The Malawian context of the new WHO recommendations for HIV treatment

The WHO on the eve of World Aids Day (30th November) issued new recommendations for treatment, prevention and infant feeding in the context of HIV,  based on the latest scientific evidence.  Highlights of the new recommendations include starting antiretroviral therapy (ART) earlier in adults and adolescents, delivery and use of better-tolerated and more conveniently administered antiretroviral drugs (ARVs), and longer use of ARVs to lower the risk for mother-to-child HIV transmission.

In the last five years close to 50 scientific articles have published research on Malawi, recommending similar actions. The Ministry of Health in Malawi has been slow to act, ignoring these findings and awaiting guidance from the WHO. This is ironic because some of the WHO advisers are the very same said local researchers but government  prefers WHO to rubberstamp new guidelines.  I am certain that our local research has influenced the revised WHO policy, however  I am not sure to what extent, but none the less I would like to highlight some papers that were published and discuss the implications of these recommendations in reference to Malawi.

Earlier start to ARVs and clinical laboratory tests

The WHO advocates starting ART when CD4 cells, which are defense cells of the immune system, fall below 350 cells per millilitre. The previous recommendation was 200 cells per millilitre but research has shown that an early start can reduce death rates.  A paper published last year  found that death rates were high in those who started ART at CD4 counts of less than 200. However,  in some cases  in the absence of diagnostic equipment, WHO clinical staging has been used. This system uses patient’s clinical symptoms to guide decision making but often fails to diagnose those eligible to start ART.

In accordance with the change in the CD4 level threshold, WHO is also encouraging increased access to laboratory tests that can not only determine CD4 levels but also viral load, the amount of HIV in the blood.

Breast feeding and mother to child transmission

WHO is recommending, for the first time I must add,  that HIV-positive mothers take ARVs during the entire course of breastfeeding to prevent disease transmission.  Several seminal papers have been published by researchers at Johns Hopkins in Blantyre on mother to child transmission, which have called for extended prophylaxis for infants.  The argument in the past has been  – to reduce mother to child transmission,  mothers should not breastfeed, but  in resource poor settings, mothers  often cannot afford to give their baby formula, plus there is  the added problem of providing formula with safe drinking water.  The new recommendations also call for HIV pregnant mothers to start ARVs at 14 weeks instead of the previous 28 weeks.

ARV drugs

The WHO is also urging for the replacement of stavudine, or d4T — a first-line antiretroviral with tenofovir or zidovudine. Stavudine is readily available and cheap in developing countries but has been known to produce irreversible side effects.

The new recommendations will lead to more people needing treatment, said the WHO, but they say: “The associated costs of earlier treatment may be offset by decreased hospital costs, increased productivity due to fewer sick days, fewer children orphaned by AIDS and a drop in HIV infections.” But I ask what could this mean for Malawi?

Some reports estimate that the new recommendations would mean 2.5 to 3 times as many people will be eligible for treatment. In 2005, only 14,300 people were on treatment, in 2009 250,00, this is a commendable achievement by Malawi’s National AIDS Council (NAC) although this still falls short of the number in need of treatment which was estimated as 340,000 by UNAIDS in 2007. Therefore NAC has to double their efforts in order to provide universal access to the “newly” eligible .

Access to laboratory testing facilities must be improved so that people in remote areas should be able to conveniently and regularly have CD4 count and viral load tests  and even in the absence of these tests should not be denied treatment.  This will require machines and trained staff in places as far as Nsanje and Chitipa.  A paper by van Oosterhout has discussed how viral loads can also determine patients whose treatment is not working.

The current recommended first-line treatment for ARVs in Malawi is a combination of three drugs that include stavudine, with the average cost of this combination therapy pegged at  US$ 15 per person per year (2005) . Replacing this drug will be expensive but if the President follows through with his commitment,  we could be manufacturing our own ARVs which would drastically reduce the cost.  The drugs recommended to replace stavudine , tenofovir or zidovudine, although more expensive will offset the cost of reduced toxicity management in hospital.

All the recommendations urgently require money, but with so much criticism of late in funding AIDS programs, where will the money come from?

Language domination debate, a history of glamour and music experiments

Glamour, a definition

A language domination debate, a history of glamour and music experiments, these were the three activities I attended on a very miserable gloomy Saturday. The first event featured Professor Stephen Gundle from Warwick University, the author of the book Glamour: A History, interviewed by Dr.Sean Campbell from Anglia Ruskin University. I never attended a session like this before which essential is a live interview. Sean asked Stephen questions and Stephen when answering faced the audience and when he had finished answering would turn to Sean. There were moments when I thought that the two were reading from two different scripts – one having prepared questions he wanted to ask and the other information he wanted to present regardless of the question. He began by commenting on how “slippery” defining glamour is – its different things to different cultures in different times but it is all about image and therefore requires an audience. Leisure, fame, wealth, sex appeal, and beauty are some of the values associated with glamour and the more of these values a person, object, event or place has the more glamorous it is. Glamour is an appealing combination of trash, class, style, and elegance mixed with a pinch of vulgarity.

West African glamour!

West African glamour!

Gender roles in glamour as producers, performers, consumers were discussed as well  glamour in popular music. One of things I found was missing and only gets a cursory mention in his book is the Black American take on glamour, “pimping” and “bling bling” and glamour in the African context which has roots in African culture and tradition. For example in West African fashion and style, the women wear ostentatious headwraps, adorn flamboyant bubus during lavish feasts and celebrations. If there are no books out there, I suggest someone writes one on African Glamour. I also find out it strange that a talk on glamour did not have any pictures – I think he could have illustrated his talk  with a visuals, after all, all the Powerpoint equipment was there.

