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CMAJ
CMAJ - September 8, 1998JAMC - le 8 septembre 1998

Facing reality

CMAJ 1998;159:443-4

The lack of appreciation of the sub-Saharan HIV/AIDS pandemic was emphasized by Dr. Meb Rashid in his article "AIDS in Africa: a personal experience" (CMAJ 1998;158[8]:1051-3). When I volunteered in 1995 for 5 months in the mission built and supported by Tebellong Hospital in Lesotho, southern Africa, I had no idea that, according to the World Health Organization (WHO), this region was home to 20 million people with AIDS (two-thirds of all cases worldwide). Nor was I aware that the Minister of Health of South Africa had estimated that 20% of that country's population (i.e., 40 million people) was HIV positive, with men and women equally affected but blacks much more affected than whites. Lesotho, a country completely surrounded by South Africa, appeared to have similar statistics.

When my wife and I arrived in Lesotho, medicine at the isolated 46-bed hospital was primitive: no telephone, no blood transfusions, no assays for hemoglobin or glucose. A retired Canadian family physician was the only doctor. Two-thirds of the $1 million for annual hospital operation came from the Africa Inland Mission. Transport of patients to the referral hospital in the capital city of Maseru, of staff and of any medical supplies was provided by the Mission Aviation Foundation. Pilots flew a 4-seat Cesna over mountains 3350 m high and landed on a short dirt airstrip. Conditions for air travel are treacherous, and our pilot later died in a crash.

About half of the adult patients were being treated for tuberculosis, and a third (probably 50% by now1) were HIV positive. This combination is a serious double burden in sub-Saharan Africa and has led to a secondary tuberculosis epidemic.2 I pricked my finger after taking blood from a patient with tuberculosis. It took a month for his HIV test result to come back: positive. And no drugs for treatment were available.

Relatively few patients had symptomatic AIDS in 1995, but this has changed. A recent letter from the able public health nurse stated that her friends, relatives and neighbours are starting to die from AIDS. Home care has been started, and village health workers and family members are being taught to care for the terminally ill. The increasing number of untreated cases will probably reduce farm output and education and lead to increases in crime and serious government problems.

What can be done? The aim is to prevent transmission by reducing the number of sex partners, promoting condom use and controlling STDs. School education for the children,2 for whom I was told sexual activity often starts at age 11 or 12, needs much improvement. High school graduates asked me if I believed that AIDS existed. The government has avoided taking responsibility. Political and tribal leaders and traditional doctors must play a role through educational radio programs and village visits. More medical staff is needed. The hospitals should make more educational videos about HIV, AIDS and STDs, featuring local residents, and show them on battery-powered televisions in hospitals and villages.

Drugs might start as gifts, such as those used for tuberculosis in Lesotho's mission hospitals. For example, I am sending recently outdated drugs. If only zidovudine were available for HIV-positive pregnant women, even for short periods.3 Unfortunately, a diagnosis of HIV can mean violence if the woman's husband finds out, and without treatment such a diagnosis yields no benefit.

Considering the drug-related improvement in AIDS mortality in the US4 and the worsening statistics in most developing nations, which bear over 90% of the world's HIV/AIDS burden (a reflection in part of social inequities1), governments, pharmaceutical companies, international agencies and philanthropists will have to give very generously if this pandemic is to be controlled.1

M. Henry Gault, MD
Professor Emeritus
Memorial University of Newfoundland
St. John's, Nfld.

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References
  1. Msamanga GI, Fawzi WW. The double burden of HIV infection and tuberculosis in sub-Saharan Africa [editorial]. N Engl J Med 1997;337:849-51.
  2. Morris K. HIV epidemic could number 40 million by year 2000 [news]. Lancet 1997;350:1683.
  3. Kigotho AW. Trial to reduce vertical transmission of HIV-1 on schedule in Uganda [news]. Lancet 1997;350:1683.
  4. Steinbrook R. Battling HIV on many fronts [editorial]. N Engl J Med 1997;337:779-80.