REPOST: Malawi's success story in reducing HIV infection

Malawi has been seeing a decrease in the number of HIV-related deaths and infections recently. The Guardian discusses further the details of this medical success.

Taking a blood sample to check HIV levels at a clinic in Bvumbwe, Malawi.
Image source: Guilio Donini/Unitaid via TheGuardian.com

Margaret Chiyabwa sits behind a wooden desk, piled with papers and packets of antiretroviral drugs (ARVs). She is filling in a green patient card. It's raining outside and the room at Bvumbve health centre in rural Thyolo, a district in southern Malawi, is crowded and stuffy. Men, women and children queue along the wall, waiting for a check-up, or to collect medicine. Outside, more people squeeze under the roof of a brick walkway connecting two of the health centre's buildings to shelter from the showers. It's not yet 9am.

This is a quiet morning, says Chiyabwa, a Médecins Sans Frontières (MSF) nurse, as she assesses whether the patient sitting in front of her, who is HIV-positive, should have her viral load (VL) tested.

Around 35,000 people are on ARVs in Thyolo, which has an HIV prevalence rate of more than 14%, higher than the national average of around 10%. By the end of June, 14 of the 27 health facilities in the district, supporting around 75% of ARV patients, were offering VL testing.

"After six months on treatment, we will be asking to test patients' viral load," says Chiyabwa. "It's a good thing because those with a high viral load, we are able to assess if they should go on second-line treatment, before it's too late for them."

Unlike CD4 cell counts, which monitor immunity levels, VL testing detects the level of the HIV virus in the blood, which indicates the extent to which treatment is working. This information allow doctors to determine whether to change treatment if levels are too high, before a patient's condition gets too serious – moving them from first-line to stronger second- or third-line drugs, for example – and also stops patients being put on more expensive drugs unnecessarily.

While the cost of first-line drugs has fallen significantly, from about $10,000 (£6,100) per person, per year in 2000, to about $140, second-line treatment is more than double that amount, at about $300, while third-line treatment is more than £2,000.

VL testing is being heralded as the gold standard in monitoring the virus. This year the World Health Organisation recommended its use to monitor HIV at six and 12 months after the start of treatment, then at least every 12 months after that. However, high costs and the difficulty of introducing the VL technology in poor, rural settings, means this is not an option in many developing countries. According to MSF, laboratory-based tests can cost up to $72 per test result, out of reach of many government budgets.

In an MSF survey of 23 developing countries last year, viral load testing was widely available in only four. MSF said there was an urgent need for simple and affordable viral load technologies that can be used in district laboratories, clinics and communities. There are also calls for more HIV funding to be used to develop new tools and treatments for local health facilities.

Getting tested

At Bvumbve, up to 30 people a day are having their viral loads tested as part of a three-year MSF project funded by Unitaid, a global health initiative funded in part by levies on airline tickets.

The MSF project is evaluating the effectiveness of different viral load and CD4 testing technologies in seven African countries with high rates of HIV – Lesotho, Malawi, Mozambique, South Africa, Swaziland, Uganda and Zimbabwe – to see what works best in poorer settings.

Madalitso Nkumbi, 33, a mother of two, is waiting for a blood test. She discovered she was HIV-positive in 2008, after attending an antenatal clinic when she was pregnant with her second child. She's been living well on ARVs ever since, but is pleased to be offered the viral load testing.

Nkumbi's husband left her when he discovered she was HIV-positive, so she needs to keep well to look after her children, she says. "Since I started getting ARVs, I feel OK, and with the viral monitoring I'm so happy because I know if the drugs are working."

Nkumbi's blood is taken from a finger prick and blotted on to absorbent paper. It will be taken by motorbike to the district hospital for testing. The collection of dried blood samples is being trialled by MSF at Bvumbve. If this method proves effective, it will ease storage and transportation, as samples taken in this way do not need to be kept in a fridge. It should also ease the workload of medical staff, as tests can be taken by healthcare assistants.

