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The shortcomings of the "seroepidemiology" approach as opposed to the traditional "clinical epidemiology" approach in answer to Africa's acquired immunodeficiency syndrome (AIDS) problem, are discussed. Investigators with a knowledge of tropical medicine have observe that recurrent malaria and other infectious diseases are associated with excessively high rates of false-positivity with H9/HTV-III, enzyme linked immunoabsorbent assay (ELISA), leading to a dichotomy between seroepidemiology and clinical epidemiology in tropical Africa. In addition, patients with alcoholic liver disease have a high incidence of false positive results on tests for HTLV-III antibodies, while acute malaria infections have produced false positivity even with the Western blot. When the conclusions of clinical epidemiology differ from those of seroepidemiology, clinicians should always believe the former. Serological work should be limited to assessing the specificity and sensitivity of the various kits under African conditions, screening all blood before transfusion, and serving as a back up procedure when clinical features are not clear cut. In his Krobo tribe, in southeastern Ghana, Dr. Konotey-Ahulu suggests that the bulk of any available funds should be resourcefully utilized in answering the questions: how, when, who, which, why and where?
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PMID:Clinical epidemiology, not seroepidemiology, is the answer to Africa's AIDS problem. 311 44

AIDS in rural Africa seems to differ in its epidemiology from hepatitis B and appears to be spread predominantly by preexisting patterns of heterosexual activity responsible for high rates of other sexually transmitted diseases. The authors compared the seroepidemiologies of AIDS, hepatitis B, and syphilis at 2 rural hospitals in southwest Uganda. During August 1986, 3% of 357 outpatients, reflecting the age and sex composition of the general population, were anti-HIV positive. Anti-HIV seropositivity, both in the outpatients and among 36 suspected prostitutes and 14 suspected AIDS cases, was confined to individuals aged 20 or over. For men, seropositivity was associated with sexual contact with prostitutes (a risk factor for 61% of young men in the study). In the prostitute group, 25% were anti-HIV positive and 46% were positive on the Treponema pallidum hemagglutination (TPHA) test for syphilis. The risk factors for HIV, but not hepatitis B, were the same as for having a history of sexually transmitted disease (STD). However, there was, surprisingly, an association between a history of STD and seropositivity for hepatitis B virus but not for HIV infection. The geographical and age distributions of seropositivity for HIV and hepatitis B virus were also quite different. Finally, blood transfusions, scarification, and exposure to mosquitoes (as assessed by a history of malaria) were not evident risk factors for either HIV or hepatitis B virus.
AIDS 1988 Aug
PMID:Risk factors for the spread of AIDS in rural Africa: evidence from a comparative seroepidemiological survey of AIDS, hepatitis B and syphilis in southwestern Uganda. 314 Aug 31

In the efforts to develop a vaccine for human immunodeficiency virus (HIV), attention has focused on sub-Saharan Africa, where large populations at risk for HIV infection could be studied easily. Cross cultural bioethics must be examined to address the ethical implications and cultural obstacles of such research. Autonomy and informed consent are difficult to achieve in cultures with limited personal choice. In some cultures, individual personhood is secondary to social relationships in the tribe or village. Language barriers, illiteracy, and the lack of knowledge about modern science all make it difficult to adequately inform participants. While the Helsinki Declaration emphasizes that a subject's well-being takes precedence over the interests of science and society, health policy decisions in nonautonomous populations often place state interests over the individual. Political sensitivities have been aroused by attempts to attribute the origin of AIDS to western or central Africa, leading political controversy and discrimination against Africans. Foreign researchers often exclude African participation once they have obtained the body fluid samples for study. Without joint collaboration and education, human research in developing countries can easily become exploitative. Justice dictates that research subjects be chosen for scientific reasons, not due to easy availability or ability to be manipulated. In vaccine development, Africans should not experience a disproportionate amount of risk without an equal share in the benefits. Furthermore, malnutrition, malaria, tuberculosis, and many other diseases present more urgent health problems to the developing world than AIDS. The health care priorities of the developing nations must be considered.
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PMID:Ethical considerations of human investigation in developing countries: the AIDS dilemma. 317 36