Which language would conquer the world

If you were to choose the language of world domination would it be Greek or Latin. That was the topic of the debate I attended. Two Professors from each language argued the merits of each language in two rounds of seven minutes each with questions from the audience at the end. Both of Professors came well prepared one brought a Latin cartoon handout and the other dressed in t-shirt promoting the Greek Alexander the Great. A poll was done at the beginning and the end, and Latin won hands down, mainly because it is very predominate in the English language.

Music experiments

You on music – a series of experiments and talks organized by Cambridge Music Education Outreach (CAMEO) probably by far the most organized event that I attended probably because they have a dedicated community outreach project. A series of experiments, hands on activities for children and talks. I took part in the silent disco. We were a group of about fifteen people and unknowingly we were split into two groups listening  to different music through wireless earphones. I was in the group listening to the very slow song Lady in Red by Chris de Burgh and the other group were listening to a very fast track from Spice Girls. What you find is that those who are listening to the same song dance in tune with each other, interact more and more likely to remember things about the person who they were dancing in tune with. Other experiments looked at the influence of music on mood, music in movies and in film, music and memories, music and time – I even had a chance to make a 30 second clip for a action packed scene in the Transformers movie.  The only downside of this event was to find out what the experiments were about you had to go to the Discovery Zone, a room tucked away in the back that had posters explaining the reasoning behind every experiment. This was all somewhat anticlimactic for me to have to read all this information on a posterboard. I would have liked to have known what my participation meant in the big picture e.g. for the silent disco – did I remember more details of the people I was dancing in tune with.

Food for thought

A book on  the history of African Glamour. A talk in Malawi on “pimping” and “blinging”.

If you going to have a talk on something extremely visual like Glamour – why not illustrate it with some pictures.

Debate format – two speakers 7 minutes each, two rounds, first round they put forward their argument and second round they respond to the others argument with time allowed for questions from the audience. A poll should be done at the beginning and at the end to see who was able to change people’s stand point. Speakers should be witty, outspoken, and well versed on the subject. The Chair should do a good job of introducing the subject, controlling for time, handling the poll and questions from the audience. Time should be given at the end before the poll for speakers to summarize.

Children love music! Have activities that basically give children the right to clang on instruments and make noise! If you are going to run a series of experiments come up with a way that allows people to know what the experiments are about and give them a chance to analyse and interpret their results.

School outreach

I attended my first activity as a science engagement tourist. It was a meeting on school outreach. Present were members of various Faculties from the university and teachers from schools.  I learnt a lot from this meeting – first it is possible to start and end a meeting on time from 9:15 to 10:40, finished 5 minutes early, something that is extremely rare back at home in Malawi where everyone feels they must have their say on each and every agenda item!

Outreach policies

Although an office exists that coordinates outreach, there is no specific mechanism or systems in place to effectively manage schools outreach. No university guidelines or policies exist making it difficult for example to contact the appropriate person responsible for outreach in the various departments if such a person even exists. And likewise not all schools have a liaison officer. In a brief presentation by a business liaison officer from one of the schools, the benefits of schools having a dedicated person (although part time) were outlined. Since her recruitment, students have participated in several activities with academic institutions and businesses. It will be interesting to evaluate the impact of this on student’s attitudes, knowledge, and career choice. Someone present at the meeting reported that they were about to embark on a longitudinal study looking at the outcomes of long term outreach programs on students’ knowledge and attitudes.

The law on working with children

The United Kingdom has stringent laws on working with children. Any volunteer or member of staff who intends to work with children must have a Criminal Records Bureau check. Such a system protects children from offenders and abuse. I doubt if such a policy exists in Malawi but I can see the potential benefits especially with the increasing number of cases of teachers using their authority to take advantage of female pupils.

Short of funds

The global economic crisis has left no institutions untouched. Cut backs are eminent, decisions need to made on what is core and what is extra and sadly public engagement and schools outreach may not be considered  vital. The defence would be to present the specific positive outcomes and significant impact outreach has on increasing knowledge, attitudes, and understanding as well as to show increasing number of students pursuing degrees in science. In the long term science is beneficial to economic development. A more immediate strategy could be to charge a small fee for children to attend outreach events.

The cost of excursions

Outreach from a school’s point of view in the UK is a costly exercise. For any trip, transportation costs, cover for the teacher going on the excursion, and the change in normal teaching for the students remaining must all be factored in. To counter this, academics can be invited to the school but students are excited to get away from school and visit the places where the work actually gets done. There are however cost savings to schools when scientists visit with the added potential of having several local schools congregate at one location so that more students can be reached in one visit. Alternatively outreach projects can offer a lot more programs during mid term breaks as this transfers the expense to the parents and not the school.

How do you engage the disengaged?

During the meeting an important question was asked “How do you engage the disengaged?” How do you connect with schools that do not have a dedicated outreach member of staff, that have no funds for science engagement, that have overworked and underpaid teachers, and poor science facilities.  This is a question that I can extend to Malawi because although the context is different the problem is the same. Does anyone out there have any answers?

Food for thought

Science institutions should have a  framework, policy, or guideline for school outreach. Included in this should be points of contact for persons responsible for outreach.

Investigate what the law in Malawi is on working with children.

To overcome the costs associated with an excursion, invite scientists to the school and have several schools meet in one venue so that more students can be reached.

With budget cuts looming, to raise funds charge a very small fee to cover event expenses.

Offer a lot of activities during the mid term breaks so that the expense will be covered by the parent and not the school.

Evaluation is important to show the benefits of outreach.