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Some thirty features of
AIDS in Africa - |
Article by Konotey-Ahulu FID*. Annales Universitaires des Sciences
de la Santé 1987; 4: 541-544.
*Cromwell Hospital, Cromwell Road, London SW5 OTLI. Former
Director Ghana Institute of Clinical Genetics, and Consultant Physician,
Korle Bu Teaching Hospital, Accra. Ann. Univ. Sc. Sant6 4 (4), 541544
(1987)
In
1987 I visited sixteen African countries to acquaint myself with the AIDS
situation on the continent. I obtained information from doctors and health
workers about many of the countries I could not visit. 1 was refused a
visa to go to Zaire. A synoptic overview of clinical and other features
of AIDS in Africa as I learnt on my sub-Saharan tour is here presented,
making mention of some of my teachers. Those not referred to are being
protected because the authorities forbade them to take any foreigner on
a ward round. What I learnt from the prostitutes is to be published elsewhere.
Aids
is not uniform
over the 50 countries in Africa. In most it is now in the introductory
phase. In 5 or 6 countries AIDS is in the propagation phase with the highest
incidence in some French speaking (but not necessarily French related)
regions and countries bordering them.
Age
block gap.
No patients were found between infancy and teens except the blood trans-fused,
thus excluding insect vectors in transmission (Dr. Miriam Duggan and Dr.
Sewankambo of Uganda, Professor McLarty. Tanzania; Dr. Fleming. Zambia.)
Repatriation
AIDS.
In my Krobo tribe in Ghana, all patients had been sent home to die from
Ivory Coast (1). Most of West Africa is like that.
100
% Female preponderance.
In certain tribes in West Africa males have yet to manifest the disease
(1-4).
Perineal
devastation
easily visible from the foot of the bed with undressed patient lying prone
(Dr. Mate-Kole, Korle Bu Teaching Hospital, Ghana.)
Virgins
and the nulliparous
can get AIDS from the first intercourse due to tears (Dr. Mate-Kole, Korle
Bu Teaching Hospital, Ghana). Pervisemos i.e. 'persistent virus secreting
mothers' who are asymptomatic but continue to bring forth sick children
(Dr. Duggan and Dr. Hanny Friesen, Kampala ; Dr. Chintu, Lusaka).
AIDS
Precipitators.
Caesarian section and minor procedures like salpingohistograms can turn
the asymptomatic into full blown AIDS. (Dr.
Duggan, Kampala.) (5).
Symptomatology
of Slim.
20-40 % weight loss, persistent diarrhoea, fever, lymphadenopathy, respiratory
symptoms, oral candidiasis and amenorrhoea in child bearing women, with
frequent previous history of sexual exposure, of blood transfusion, and/or
unsupervised injections (Dr. Sezi, Serwadda & colleagues in Kampala, physicians
in Dar es Salaam, and in Lusaka and Ndola, Zambia, Dr. Neequaye et al,
Ghana) (6, 7, 8).
Intractable
Pruritus.
In adults and in infants: this could be the commonest cause of insomnia
(Dr. Chintu and Dr Subhash Hira, Lusaka.)
Generalised hyperpigmentation with crazy-pavement dermatopathy.
(Professor. Bodo, Nairobi). Papulo-vesicular eruption rather like chicken
pox (Dr. Sezi, Kampala).
Dupuytren's Contracture.
(Professors Badoe, Archampong and Jaja's new book "Surgery in the Tropics"
p.210 shows this physical sign as a complication of plaque Kaposi's sarcoma)
(9). Professor Anne Bayley (Lusaka) showed me two cases of aggresive atypical
Kaposi's sarcoma (AAKS) with this sign.
Elephantiasis
of limbs (upper and/or lower) and genitals from AAKS (Professors Bugingo,
Rwanda and Anne Bayley, Zambia).
Multidermatomal Herpes.
Zoster heralds full blown AIDS (Dr. Subhash Hira, Zambia and Dr. Sezi,
Uganda).
Adult Kwashiorkor.
I saw this syndrome in my Krobo tribe where girls with Repatriation AIDS
whose diarrhoea must have included creatorhoea with consequent protein
calorie malnutrition.
Accelerated
orphan Kwashiorkor.
I saw this at Dodowa, Ghana, in a baby boy whose mother had died a week
after repatriation from Ivory Coast.
Tuberculous
pericarditis
as a common complication (Dr. Mboussa, Brazzaville and Dr Jahazi, Dares
Salaam).
Non-AIDS
Diseases
producing HIVseropositivity. (Dr. Fleming and Rosemary Mwendapole, Ndola,
Zambia) (10). Liver pathology can confuse results and Tanzanian physician
Professor Aaron Massawe postulates "immunoligical turbulence" with Anti-TB
treatment to fake seropositivity.
Radiological
"bat's wing" lung
in AAKS (Professors Bugingo Rwanda, and Anne Bayley, Zambia) (11)
Sworl Facies.
A characteristic "Strikingly worried look", on the faces of the more
discerning patients I visited on ward rounds in Uganda, Rwanda, and Zambia.
Relative
Paucity of full blown AIDS.
It came as a surprise to find a Zairean man and wife, and a Kenyan itinerant
salesman as the only AIDS patients in the 2100-bed Kenyatta National Hospital.
