Tuesday, July 14, 2009

Aa Malawian Feast of HIV Knowledge

A virtual feast awaited us in Lilongwe, Malawi, in our first week in Africa. The National AIDS Commission had invited all groups doing HIV research in Malawi to present their results at a national conference which occurred on Thursday and Friday, the 2nd and 3rd of July. One member of the Landmark Church group, with which we are enjoying the Malawi portion of this summer’s trip, saw a sign in the center of the city advertising the event. A few days later we drove by the sign, saw that the event would be at the Crossroads Hotel the following day, then headed for the Hotel, learning that the event was sponsored by the National AIDS Commission. On the way home we dropped by the Commission’s offices where we were invited by two different staff members to attend. So we did. It was a very worthwhile investment of two days’ time.

A paper by epidemiologists from the Ministry of Health reported that at the end of 2008, 147,500 patients (about 50% of those needing it) were on treatment at some 211 clinics across the country. Over time progressively more patients have been added to treatment each year, and those patients beginning treatment are increasingly younger and earlier in the progression of their disease. Men have continued to get tested and start treatment in smaller numbers than women, and the men usually have more advanced disease when they come to treatment.

The Malawian Ministry of Health (MOH) and Howard University noted that 100 laboratory technicians had been trained in the last six years to do complex laboratory procedures such as counts of the number of CD4 lymphocytes (the primary target of the HIV virus—basically, the more you have the better) and the “viral load” or the number of HIV viral particles themselves in patients’ blood (the less you have the better). More than 80 additional working technicians had received updates in these procedures. More availability of the CD4 count will spread the ability to track the success of HIV treatment under current Malawian protocols, and access to viral load determinations will apparently prepare Malawi to move to treatment follow-up based on the more precise and sensitive (though also more expensive) use of the viral load for follow-up.

GOAL Malawi reported good results in several senses from having fathers participate in the counseling sessions for pregnant women in which their newly-discovered HIV infection and the medications they would take to reduce risk of transmitting the virus to the baby are discussed. As a result of this special effort to include fathers, the number participating doubled to between 60% and 85% of the number of mothers attending the participating clinics. Male membership in support groups increased by 82.5%. Other desired and possible outcomes that were not documented included reducing emotional and physical abuse by their partners of pregnant women found to be infected with HIV.

Dignitas International and their partners found that provision of HIV care in 16 decentralized sites in one area of the country (as opposed to only 6 in addition to the central hospital in the pre-study period) decreased death and drop-out rates in persons beginning HIV care. Another session found the use of trained community volunteers helpful in enrolling patients on medications, keeping them on medications and ensuring return for clinic appointments.

The Malawi Interfaith AIDS Association found in a national survey that clergy were well-informed regarding the way HIV works to cause disease but most were very opposed to condom use. Thirty-two percent believed that prayer could be an effective treatment for HIV, a fact that seemed to disturb at least some of those present. While I do not think we should ignore the wonderful gift from God of the medications currently available for treating HIV, I wonder why only 32% of church leaders believe that prayer can be an important and efficacious part of an effective treatment regiment.

For a number of good reasons African protocols for treating HIV are generally simpler than those usually used in the USA, including treatment for pregnant women. A group named Sant’ Egidio for the Roman Catholic renewal and discipleship movement of which they are a part reported on their efforts to treat pregnant women with more aggressive protocols, in some ways more like those in the U.S. and western Europe. A part of the Sant’ Egidio protocol was using full anti-retroviral treatment starting early in the pregnancy, while another, quite different from the U.S., included continuing full anti-retroviral treatment of the mother for the first six months of the baby’s life while the mother was breastfeeding. They found that all outcomes were improved, including maternal death, miscarriage, still-birth, pre-term birth, as well as HIV transmission from the mother to the baby. The results were impressive, but not surprising. One member of the audience was encouraged by the outcomes to ask if they were sufficient to seek a change in Malawian policy. A more aggressive protocol for preventing mother-to-child transmission of HIV might yield better results nationwide.

We were impressed with the variety of projects as well as with the rigor of the evaluations. We learned a new technical term with a special meaning in this field--“task shifting”-- which means the delegation of certain medical tasks to personnel with less training than is usually required. We were able to meet many people including the regional representative of the Clinton foundation, an epidemiologist from the CDC, multiple personnel from the Ministry of Health and the National AIDS Commission, and physicians from Baylor Medical School’s project in Malawi and the Sant’ Egidio project. We were encouraged by many to come and join them in the fight they are waging against this disease in Malawi, and we are anxious to return and do so.