Nkumbi should get the results in a week. If her VL is low or "undetectable", she can continue on her one tablet a day regime. But if levels are high, she will receive counselling for three months before a second test is taken to see if any change has occurred – sometimes lack of nutritious food or a short illness can cause a temporary blip in VL levels. If after three months high levels are still recorded, she may need to switch drugs.

"Viral load is a strike in HIV management," says Arthur Mateyu, technical supervisor for eight health centres in Thyolo. He predicts more people will be put on second-line treatment as a result of the VL rollout. "What we're seeing is a lot of clients who were supposed to be on second-line, but were still on first-line drugs. People were dying, nothing could be done because of treatment failure. But viral load testing is helping us to monitor adherence to ARVs."

Malawi is considered a success story in reducing HIV infection rates, passing the tipping point – when the number of people starting treatment exceeds the number of new infections. According to UN figures, between 2001 and 2011, the rate of new HIV infections dropped by 73%. This was helped in part by the introduction of ARVs in 2003, which have slashed death tolls from 92,400 to 45,600 over the past decade.

But, with an HIV prevalence of about 10% among people aged 15 to 49, Malawi has the ninth highest HIV rate in sub-Saharan Africa, according to UNAids estimates. And more than 40% of new infections are among 10- to 19-year-olds. The country is heavily reliant on support from international donors to fund its national HIV and Aids programmes. Any increase in the number of people on second-line treatment could exacerbate the problem.

Stigma still surrounds the condition, but things are improving, says Chiyabwa. "People are opening up and feel free to come to the clinic. This year we have had more patients collecting ARVs because patients are opening up and are free from stigma," she explains.

Establishing HIV support groups has helped. The Chidothe village support group, about three miles from the clinic, meets every Monday afternoon to talk through any concerns they have about treatment or other aspects of living with HIV.

Ennet Manda, 49, from Nanthereza village, is a member. She suspects her husband passed on HIV to her because he died of unknown causes in 2002. Discovering she was HIV-positive was a relief, she says. She recently had her VL tested and her levels came back as "undetected", which means she has a very low chance of transmission and, crucially, that the drugs are working.

Manda adds: "I never worried. I accepted it [the result]. I wasn't shocked. I was happy that I finally knew my status. I started to take drugs and I've got my life back."

Currently based in New York, Dr. Paul Frymoyer has also spent some time practicing medicine in Malawi, Africa. Visit this blog to read more about his experiences as a travelling physician.

REPOST: 11 new genes tied to Alzheimer's disease

Alzheimer's disease, characterized by memory loss and dementia, is a fatal progressive brain disorder which medicine cannot cure as of yet. Time.com recently reported the discovery of a connection between 11 new genes and the disease, a development that may help the search for the best treatment. Read more:

Scientists have doubled the number of genes associated with Alzheimer’s disease, giving researchers twice the number of targets for drug therapies.

The genetic bonanza, reported by an international group of researchers known as the International Genomics of Alzheimer’s Project (IGAP), emerged from a study of 74,076 patients and healthy subjects from 15 countries.

Some of the new genes–which are involved with late-onset Alzheimer’s–are tied to immune response and inflammation, while others are related to cell migration and brain pathways.

Identifying so many new genes opens the opportunity for more precise drug therapies that have the chance of being more effective in treating the cognitive decline, such as memory loss, that are the hallmark of the disease.

The researchers, who published their study in the journal Nature Genetics, plan to expand the data set to look for rare variants of the genes that may help to explain the different ways the disease can develop. That may also yield clues for better drugs as well. Currently, medications can only reduce some of the cognitive symptoms of Alzheimer’s without affecting its basic disease-causing processes.

Paul Frymoyer, M.D. is dedicated to learning about breakthroughs in medicine in order to help those who need medical attention. Visit this Facebook page to find updates about modern medicine and healthcare.

REPOST: UK firm seeks to market world's first malaria vaccine

Malaria is a disease that has plagued Africa and various parts of the world without an effective means of prevention for decades. Now, a BBC article reports that global pharmaceutical leader GSK may have the first malaria vaccine that actually works.

