Back in Malawi in 2012 and Ruminations on AIDS in Africa

on Friday, 07 March 2014. Posted in Health and Politics

 

This is part of an original blog written soon after arriving in Malawi in February 2012

 

Chintheche is a small dusty town on Lake Malawi, a glorious mass expanse of fresh water over 60 kilometres wide and maybe up to 600 kl long. It is quite beautiful. There is apparently great fish in the lake, which are basic sustenance for most people. It is a stunningly poor area. Most people are walking. Few even seem to own bicycles and many people are surviving without much money. Malawi is one of the poorest countries in Africa. It is not desperate, as one can see in Niger, parts of Mali or war torn areas of Chad and South Sudan but it is a small country of about 18 million people and has very little natural resources or exports. Where we are is a rural farming area. People have a simple house, maybe a little land to grow food and that is it. Few have any real income and mainly rely on the food they grow. Some of the houses are very well maintained, often surrounded by maize they are growing, but it is very very simple. We are staying in the Flame Tree Lodge, situated right on the lake and about a 40 minute walk from town. It is quite tranquil if a bit on the seedy side. Our room is cramped, with little natural ventilation and of course the fan broke on the 1st day.

The owner is a British expat, married to a local, and with two grown kids. A rather avid beer drinker it seems, he conforms to a stereotypical expat character. He speaks rather disparagingly about the locals, including his staff, and placates himself by having a few drinks in the evening. His restaurant/bar has the obligatory Fosters Lager poster, a framed poster of all the sayings attributed to Murphy’s Law and other assorted colonial paraphernalia. The furniture is of that monstrously heavy and ugly African variety, nothing subtle about it at all. The food consists of Steak and Chips, Fish and Chips, Other meat and chips, or vegetables with either rice or nsima, the local maize/cassava gruel. We are presently in negotiations to bring our own food in and give it to them to cook and also to get some porridge and fruit in the morning, instead of the white bread, fried egg and the weirdest jam you have ever met. At least the tea is OK.

Our walk to the clinic in town is very beautiful, weaving our way through the rice fields and maize and cassava, past a school where the most unique tree I have ever seen is situated. The tree has the most complex root system that starts about 10 feet above ground, and it is so intertwined that it creates a large fan shape, spanning out on all sides of the trunk, making it look like an upside down cone with a tree sticking out the top.

On our first day, we went to the local hospital and met the head clinician who told us about what is happening there, including the lack of medicines. Right now they don’t even have the appropriate malaria medicines. They recently got equipment to measure the CD4 counts in HIV positive patients. Before this, they would base the diagnosis on the HIV testing, plus any clinical symptoms they would see. They have been donated ARVs (antiretrovirals) (as part of the multi billion dollar AIDS project for Africa and other parts of the world, called PEPVAR) so they do treat HIV positive people. However, without having a CD4 counter until now, it may be the case that many people are on these meds when they may not truly be HIV positive or need the meds right now. It is known that some people can test false positive for HIV as the tests used in Africa are not that accurate. (They used to do 3 kinds of rapid HIV tests. If the first is positive, another one is done and then a 3rd if there is any doubt. However, the 3rd test was removed from use 2 years ago, (2012) in most of Africa as it was shown not to work, but only was taken away in Malawi in 2013). Frequent other infections and also nutritional issues and other factors that lead to a suppressed immune system may attribute to the false positive tests. Pregnant women are all tested for HIV and if positive are immediately put on ARV’s. In Malawi, the WHO has instigated an experiment to put all HIV positive women on ARVs for life, even if healthy, and not just for the pregnancy, to try and prevent all mother to child transmission. That is not being done anywhere else, as far as I know. But it is possible that merely by being pregnant can lead to a positive test, and it doesn’t indicate the person has HIV/AIDS. So many pregnant women are likely being put on ARV’s when they don’t need to be.

A movie was made on this subject called House of Numbers. It is worth checking out if you are so inclined. So being HIV positive here doesn’t necessarily mean that you have HIV/AIDS. It is part of the controversy around the diagnosis and treatment of AIDS, especially in Africa. As is also recognized now, you can be HIV positive and be healthy, as long as you keep your immunity up, eat well and basically maintain a healthy lifestyle. Staying away from sexually transmitted disease and other infectious conditions also makes a big difference whether you get sick or not. So, the debate is really whether HIV in and of itself is that dangerous unless you consider behavior and health issues that suppress immunity enough for HIV to act on the system. One other factor is that it has been seen that people can spontaneously sero-convert from positive to negative, making one question again the finality of a HIV positive diagnosis.

So the question is what is HIV and what are the behavioral dynamics that suppress the immune system allowing HIV to perhaps become active. Not so long ago in the West, it was presumed and accepted as law that the vast majority of HIV positive people would get active AIDS sooner or later. Therefore being HIV positive was a death sentence. However, that has not transpired to be the case and not just due to ARV’s. Many people who are positive remain healthy without taking drugs as long as their immune system remains strong. This assumption has also been very common in Africa and so being diagnosed with HIV was like being hexed for many people. They would become social outcasts and at the same time, true cases would not be spoken about as the cultural stigma was too great. People on one level were in denial and on the other believing the dogma being given to them by western doctors and drug companies. Therefore the combination of the power of the word to hex people in Africa has created a huge stigma and social isolation from a positive diagnosis, and combined with very questionable results from the HIV tests which are not HIV specific perhaps has distorted the number of actual cases in many parts of Africa. Even the fact of believing the HIV diagnosis is a profoundly immune suppressive impact. Enough to kill people even as if you give up hope and suffer social ostracization, then there is not much to live for. On top of that, the constant health challenge of dealing with a variety of infectious diseases prevalent in much of Africa and the effect of gross or subtle forms of malnutrition that suppresses the immune system further all contribute to the picture of AIDS in Africa.

So the big question here in Africa is whether many of these people really need to be on ARVs. So many people have malaria, many have TB, and many do not eat well enough and may have had other conditions and so are likely to test positive. But it simply doesn’t mean that they have AIDS. A large increase in T.B (and also Malaria) has been attributable to HIV infection and therefore the 3 diseases are distinctly connected now and in Malawi it is said that about 60% of TB sufferers have HIV infection. But it is also possible that they simply test HIV positive from having TB or malaria and not the other way around and therefore the amount of AIDS cases are actually exaggerated. However, so much more money now goes into AIDS research and treatment than other diseases so therefore that is where all the focus is. At our local hospital they frequently run out of nearly all medicines, including malaria meds and bandaids!! They don’t have blood pressure machines, but they never run out of ARV’s.