni in today’s Mwingi South Constituency. Ndetema (as we called Fever) was very common, and it was treated at first with quinine- that horribly bitter stuff from the cinchona tree. We had our noses squeezed which forced our mouths to open for the colourless liquid to be poured down our throats, three times a day. Then I was told my spleen was large (wasyungu) and was not improving with the quinine alone, so my grandmother was brought in. I can never forget the experience. Although I was particularly very fond of my grandmother, I always anticipated her visits to our home with a lot of apprehension. All the same it seems she successfully treated my splenomegaly with her nasty herbal concoctions accompanied by hot massages over the organ using leaves of the aloe vera plant.

When the Japanese occupied Indonesian islands where the cinchona tree grew they cut off supply of quinine to the British (who were ruling us those days), and it took a few years before quinine was replaced with mepacrine. The latter is a greenish yellow dye discovered at Bayer, Germany way back in 1931. Mepacrine-hydrochloride (also known as Quinacrine and Atabrine) was one of the first synthetic substitutes for quinine although later superseded by chloroquine. I remember being taken to the Native Civil Dispensary  in Nairobi, (it stood next to Kingsway Police Station- today’s Central Police Station), for weekly supply of mepacrine which was dispensed in large topped-up mugs. It was horrible! Among the side effects of the drug were toxic psychosis and ringing ears. Incidentally, Quinacrine has been used for non- surgical sterilization for women, and several peer reviewed studies suggested the procedure was potentially safer than surgical sterilization. Nevertheless, in 1998 the Supreme Court of India banned the import or use of the drug, based on reports that it could cause cancer or ectopic pregnancies.

Chloroquine, discovered at the same Bayer laboratories in 1934, was not introduced into clinical practice for the treatment of malaria until 1947. The drug would then hold supreme until the 1990s when emergence of widespread resistance to chloroquine led to its withdrawal from use in most countries in Africa, being systematically replaced by Artemisinin. It is thus with trepidation that we receive news that the most deadly species of malaria parasites, Plasmodium falciparum, is becoming resistant to artemisinin.

Another encounter with malaria was in the early 1960s, while a student at the Makerere College Medical School in Kampala, Uganda, where I came across a disease called Big Spleen Disease, a syndrome diagnosed in men and women characterised by evidence of recent malaria, anaemia and splenomegaly. Later, during 1967 and 1968, when I was practicing medicine at the Kenyatta National Hospital I conducted a study on anaemia in pregnancy[i], the findings of which revealed that among the very severely anaemic pregnant women splenomegaly was commonly found, and most of the women had evidence of recent malaria infection.

In areas endemic for malaria pregnancy is associated with a reduction in already acquired immunity, with consequent increase in clinical attacks of severe malaria (including cerebral malaria) and other complications such as haemolytic anaemia. Malaria-induced haemolytic anaemia is particularly common among women with their first pregnancy and tends to cause more severe anaemia with rapidly dropping haemoglobin in a woman who only a few days earlier had normal level of haemoglobin. These attacks can be prevented through intermittent preventive treatment with an effective antimalarial, for all pregnant women living in endemic areas, also use of insecticide-treated mosquito nets, and indoor residual spraying..

Let me end by mentioning an indirect involvement with malaria; this time concerning my father who in the late 1940s and early 1950s was a member of the Nairobi Municipality crew that eradicated malaria transmission in Nairobi. They used DDT before its name became an anathema. Yet to date there has not been any equally effective ‘safer’ substitute. Shall we continue watching our children die of malaria in order that we protect those of the future from little understood risks?

[i]Mati JKG, Hatimy A, and Gebbie DAM (1971) The importance of anaemia of pregnancy in Nairobi and the role of malaria in the aetiology of megaloblastic anaemia. Journal of Tropical Medicine and Hygiene, 74:1
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