Even in Uganda, Rwanda, and Burundi, wards were not overflowing with patients.
I entirely agree with Professor Gottlieb Monekossoo, Director of the WHO's
Regional Office for Africa when he is reported by The New Scientist as
saying: "For many countries in Africa AIDS does not represent the same
threat that it does in Europe. In the eyes of health managers AIDS probably
ranks only tenth or lower on a list of serious tropical diseases. Malaria,
measles, diarrhoeal illnesses, tuberculosis, cholera, meningitis, yellow
fever and various cancers account for more deaths and illnesses than AIDS
does, at the moment" (12).
Patients
are not dying "like flies"
as world media report (13). When Uganda's Dr. Sewankambo was recently
asked in London what proportion of a hundred gravely ill patients for
admission would be AIDS and he replied two, or at most three at the worst
times", he was glared at with incredulity.
Seropositive
twin baby lives while seronegative twin dies.
Born to a pervisemo (ie persistent virus secreting mother) the infected
twin lived while the seronegative twin died from AIDS, in Kigali, Rwanda.
AIDS
has not changed health priorities in Africa.
I cannot speak for Zaire where I was not permitted to visit, but in no
country has AIDS moved into the first 6 health priorities, even in Rwanda,
Burundi, Zambia, and Tanzania.
Disagreement
about seriousness of the problem
Some expatriate workers in Africa prophesy doom, but most
indigenous doctors while not underestimating the gravity in some countries,
consider forecasts exaggerated (Uganda, Rwanda, Burundi, Zambia). I myself
have judged the gravity of AIDS in Africa at 5 clinically graded levels.
Grade I, not much of a problem; Grade II, a problem exists; Grade III,
a great problem; Grade IV, an extremely great problem, and Grade V, a
catastrophe (13). I recommend this approach to health workers and urge
them to have their own grading criteria. Clinicoepidemiology rather than
seroepidemiology will best bring out the truth about the real state of
affairs of each country (1).
The
Juliana Phenomenon.
AIDS in the lake region of Tanzania, bordering Zaire, is known as "Juliana"
because, as one prostitute told me, "A few years ago when the Navy visited
Mombasa with 9,000 troops, some of our girls who travelled there for business
were given T shirts with Juliana marked on them. Many of those who wore
the Juliana shirts have since had Slim and died".
Non-Africans
with AIDS.
The 6 patients seen in Mombasa with AIDS (1983-1987) by a specialist,
were a Zairean, and 5 non-Africans from Europe and the USA; in South Africa
all the AIDS has so far occured in non-blacks (Dec 1987), and in Zaire
at least 21 Europeans and Americans were known to have had AIDS (Source
: Resident Greek Businessman). HIV-2 in West Africa is not specifically
African, having been seen in two homosexual men in France (14) and is
now known to have Portuguese connections. (15).
Complete
Cure Anecdotes
were heard in Uganda, Rwanda, Congo Brazzaville (related to tuberculosis)
(1), Tanzania, and herbal preparations are being tried in domiciliary
management of the disease in Ghana. (16).
Comment.
It is important that doctors living and working in Africa adopt their
own approach to a new disease like AIDS, and not import wholemeal terminologies,
diagnostic criteria, and preventive slogans from abroad. Africa in my
opinion should abandon the use of "homosexual", "heterosexual", "bisexual"
etc., and should call a spade a spade. African prostitutes are said to
be "heterosexual" but I met girls of whom anal intercourse was demanded
by some expatriates for extra money (4), and in Burundi I recently asked
a prostitute, "Y-a-t-il quelqu'un qui vous a demande de faire l`amour
dans la bouche ?" And she replied, "Oui Monsieur, mais je leur demande
une grande somme d'argent" (17). So one should now use "peno-vaginal sex"
for so called heterosexual sex, and "anal sex" or "sodomy" for what is
called "homosexual relationship". Anal sex has been demanded sometimes
for money in several countries in Africa. And in the first description
of the AIDS problem to come from Africa one AIDS patient had a "high recto-vaginal
fistula of recent onset" (6), while the Ugandan traders who were found
to be seropositive admitted to, "both heterosexual and homosexual casual
contacts"(6). It is far better perhaps to say that these traders admitted
to both peno-vaginal and anal intercourse (4). As regards diagnosing AIDS
without blood tests the Muhimbili Criteria show that one does not have
to use criteria from abroad (18). Finally the kind of research that will
help Africans curtail AIDS does not have to be the vaccine orientated
research of the developed countries. Public Health methods and clinical
epidemiology are Africa's best tools (1).
Acknowledgements.
I thank the clinicians who took me on ward rounds during my recent African
tour, and the Health Administrators who readily agreed to see me.
REFERENCES.
1. KONOTEY-AHULU F I D, (1987) Clinical epidemiology, not seroepidemiology,
is the answer to Africa's AIDS problem. British Medical Journal 294: 1593-1594
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15. KINGMAN SHARON. (1987). The Portuguese connection. New Scientist,
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16. QUARTEY J K M, MATE-KOLE M O, OKAI GLORIA, BENTSI CECILIA,
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18. PALLANGYO K J, MBAGA I M, MUGUSI F, MBENA E, MHALU F S, BREDBERG
U, BIBERFIELD G. (1987). Clinical case definition of AIDS in African adults.
Lancet, ii: 972.
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