2 cases are reported from Nigeria of patients with illnesses compatible with a diagnosis of AIDS, but whose serum was HIV-negative. The 1st patient had Kaposi's sarcoma and cervical lymphadenopathy. The 2nd patient had lymph node tuberculosis and generalized lymphadenopathy. The 1st patient had had intramuscular injections for malaria at a local pharmacy, and the 2nd patient had received a blood transfusion after an appendectomy. They may have been infected with HIV-related but antigenically distinct retroviruses.
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PMID:Deaths from AIDS-like illnesses in west Africans. 323 78

In different countries opinions differ as to which chemotherapeutic methods should be used for malaria prophylaxis. It has long been the opinion of the Nordic countries, that WHO should give an official recommendation and the result is reflected now in the publication "Vaccination certificate requirements and health advice for internation travel." The malaria-endemic regions of the world are divided into 3 categories: regions without risk and no need for prophylaxis, low risk regions (A) with predominantly vivax inflections, risk regions (B) with predominantly chloroquine sensitive P. falciparum, and high risk regions (C) with often both chloroquine as well as sulfa/pyrimethamine resistance. Chloroquine is a sufficient prophylaxis for A-regions. For B-regions proguanil should be added and for C-regions only mefloquine is given. Proguanil was reintroduced basically because of Swedish research results in Liberia. An American initiative recommends for all regions, A-C, chemorprophylaxis as an alternative. However, a precondition is an observant traveller and clear instructions for self-treatment. Travellers who fall ill in a B-region should choose between Fansidar, mefloquine and quinine for self-treatment. Mefloquine has the least serious side effects, whereas quinine is therapeutically more safe. Fansidar very seldom gives any side effects. For C-regions only mefloquine is recommended for self-treatment. Nordic colleagues have recommended to double prophylaxis (chloroquine + Paludrine) treatment for the entire African tropical region. For short-time travellers to Kenya, Tanzania and Uganda, 6 tablets Lariam should be added. Only chloroquine is recommended for India and the Amazon region of South America. No chemoprophylaxis can guarantee full protection. Insect protection is therefore more important than ever. Malaria decreases the unspecific immune defense system. Surprisingly, repeated tests have shown that the AIDS frequency is not higher in patients with chronic malaria than for persons without plasmodia in the blood. In WHO's new little yellow booklet, a page concerning prophylaxis against AIDS appears. Equipment that is not new should be steamed or cooked for a least 20 minutes or treated with chemical disinfectants for at least 30 minutes. These measures should be enough to prevent HIV-infection.
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PMID:[Malaria and HIV prevention in WHO's "little gem"]. 338 44