The trial showed a reduction in cases by 25% in infants and 50% in older babies | Image source: BBC

Continue reading the main storyWatch

British drug maker GlaxoSmithKline is seeking regulatory approval for the world's first malaria vaccine after trial data showed that it had cut the number of cases in African children.

Experts say that they are optimistic about the possibility of the world's first vaccine after the trial results.

Malaria, a mosquito-borne parasitic disease, kills hundreds of thousands of people worldwide every year.

Scientists say an effective vaccine is key to attempts to eradicate it.

The vaccine known as RTS,S was found to have almost halved the number of malaria cases in young children in the trial and to have reduced by about 25% the number of malaria cases in infants.

GlaxoSmithKline (GSK) is developing RTS,S with the non-profit Path Malaria Vaccine Initiative (MVI), supported by funding from the Bill & Melinda Gates Foundation.

"Many millions of malaria cases fill the wards of our hospitals," said Halidou Tinto, a lead investigator on the RTS,S trial from Burkina Faso.

Malaria is caused by protozoan parasites that are transmitted by the bites of mosquitoes.
Image source: BBC

"Progress is being made with bed nets and other measures, but we need more tools to battle this terrible disease."

The malaria trial was Africa's largest-ever clinical trial involving almost 15,500 children in seven countries.

The findings were presented at a medical meeting in Durban, South Africa.

"Based on these data, GSK now intends to submit, in 2014, a regulatory application to the European Medicines Agency (EMA)," GSK said in a statement.

Continue reading the main story

The company has been developing the vaccine for three decades.

The statement said that the hope now is that the Geneva-based World Health Organization (WHO) may recommend the use of the RTS,S vaccine from as early as 2015 if EMA drugs regulators back its licence application.

Testing showed that 18 months after vaccination, children aged five to 17 months had a 46% reduction in the risk of clinical malaria compared to unvaccinated contemporaries.

But in infants aged six to 12 weeks at the time of vaccination, there was only a 27% reduction in risk.

A spokeswoman for GSK told the AFP news agency that the company would file its application to the EMA under a process aimed at facilitating new drugs for poorer countries.

UK politician Lynne Featherstone, International Development Minister, said: "Malaria is not just one of the world's biggest killers of children, it also burdens health systems, hinders children's development and puts a brake on economic growth. An effective malaria vaccine would have an enormous impact on the developing world.

"We welcome the scientific progress made by this research and look forward to seeing the full results in due course."

Dr. Paul Frymoyer is a physician who has travelled to Malawi, Africa to practice medicine.  He writes about his experience as a travelling nephrologist in his blog.

REPOST: The Wait for the No-Hangover Beer Continues

Beer and other alcoholic beverages contain some of the most dangerous chemicals for the kidneys. Read this article to learn how these beverages can also be detrimental to other organs and metabolic processes in the body.

A new type of beer claims to decrease dehydration. | Getty Images

Image source: abcnews.com

Whether you're watching the big game at your local bar or playing an intramural kickball game under the influence, beer and sports seem to be a natural pairing.

Even so, if you have one pint too many, you'll be writhing in pain the next day because of nausea and headaches. Is there a way to drink your beer without the fear of the morning hangover?

Ben Desbrow, inspired by the beer-sports connection, ran an experiment to see how beer affected the balance of fluids in the body. Desbrow, a researcher at Griffith Health Institute in Australia, examined whether making beer more like Gatorade and adding some electrolytes would mitigate its alcohol's tendency to dehydrate people who drink it.

"We basically manipulated the electrolyte levels of two commercial beers, one regular strength and one light beer, and gave it to research subjects who'd just lost a significant amount of sweat by exercising," Desbrow said in a statement. "We then used several measures to monitor the participant's fluid recovery to the different beers."

According to the research, published in the International Journal of Sport Nutrition and Exercise Metabolism, subjects lost about two percent of their body mass after exercising and replenished most of the fluid they lost with beer.

The light beer (with 2.3 percent alcohol by volume) fortified with sodium fared the best, helping the subjects retain about one-third more of their body's fluids and urinate less. However, the result was not statistically different than the regular light beer, which had less alcohol than regular beer.

