Malawi's struggle with AIDS
frica is a continent without hope because of war, crime, poverty, hunger, but mostly because of disease," said Calgary physician Dr Chris Brooks citing a recent article from The Economist.
Yet Brooks gave up a well-paid medical position in Canada to found and operate Lifeline Malawi, a faith-based Non-Governmental Organization in the remote village of Ngodzi, Malawi. His motivations and experiences with pioneering HIV/AIDS interventions in southern Africa were the focus of a public seminar at the University of Calgary on Tue., Nov. 13.
Nearly one-third of Malawi's adult population is HIV-positive according to the latest UNAIDS survey. When Brooks arrived in Malawi in 1998, the country of 12 million inhabitants had only 120 registered physicians and one of the worst health infrastructures among African nations. Life expectancy has been dropping steadily since the pandemic took hold in the early '80s. Today, Malawians can expect to live only 42 years on average according to a 2007 UNAIDS survey.
Initially Brooks noted he had doubts about what he could contribute to Malawi.
"When I got there, I knew nothing about AIDS," he said.
However, with so few physicians, his expertise of general medicine and tropical diseases were well utilized. After a crash-course in AIDS testing and treatment, he set up a medical practice in an orphanage providing care for primarily HIV-positive children, most of whose parents had died from the disease.
"Seeing the care we were providing in the orphanage, village children would come up and ask, 'can I please be an orphan too?'" said Brooks.
Realizing that treatment needed to reach the wider community, Brooks set about forming his own clinic--Lifeline Malawi. From humble beginnings with a table, two chairs, and a box of medicine beneath a baobab tree, demand for his services was high.
"In those days, my translator, my nurse and I would see 400 patients a day," he said. "The treatments were very basic, but that was all that was available."
Today, Brooks operates two clinics with 65 staff, seeing approximately 3,000 patients per month.
Brooks explained making a real difference to the Ngodzi people was only possible after earning the trust of both the community and benefactors.
"People are very suspicious of faith-based NGOs" he said. "We don't require patients to convert to Christianity."
He noted that the only requirement is that patients make it to the clinic.
"We only require that patients have two legs--and even that is negotiable," he added.
The clinic's credibility grew significantly after the tribal elders came to trust him, noted Brooks. Additionally, financial and pharmaceutical donations now require stringent managerial and accounting practices from an NGO, adding further challenges to providing service to the community.
"In order to deliver an intervention, you need to demonstrate integrity, credibility, accountability, and transparency," he said.
Brooks noted it took Africa 20 years to get Anti-retroviral drugs.
The cost of ARVs was previously a prohibiting factor, with a month of treatment costing over $1,200.
Organizations such as the Global Fund and Health Partners International Canada now provide a monthly course of Highly Active Anti-Retroviral Therapy for as little as $12 monthly, according to Doctors Without Borders.
There's no question about the impact ARVs have had on HIV-positive Malawians. Last year, a nurse from the clinic contracted HIV/AIDS and rapidly became ill with fungal meningitis and active pulmonary tuberculosis, explained Brooks. After treating these infections and starting a course of HAART, she recovered in under a month and has been happily providing service at the clinic ever since.
However, ensuring patient compliance continues to be a problem in Malawi, he noted. Continued supplies of ARVs from health organizations are dependent on strict patient compliance.
"HIV can become resistant to HAART" explained Brooks. "Many patients stop the course after they feel a little better, then either sell or give away the remaining pills, and if you stop the treatment, you're worse off than when you started. You're left with very few treatment options."
At his clinic, adherence is maintained through rigorous screening and counselling.
Unfortunately, despite subsidized, generic drug availability, ARVs are still the least cost-effective intervention. Brooks noted the most effective intervention is education. Promoting and encouraging testing is a priority for the clinic.
"The stigma of HIV testing is one failure of present interventions," explained Brooks. "In Uganda and Tanzania, where testing and treatment are widely accepted, the incidence of HIV continues to drop dramatically."
Other education initiatives include teaching patients about how to stay healthy and avoid opportunistic infections and diseases such as tuberculosis, herpes, lymphoma and carcinoma. The other priority is prevention.
"We often use 'drama intervention'--performing plays about avoiding HIV in a funny way," said Brooks, noting they try to target children with the plays. "They will listen, and they won't forget."
The power of education as an intervention method is undeniable explained Anna Tsien, a Canadian who recently returned from a two-month term volunteering at a HIV clinic in Tanzania.
"Until a vaccine can be found, education is really the only effective way to control [the pandemic], especially since resources are so limited," she explained.
Her clinic focused on school-aged children, teaching them to either abstain from sexual activity outside of monogamous relationships, or at least practice safe sex, she explained.
"We also targeted high-risk women such as those in the sex-trade," she said. "Many of them were actually having unprotected sex for a higher payment."
Support is growing for interventions that prevent the spread of HIV from mother-to-child, encouraged by the World Health Organization. This relatively cost-effective intervention can decrease the risk of transmission of HIV from mother-to-child by up to 70 per cent, through safe birthing and feeding practices, and administering a short course of ARVs during pregnancy, according to the U.S. Center for Disease Control.
Brooks recognized its potential as another effective intervention to slow the pandemic, but also highlighted the wider problem of high maternal mortality in Malawi.
"Our next project is to build a maternity ward and encourage more women to give birth here and not isolated in the bush," he said.
Brooks noted that after 10 years he's seen improvement
"They predict that overall, the HIV/AIDS pandemic will claim 600 million people, and we want to help keep it at that," said Brooks. "The Economist says there's no hope for Africa. Well. I believe there is hope--with intervention."