Ethiopia is a country of 45 million people in northeast Africa. With a stagnant, agriculture-based economy and a per capita gross national product of $110 in 1984, it is one of the world's poorest nations. 70% of the children are mildly to severely malnourished, and 25.7% of children born alive die before the age of 5. Life expectancy is 41 years. The population is growing at the rate of 2.9%/year, but only 2% of the people use birth control. After the 1974 revolution, the socialist government nationalized land and created 20,000 peasant associations and kebeles (urban dwellers' associations), which are the units of local government. The government has set ambitious goals for development in all sectors, including health, but famine, near famine, forced resettlement programs, and civil war have prevented any real progress from being made. The government's approach to health care is based on an emphasis on primary health care and expansion of rural health services, but the Ministry of Health is allocated only 3.5% of the national budget. Ethiopia has 3 medical schools -- at Addis Ababa, Gondar, and the Jimma Institute of Health Sciences. Physicians are government employees but also engage in private practice. A major problem is that a large proportion of medical graduates emigrate. Ethiopia has 87 hospitals with 11,296 beds, which comes to 1 bed per 3734 people. There are 1949 health stations and 141 health centers, but many have no physician, and attrition among health workers is high due to lack of ministerial support. Health care is often dispensed legally or illegally by pharmacists. Overall, there is 1 physician for 57,876 people, but in the southwest and west central Ethiopia 1 physician serves between 200,000 and 300,000 people. In rural areas, where 90% of the population lives, 85% live at least 3 days by foot from a rural health unit. Immunization of 1-year olds against tuberculosis, diphtheria-pertussis-tetanus, poliomyelitis, and measles is 11, 6, 6, and 12% respectively. Infectious diseases dominate the medical scene in Ethiopia. In 1984, tuberculosis accounted for 11.2% of hospital admissions and 12.2% of deaths. The leading cause of childhood mortality in 1984 was diarrhea (45%). Malaria, trypanosomiasis, schistosomiasis, leishmaniasis, and meningococcal meningitis are endemic. Intestinal parasitism is rampant, and the nationwide prevalence of leprosy is 3/1000. Venereal diseases were the 9th most common cause of hospital outpatient visits in 1984, but AIDS is rare. The leading noninfectious diseases are rheumatic and syphilitic heart disease, hypertension, diabetes mellitus, hepatoma, and elephantiasis. Ethiopia has the highest number of cases of nonfilarial elephantiasis -- an estimated 350,000 cases -- in the world. Aside from a large influx of money, the most necessary changes to improve the health system are lowering the salaries of doctors and nurses, reorienting physician training toward primary health care, increasing the quality of existing health services, more efficient management, and better coordination between the Ministry of Health and the voluntary organizations.
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PMID:Health and medical care in Ethiopia. 271 Jan 85

The widespread emergence of chloroquine-resistant Plasmodium falciparum led to the formulation of an effective, fixed combination of two antimalarial agents, pyrimethamine and the long-acting sulfonamide sulfadoxine, for prophylaxis and treatment. These drugs act at sequential steps to inhibit the formation of tetrahydrofolate in the parasite. Recently, their use for malaria prophylaxis has been associated with severe, at times fatal, cutaneous reactions including erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis. These reactions have necessitated a major reassessment of the indications for pyrimethamine-sulfadoxine use and increased the search for pharmacologic, immunologic and behavioral approaches to the prophylaxis and treatment of infection with P. falciparum. Pyrimethamine-sulfadoxine may be effective in preventing recurrent pneumonia caused by Pneumocystis carinii in patients with the acquired immunodeficiency syndrome, but life-threatening cutaneous reactions have also been reported in this setting.
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PMID:Use of pyrimethamine-sulfadoxine (Fansidar) in prophylaxis against chloroquine-resistant Plasmodium falciparum and Pneumocystis carinii. 355 13

The characteristics of AIDS in Africa differ sharply from those in North America with respect to diagnosis and epidemiology, and in a clinical sense. The study of 78 patients treated in Kinshasa, Zaire during the period of October 1983-July 1984 yielded the following results: 159 out of a total of 1051 hospitalized patients were suspected of having AIDS, and there were 78 proven cases (54 of them died). The average age of 40 women and 38 men was 27 and 31 years, respectively, and the ratio of married people was 35% and 74%, respectively, with a lot of men living in polygamous relationships. In the first stage of the disease weight loss appeared in 100%, recurrent diarrhea in 83.3%, significant loss of strength in 75.6%, febrile conditions in 68.3%, and skin lesions in 58.9%. The ratio of men to women was 5:5, since heterosexuality and polygamy prevailed. Cigarette smoking was the main addition, thus drug addition per se did not appear as a risk factor. Blood transfusions occurred frequently (for instance, in malaria), but hemophilic patients receiving lyophilized preparations were rare. Haitians visited in fairly large numbers after the 1960's propagating the risk of AIDS. Black Africans accounted for 100% of cases. The number of concomitant, opportunistic diseases in AIDS patients in Zaire were: 34 cases of tuberculosis, 32 cases of candidiasis, 30 fungal infections, 21 Herpes labialis and/or genitalis, 19 cases of dermal and cerebral cryptococcosis, 12 cases of cryptosporidiosis, 9 cases of Kaposi's sarcoma, 5 cases of Herpes zoster, 3 cases of aseptic cerebral infections, 3 cases of coccidiosis, 2 cases of toxoplasmosis, and 1 case of pneumonia (Pneumocystis). Tuberculosis, cryptococcosis, cryptosporidiosis, and toxicosis were more frequent opportunistic diseases in Zaire than in the U.S.A., while pneumonia caused by Pneumocystis and Kaposi's sarcoma were relatively rare.
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PMID:[Acquired immunodeficiency syndrome (AIDS) in the African environment]. 382 54