In addition to more research being required on the dehydrating effects of beer additives, there is more to the hangover than dehydration. Michael Oshinsky, the director of preclinical research at the Jefferson Headache Center in Pennsylvania, said that one of alcohol's metabolism byproducts, acetate, plays a big role in the hangover headache.

"We reproduced the alcohol-induced headache in rats," he told ABC News. "If you block the enzyme that breaks down acetaldehyde to acetate, you don't get a headache."

There is also some human evidence for acetate playing a role in the hangover.

"In the past, about 25 percent of kidney dialysis patients said they had whopper headaches," said Oshinsky. "They changed the concentration of the acetate in the dialysis bags, and now it's less than one percent. It's not dehydration that induces the headache."

Find out how important it is to care for the kidneys by reading this blog for Dr. Paul Frymoyer.

REPOST: Many Africans with Diabetes Unaware of Illness

A study published by the World Diabetes Atlas found that more than 15 million Africans are unaware that they have diabetes. It also predicted that this number will surpass 500 million by 2031. The Voice of America provides a detailed report on this issue.

YAOUNDE, CAMEROON — A study published in the World Diabetes Atlas says that more than 80 percent of people living with diabetes in sub-Saharan Africa do not know that they suffer from the disease. Sub-Saharan Africa has more than 15 million of the 371 million people living with diabetes in the world.

The report states that diabetes is a global burden as the number of people living with the disease continues to rise. But it says the situation is worse in sub-Saharan Africa.


Image source: voanews.com

Dr. Palma Mesumbe of the Cameroon Diabetes Association said even in North Africa where many more people visit hospitals, half of the patients did not know that they had diabetes.

“It is clearly established today that the number of diabetics is increasing on the day. Half of the people who have diabetes do not know they have it. We are talking about 52.9 percent for instance in North Africa that do not know that they have diabetes,” said Dr. Mesumbe.

The World Diabetes Atlas study adds that the greatest number of people with diabetes are between the ages of 40 and 59. Another medic, Dayawa Akuns, said a lot more within the same age group may be living with diabetes without knowing it, since symptoms can only be noticed at chronic stages.

“At the moment when we have the signs and symptoms of diabetes, it is assumed that more than 50 percent of the cells that have the responsibility to produce insulin have been destroyed. Over time as these cells are being destroyed, we are not going to see the symptoms because it has not reached a particular threshold to trigger signs and symptoms,” said Akuns.

It is projected that by 2031 the number of people living with the disease will increase to more than 552 million. Palma Mesumbe said that it would be a serious problem, especially in Africa which is socially and economically disadvantaged.

“It's going to be a problem in Africa where we are going to see a doubling in the prevalence of diabetes. We are at 4.3 percent and in 20 years that percentage is going to double, and the problem is how ready are we to handle that situation,” said Dr. Mesumbe.

To control the situation, the report says governments must reinforce diabetes awareness strategies and support associations fighting the disease.

Paul Frymoyer, MD, has been instrumental in helping South Africa’s poor, having provided medical assistance to native Africans with various diseases. Check out this Facebook page and learn how Dr. Frymoyer became closer to the continent’s culture.

Bladders are not made of steel

Image Source: caregiverpartnership.com

When you’ve got to go, you’ve got to go.

Sometimes, people feel the need to urinate at inopportune moments. The potty emergency is a staple of rather vulgar comedy and has been a recurring source of fun in The Sims and its successors, where players can enjoy the writhing misery of their digital people who can’t access toilets.

This is normal—assuming that you can hold it in until long enough for you to find a bathroom. However, this is even more inconvenient if you happen to have urinary incontinence. Having to control your bladder can be an embarrassing and unnerving experience, and it can make daily life extremely difficult. These unhappy little accidents may also lead to serious complications, such as skin and urinary tract infections, and drastic changes in your work and personal life.

