A couple of sample dilemmas faced recently in the clinical programmes of the medical humanitarian organisation Médecins Sans Frontières (MSF).

“This HIV positive woman in her first trimester of pregnancy is currently on an efavirenz-based regimen, what should we do?”

“The patient I just saw in clinic has HIV infection and is hepatitis C antibody positive; he is doing well on antiretrovirals. His liver function is mildly abnormal—he asked whether we can treat the hepatitis C. Can we treat hepatitis C in this country?” more…

Yekaterinburg city tuberculosis (TB) clinic on Kamskaya Street specialises in the treatment of TB/HIV co-infection. We first visited in November 2009, as part of an ongoing qualitative study undertaken by the Centre for Research on Drugs and Health Behaviour at the London School of Hygiene and Tropical Medicine, and funded by the World Health Organization Regional Office for Europe. While we were there, both patients and doctors referred to the clinic as “the last way.” From patients’ accounts of Kamskaya Clinic, you would not think that tuberculosis is a curable disease:

“Our hospital is called ‘the last way.’ People come here only to die.”

“[The HIV doctor] told me I had to go to Kamskaya. I say, my immune system is strong enough for treatment, and you shouldn’t send me to Kamskaya! Because that is “the last way.”

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“Finally, someone is talking about this.” I heard this refrain frequently at the recent International Conference on HIV/AIDS and Sexually Transmitted Infections in Africa (ICASA) in Addis Ababa, Ethiopia, after telling people about the satellite session hosted by Médecins Sans Frontières (MSF). The difficult topic: false positive HIV tests.

In resource limited settings, HIV diagnosis is done with rapid diagnostic tests (RDTs). Two or three different RDTs are used in either a serial or parallel algorithm (according to national guidelines). RDTs allow scale-up and decentralisation of treatment, both of which are essential to saving lives. Yet RDTs are screening tests—they were not designed for definitive diagnosis. They work well for screening blood transfusions and identifying people who need further tests, but are known to yield false positive results owing to serological cross reactivity (or inadequate quality control and human error, e.g. mislabelling of specimens). I first came across this unpleasant reality in Bukavu, Democratic Republic of the Congo, while working as a medical coordinator for MSF in 2005. We were running the first programme offering antiretroviral therapy to the province and had tested nearly 6000 people. But late in 2004 we realised that some people in our programme did not have HIV, so we retested a number of them—and identified almost 50 who we suspected had a false positive HIV diagnosis. This news was devastating, considering the consequences a false diagnosis can have on people’s lives. more…

“All truth passes through three stages: First, it is ridiculed; Second, it is violently opposed; and Third, it is accepted as self-evident.” — Arthur Schopenhauer

Last week, the Nigerian senate signed a bill to outlaw homosexual marriage, homosexual association, and support for homosexual people. Same-sex couples who marry face up to 14 years each in prison. Witnesses or anyone who helps a marriage face up to 10 years. “Public show of same-sex amorous relationships directly or indirectly,” carries a penalty of 10 years in prison. And organising, operating, or supporting gay clubs, organisations, and meetings will attract a 10 year sentence. Beyond violating the human rights of gay people, these provisions effectively threaten HIV/AIDS care for men that have sex with men. more…

“Research highlights” is a weekly round-up of research papers appearing in the print BMJ. We start off with this week’s research questions, before providing more detail on some individual research papers and accompanying articles.

• What is the efficacy and safety of bronchodilators and steroids in acute management of bronchiolitis?
• How effectively does co-trimoxazole prophylaxis protect against malaria in HIV uninfected children born to HIV infected mothers in Africa?
• Do statins protect against all cause mortality after a diagnosis of pneumonia?
• What is the cost effectiveness of low dose statins for primary prevention of vascular disease? more…

The biggest problem with treating hypertension in rural Kenya is lack of drugs. Health workers are plentiful, and there is an impressive health system—but drugs are scarce.

I learnt this when I visited the hospital in Eldoret, a small city in the West of Kenya, and a close by community clinic. My colleagues and I were the guests of AMPATH (Academic Model Providing Access to Healthcare), an organisation that has done an extraordinary job in treating the many patients in that region infected with HIV. Now AMPATH wants to “layer in” the treatment of patients with hypertension, diabetes, chronic obstructive pulmonary disease, and other chronic conditions. Dr Sylvester Kimaiyo points out that HIV infection is a chronic disease now that it can be treated with antiretroviral drugs and that it should be entirely possible to use the established system treat patients with other chronic diseases. more…

What to do when you are a sexagenarian physician who has retired from hospital practice with 40 years in the NHS under your belt and golf/Sudoku not really appealing? Well, my health visitor wife and I applied to Voluntary Service Overseas (VSO) and I am writing this from a hospital in Kampala, Uganda, where I have been working for five months. more…

There is a famous proverb in Nepali which says we learn something either by reading about it or by facing it. I prefer the latter because of the everlasting impression that “facing something” leaves, in contrast to the hazy-sketchy memories of reading. I have been reading about HIV and AIDS since my first year in my medical school but never have I really thought beyond my textbooks until earlier this month in Kuala Lumpur at the 22nd East Asian Medical Students’ Conference (EAMSC). It was at this conference that I really saw HIV from different perspectives which changed my own perception of this condition. more…

Those who campaign on diabetes envy those who campaign on cancer because cancer gets so much more attention than diabetes. Indeed, the diabetes campaigners are very frustrated that diabetes is so consistently neglected. Around 250 million people globally have diabetes, and because of the pandemic sweeping the world that number will increase to 380 million by 2025. Then at least half of the people who have diabetes are undiagnosed, and in countries like Nigeria and India around 90% are undiagnosed. How is that governments can be so lackadaisical? more…

It has been 25 years since HIV, the virus that causes AIDS, was isolated. Since that time, 25 million people have died of HIV related illnesses. In 2007 there were an estimated 33 million people (CI 30-36) living with the virus and three quarters of all related deaths and two thirds of incident cases were in sub-Saharan Africa. more…