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Thursday, August 09, 2007

South African AIDS disaster continues

For those following the global HIV/AIDS epidemic, the real issues have been focused on African nations. AIDS denial, for the most part, is a luxury afforded to the West where HIV and AIDS isn't as publicly noticeable. One sad outlier of course has been the Government of South Africa.


Thabo Mbeki has grabbed the headlines for years for his bizarre failure to firstly even admit that AIDS existed, then that it was a problem and that HIV was even the cause of AIDS. Public education campaigns and the supply of antiretroviral medications have been slow to non-existent. He even refused free antiviral medication offered by pharmaceutical companies. He pulled together a "Presidential AIDS advisary Panel" to discuss whether HIV caused AIDS after reading about AIDS denial on the internet. His health minister, Manto Tshabalala-Msimang, recently touted the benefits of lemon juice, garlic and potatoes as an AIDS treatment as an international AIDS meeting, to ubiquitous ridicule from the world's scientists.

One shining star however stood up to bravely try to change the course of this sinking ship. When Minister Tshabalala-Msimang was hospitalized with what turned out to be severe liver disease, the Deputy Health Minister Nozizwe Madlala-Routledge made several key statements that suggested a possible change of strategy. However this was not without risk, and several times she apparently angered the establishment enough to have to backtrack or moderate her statements.

Most recently she attended, or at least tried to attend, an international AIDS conference in Spain. Just after arriving she was told that the formality of requesting Presidential approval for such a trip had been denied. She returned immediately without attending the event.

And Mbeki had his excuse. Today, on the eve of Woman's Day in South Africa, she was fired.

Mbeki has once again shown his true colours, as a fool with enough ego to feel bruised by an intelligent woman standing up for her country's best interests. If Tshabalala-Msimang remains in control, and if the new Deputy is either of the same ilk, or too timid to risk their job, this spells disaster for the meagre progress South Africa has made to date.

5 Comments:

Blogger Martin Pêcheur said...

Dear Sir

I have posted a permanent link to your blog, from mine, at letterstotheempire.blogspot.com Please be so good as to stop by.

I'm particularly interested in your Mbeki post, being a dyed-in-the-wool, 11th generation South African.

Concerning his "bizarre" behaviour, and infuriating refusal to open the retroviral floodgates, kindly comment on the following:

Lancet Study Challenges Claims about HAART Treatment Does Not = Life

The surprising conclusion from a recent study published in the medical journal, The Lancet: After starting treatment with HARRT, viral response improved but such improvement has not translated into a decrease in mortality.

The multi-center study reported in The Lancet article tracked the effects of HAART on some 22,000 previously treatment naive HIV positives between 1995 and 2003 at 12 locations in Europe and the USA. Instead of finding data that provide a ringing endorsement of anti-HIV drug therapy, the studies results refute popular claims that the newer anti-HIV meds extend life or improve health.

Commenting on the article, Felix de Fries of Study Group AIDS-Therapy in Zurich, Switzerland had this to say: The Lancet study shows that after a short period of time, HAART treatment led to increases in precisely those opportunistic infections that define AIDS from fungal infections of the lungs, skin and intestines to various mycobacterial infections. De Fries also notes that while HAART has led to no sustained increases in CD4 counts, no reduction in AIDS-defining illness and no decrease in mortality rates, its use is associated with a list of serious adverse events including cardiovascular disease, lipodystrophy, lactacidosis, liver and kidney failure, osteoporosis, thyroid dysfunction, neuropathy, and non-AIDS cancers among users.

For more information, please refer to The Lancet, issue 368:451-58 and/or The Study Group AIDS-Therapy by telephone or fax at 0041 44 401 34 24 or by email at felix.defries@tele2.ch

3:30 PM  
Blogger Bennett said...

The Lancet study compares people starting on HAART in 1995 through subsequent years to 2003. It tells me nothing new. Culture studies and prior risk analyses showed that the "complete" viral suppression to under 500 wasn't much different to complete viral suppression to under 50 with "better" therapies, when you looked at finding HIV and the risks of opportunistic infections. This study merely puts it all together and adds real clinical context.

It isn't looking at the long-term effect of HAART on individuals during that timespan.

It isn't even a longitudinal study: it's multiple horizontal snapshots at different timepoints. It's really a study comparing the differences in the people starting HAART at each time point, and their response to HAART over a short time frame.

It isn't able to say whether HAART extends life compared to non-HAART therapies or no HAART at all, as such patients weren't included in the study. You are obviously attempting to extrapolate the data to suggest just this (or merely buying the article you quoted without even having read the paper).

MANY studies have done so in the past, and all show improvements in survival and OI occurance in the HAART era.

But them I'm assuming you knew and understood that, having read the paper...?

I didn't think so.

For one example, close to my heart, a recent publication in Pediatrics journal finds that:

Pre-HAART opportunistic infection rates were 14.4 per 100 person-years

Post-HAART opportunistic infection rates were 1.1 per 100 person years

Children with OI's were nearly 6 times more likely to die.

I leave it to your judgement as to whether or not HAART prolonged life or prevented OI's.

Pediatrics, Jul 2007; 120: 100 - 109.

Cheers

Bennett

10:31 PM  
Blogger Ned said...