Image Source: hkpr.on.ca

Dealing with urinary incontinence can be a grueling task, but it is not an impossible one. While extreme cases may require medical intervention, these are rare. Doctors would typically seek out the cause of the incontinence—which could range from certain medication doses to aging, even prostate cancer in some cases. The course of treatment for incontinence would depend on its cause, but certain lifestyle adjustments can help make the situation a lot easier if the problem recurs:

• Do not overuse douches, pads, and other control devices, and don’t wash too much. Sometimes, when it happens, it’s best to let it all dry by itself. 

• Have a bedpan or other urinating aid with you in certain parts of the day. 

• Banish any and all potential causes of temporary incontinence or take them in moderation. 

Image Source: cleanius.com

Ask your doctor on what to do when you suspect that your medication is at fault. The Mayo Clinic discusses the issue of urinary incontinence at length. View it here.  


Nephrologists, like Dr. Paul Frymoyer, are the specialists to see when you have problems with your urinary tract. Visit this blog for more articles on nephrology.

REPOST: Diet and eczema: The facts

A good diet can bring about many benefits, including comfort from the itches and pains associated with eczema. According to this article from WebMD, there might have to be considerations about the age of the patient, but the approach is definitely still worth the try.

If you have eczema, you want to do all you can to try to stop the irritation and itching it can cause. So you may be eager to try eczema diets promoted in books or on the Internet.

How helpful are these eczema diets? Research about diet and eczema is conflicting.

This article will review what experts recommend when it comes to diet and eczema.

Diet and Eczema in Children

"Some young children have eczema caused by allergic reactions to certain foods," says Donald V. Belsito.

MD. Belsito is professor of clinical dermatology at Columbia University. "But after age 3 or 4, eczema caused by foods is very rare. Food can cause hives and other skin reactions, but not eczema."

If you are concerned that a food allergy is playing a role in your child’s eczema, talk with your doctor. Although you can have your child checked for food allergies, the results are often not reliable.

"Positive results [to food allergy tests] are very common, even if your child doesn’t have an allergy," says Lawrence Eichenfield, MD, chief of Pediatric Dermatology at Rady Children’s Hospital in San Diego. "So while it’s sometimes helpful for children with severe eczema, I wouldn’t recommend it for everyone."

Diet and Eczema in Adults

Although some adults report having worse eczema symptoms after eating certain foods, no studies have been able to establish a link.

"There is no science linking certain foods with flare-ups. But it can be an individual thing," says Andrea Cambio MD, FAAD. Cambio is the medical director of Cambio Dermatology in southwest Florida. "For example, if a patient reports eating chocolate makes her eczema worse, then I would advise her to cut down or eliminate chocolate from her diet." Be sure to talk to your health care provider before eliminating any food from your diet, and before going on a special diet.

Cambio cautions that it is not always easy to figure out what’s making eczema flare. "Because we are exposed to many potential triggers in a given day, it is often hard to tell. Sometimes, it may seem to the patient that certain foods are making eczema symptoms worse. But then we find that something else, like stress, is actually the culprit."

Research Into Foods That May Help Eczema

Although most foods and supplements have not shown promise in eczema research, research is ongoing.

For example, some studies suggest that probiotics may help relieve the symptoms of eczema in children. Probiotics are a type of live bacteria. They can be found in foods like yogurt and in some supplements. Most of these studies were done in other countries and tested different kinds of probiotics. So it is not clear what type of probiotics are most useful. "More research in this area is surely needed before we can make a definite recommendation," says Cambio.

Another food being studied as a benefit for eczema is tea. Although there is no definitive evidence, a few studies suggest that drinking black, green, or oolong tea may help relieve eczema symptoms. Omega-3 fatty acids found in fish and fish oil, which help fight inflammation, are also being studied for eczema.

What Should a Person With Eczema Do?

Choose a healthy diet. Scientific research has established without doubt that a healthy diet with plenty of fruits, vegetables, low-fat dairy, and whole grains is good for your overall health. "A healthy diet and lifestyle are good recommendations for anyone with a chronic condition," says Belsito.

The road to a healthy body entails caring for one’s organs, including the kidneys. Find out how important it is to care for it by asking nephrologists like Dr. Paul Frymoyer. You can also follow this Twitter page which contains more links to related articles.