Whenever I have an opportunity to obtain original source documents/information, I make a concerted effort to read or attend a lecture which likely is as close to original information as possible. Such was the case today. A MSU Medical School graduate, who has been working in International Health for his career, gave a Pediatric Grand Rounds on "Adolescent HIV/AIDS in South Africa." Michael Banash is an Infectious Disease expert who had developed infectious disease control and treatment programs in Calcutta Bangaldesh, has, over the last 7 years, been in the Zulu Homeland of South Africa, Natal, studying HIV/AIDS in adolescents and young adults.
The scope of the HIV/AIDS problem in sub-Sahara Africa is huge ranging from 6% prevalence in populations of West Africa, to 13% in Central Africal countries, 20% in South Africa, and in the Zulu Homeland, 10% of 14 year old women having thier first child and 50% of women 20 to 34 years of age are infected with HIV. That means that within 7 to 10 years, these HIV infected women will die of AIDS and its related complications. The women have their first sexual intercourse about 5 years younger than the males. The male prevalence data for HIV is highest amongst the 25 to 40 year olds. All of the African prevalence data may underestimate the true prevalence since such information is collected after the mother has delivered her first child and she consents to be tested for HIV, and informs who her partner is. The consent process is complicated by the societal shame associated with HIV infection. Societal shame has multiple factors. The person with AIDS and just being sick is believed to reflect badly upon one's self and dishonors one's ancestors. One is a victim of a spell cast by another or an ancestor. One of the most important contributors to societal shame for this population, however, is the perceived failure of the traditional healer to cast out the "spell" which is believed to be the cause of the person's ailment. In addition, Zulu traditional healers do not acknowledge chronic illness (for the same reason as looking impotent by not casting out the spell of HIV) nor preventative care since the body does not look "sick." The conflict between traditional and Western medicine is being played through out Africa on the broader government level as well . Recently, a 30 year old South African Cabinet member died of pneumocystis pneumonia, a type of pneumonia found almost exclusive in adult patients with AIDS, and there was a denial of HIV infection in this man by governmental officials.
More than 50% head-of-households in Natal are women. When the HIV infected head-of-household mother dies, her children may be adopted into a relative's home, unless the child is HIV positive. There is a dysincentive for the mother to find out if her child/children are infected with HIV, since the children may not have any place to go when the mother dies. And, since the Zulu tradition does not involve forming villages or towns where children may gather and be visible, the initially adopted child who later on is found to have AIDS, then is "out" of the adopting relative, and disappears into the bush.
Against this background, Dr. Banash has spent the immediate last two years of his 7 years in this region, organizing an informational and interventional program which would go from school to school. To attract children to the program, school uniforms and computer lessons/time are offered to those who do not have uniforms and almost no one has access to computers. Mobile teams provide limited examinations, testing and counseling services after an initial 2 hour informational session. This traveling program then will return again and again, enhancing the educational, counseling, and testing components. The program runs on weekends and school holidays for the parents of the children. Two years were required to develop this program: to meet with government officials who did not want to look bad in front of Non Governmental Organizations (NGO), governmental personnel lacking authority to permit NGO's from operating within the various communities, central government kicking out the Luthern missionary medical services which was the only provider of medical care to Natal; need for tribal leader approval in multiple geographic and overlapping regions; and developing partnerships with traditional healers to allow information and testing to occur.
Treatment for AIDS and vacinations against HIV are a very difficult issues at this time. Current WHO recommendations to initiate Anti-Retroviral Treatment involves assessment for the complications of AIDS, individualized treatment for those complications, all by highly trained medical personnel such as doctors and advanced practice nurses. Recruiting such highly medically skilled people is difficult since they would have to go into these areas overnight and this area has a very high murder rate. (Some of the high murder rate is related to the only crop raised: marijuana.) (The people staffing the testing, educational and counseling program are recruited from the indigineous population) Vacinations against the HIV are more than 15 years away by some estimates since the HIV outsmarts the human body's defenses and adapts to the new changes in the immune system. However, the most effective preventative therapy against HIV acquisition, more than 60% effective, is circumcision of males. In the Zulu culture, circumcision is not an accepted practice, nor is it performed so there are no practitioners who could perform circumcisions. (in the Jewish tradition, a Rabbi or maven perform circucisions on the newborn male so a medically trained practitioner is not needed).
In the fourty five minute presentation, the 45 minutes of questions and answers that followed, as well as the hour spent with resident teaching during Pediatric Subspecialty Conference, there was a lot of first hand information. When I got home, KK suggested that I write down what had been discussed so that I could remember for a future date. I thought I would share some of the information to you as HIV/AIDS in Africa are regularly in the news.
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