Mr Bennett,

I have recently come across some of the dissenting arguments on the issues in Africa and I am very confused. I don't know what to think. I am a very skeptical person about our corporate culture and wouldn't assume there isn't some foul play at hand. Specifically, these are the issues that seem totally contradictory to an actual epidemic:
1. The Bangui definition of AIDS at its inception was admittedly inaccurate. JosephMcCormick, the CDC official that led the conference was quoted as saying "If I could get everyone at the World Health Organization (WHO) meeting in Bangui to agree on a single, simple definition of an AIDS case was in Africa, then, imperfect as the definition might be, we could actually start counting the cases..."
2. The definition they agreed upon consists of two categories of symptoms, major and minor. An AIDS diagnosis subsequently is made of two major symptoms and one minor one. An example of major symptoms includes weight loss, chronic diarrhea and chronic fever. Minor symptoms include coughing and 'generalized' itching. These are incredibly common afflictions in underdeveloped countries with frequent malaria problems and poor sanitation. Someone with malaria living in a hut made of dung could easily match these criteria and never actually have AIDS.
3. This definition of AIDS is totally inconsistent with European and US standards. How can a common disease cause totally different problems based on race and location?
4. There is very little actual AIDS testing going on in Africa. The scare resources contained in a hospital are typical reserved for the most vulnerable segment of its constituency: pregnant mothers and infants. Blood is drawn from all mothers for reasons related to healthy child birthing and these samples are those most frequently tested in most areas. The Elisa test has been carefully documented to produce false positives in pregnant women. The Elisa test my be 99.9% accurate at what it measures, but even it's Manufacturer admits that the anti-bodies it tests for aren't necessarily present due to a reaction to HIV. So this one subclass of people in Africa is producing what could be false positives from a test that may not be able to prove that HIV is present and those results are being extrapolated over the whole population using statistical methods of estimation.
5. When someone is diagnosed with AIDS, they are not treated with the medicines on hand since it assumed that they are going to die anyhow. Someone with malaria that is drinking non-potable water and has diarrhea and a general itching is said to have AIDS and they are left to succumb to their environmental afflictions. When they inevitably die, this is counted as an AIDS related death. This is not scientifically accurate.

So, in light of these issues I have read and summarized, how exactly am I supposed to react to statements about Africa being the epicenter of the crisis? It seems to me that the money that is being spent on condoms and education is being siphoned from money that should used to build sewers and basic infrastructure that would drastically reduce the frequency of these ‘AIDS’ symptoms. Why isn't this being considered? Doesn't it make more sense to rule out these variables than to reply on an admittedly inaccurate method of diagnosing AIDS?

1:55 PM  
Blogger Bennett said...

AIDS in Africa isn't the same everywhere in Africa. The difficulties you (mostly) rightly point out are present in some areas, and not in others. Resource rich countries don't rely on just ELISA testing to get estimates of HIV prevalence. Any decent study that hopes to get published in the literature will use multiple tests (ELISA plus two WB's for example, similar to the UK standard).

When antenatal testing has been used to produce estimates, they have tried to take into account the obvious problems with extrapolating from a population which is (obviously) at risk of an STD versus the population at large. If you have thought of it, they have thought of it. When larger population studies have been done, they have been able to correct their prior estimations. They have tended to overestimate in some instances, but not all.

The Bangui definition is often held up by the AIDS denialists as a strawman argument. I haven't seen it used to derive population estimates of HIV prevalence, so it can't have affected the numbers.

AIDS can have very different manifestations depending on race and geography. But if you were to pick up a person from the center of Africa and have them live in the middle of the Mid-West, if they had HIV they would eventually get US-AIDS as opposed to African-AIDS. AIDS is an immune collapse, and as such you'll present with the symptoms of whatever pathogens surround your location.

Your comments about drinking water and the like are fair enough. No-one is suggesting that money be _diverted_ away from such basic necessities, but we are suggesting that education and condoms be supplied _in_addition_to_ everything else!

There is one, sad, undeniable fact that has been seen in all countries that have been badly affected by HIV. Their population growth rates and life-expectancies have dropped. The successes of gradual improvements in living conditions, healthcare, infant mortality seen over the last century are being reversed on a continental scale. These aren't estimates based on a theory or a test, they are basic analyses of deaths. More people are dying - and people who have been traditionally the most healthy section of society, the young adults. The appearance of HIV has matched these changes, and where people have intervened to stop the epidemic things have improved.

The other thing you should think about is that it's not the doctors who are in Africa who are saying that the AIDS cases are being misdiagnosed, it's people like yourself who haven't seen the practice of medicine first hand in Africa before and after the appearance of HIV...

And what ludicrous idea entered your head to make you think that someone with gastroenteritis would (a) be misdiagnosed as AIDS and (b) be left to die??!

Regardless of whatever armchair criticism you can make about AIDS in Africa, people are still dying from HIV.

2:38 PM  
Blogger Webconomist said...

How very interesting. I had the (mis)fortune of sitting next to the minister herself 2 years ago on a flight from Jo'Burg to Durban. At the time I was marketing a rapid HIV test, I spoke to her and she was firm in her conviction of a diet of onions and potatoes to cure HIV, which she also said had no proven link to AIDS. This from an educated woman?

I blog on HIV/AIDS at http://slimconomy.blogspot.com
Thanks. Good writing.

6:09 PM  

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