The relationship between viruses and naturally occurring cancers, such as hepatocellular carcinoma and genital cancers, is of great importance to Africa. On the other hand, lymphomas, leukaemias and immunodeficiencies, although of less immediate public health importance, constitute an area of outstanding interest for research and their association with the Epstein-Barr virus (EBV) and the newly discovered human retroviruses merits world-wide attention. EBV-related malignancies in Africa include both Burkitt's lymphoma (BL) and nasopharyngeal carcinoma (NPC). Whether X-linked polyclonal lymphoproliferations exist in Africa remains an open question. The interrelationship between EBV, holoendemic malaria and genetic factors (oncogenes) has been deciphered in recent years, to make BL a kind of Rosetta stone for the understanding of multistage carcinogenesis. Although the role of EBV in the causation of NPC is not well understood, the viral capsid antigen (VCA) IgA test already allows both early detection of NPC in high-incidence areas and differential diagnosis in low-incidence areas. The question whether an EBV vaccine would be of value in African countries, in relation to EBV-associated malignancies, remains an open one. The diseases associated with the recently discovered human retroviruses (human T-lymphocyte leukaemia viruses: HTLVs) represent a new area for both research and public health assessment. Limited information is available today on the geographical distribution, age prevalence and association with disease in Africa of the different members of the retrovirus family (HTLV-1, HTLV-2, LAV/HTLV-3). The proportion of HTLV-related T-cell malignancies in different parts of Africa as well as the importance of immunodeficiencies caused by the different members of the retrovirus family remain to be determined. Typical acquired immunodeficiency syndrome (AIDS) appears to exist in Central Africa, especially Zaire, and HTLVs could be of public health importance if they cause severe forms of viral, bacterial or parasitic diseases through impairment of cell-mediated immunity. Africa, is and will long remain a continent of crucial importance with regard to the role of viruses in human malignancies and especially in haematopoietic proliferative disorders.
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PMID:Virus-associated lymphomas, leukaemias and immunodeficiencies in Africa. 610 Feb 86

Between 1975 and 1983 health care expenditures in Ghana dropped to a low point as a consequence of the structural readjustment program instituted by the World Bank. During 1975-76 only 15% of available funds were spent on primary health care (PHC), which was officially introduced in the late 1970s. PHC made up 20-25% of the health care expenditures by 1991 with about 25% of health personnel engaged in PHC. 2/3 of health care delivery covered urban areas when 60% of the population lived in the countryside. The district of Ejisu-Juaben in the Ashanti region had high morbidity. Tetanus, polio, whooping-cough, and diphtheria had been brought under control, but measles, diarrhea, and malnutrition were still widespread among children under 5 years old. Malaria, bilharzia, intestinal parasites, respiratory infections, hepatitis, anemia, hypertension, and vitamin A deficiency were also grave problems. AIDS was on the rise. Child mortality amounted to 130/1000 live births and maternal mortality to 1400/100,000 cases. The medical structure of the district comprises 10 health posts (6 governmental and 4 mission). Only 72 villages and 120,000 people are cared for. Each post has a mobile team. In 1993 a new community-based health care program began funded by Save the Children Netherlands. In 60 villages a village health committee existed but they were substandard. They were either reactivated or new committees were set up. Training activities were also started in prenatal care, delivery, care of malnutrition and diarrhea, hygiene, and sanitation. Two years later safe motherhood indicators had improved; postnatal care increased from 16% to 49%; medical deliveries increased from 27% to 37%; the share of families with contraceptive acceptance increased from 7% to 21%; and tetanus vaccination among mothers was estimated to have increased from 27% to 86%.
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PMID:[Primary health care in Ghana: no pay no cure?]. 750 Oct 68


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