In early August, South African health officials announced that the HIV/AIDS epidemic in that country appears to be stabilizing after decades of rampant infection. Yet on any given day, more than half of all admissions at South African public hospitals arise from AIDS-related neurological disorders, and there are only 130 neurologists in a country of 45 million.
South Africa has an established and well-organized neurological infrastructure, but the same cannot be said for 50 percent of other African countries, according to the World Health Organization (WHO) “Neurology Atlas” of care in the developing world.
The 2005 survey draws the crisis into sharp focus: 11 countries have 1 neurologist for every 711,856 persons; 5 have 1 per 1.6 million; 23 nations have 1 neurologist for every 5 million citizens; and 12 countries, representing a total population of nearly 26 million, reported no neurologists whatsoever (Neurology 2005;64:412–415).
“South Africa is in much better shape than other African countries, but the shortage of neurologists is an extremely severe problem, especially in sub-Saharan countries,” said Johan Aarli, MD, the newly elected President of the World Federation of Neurology (WFN). “We are looking at ways to improve access to neurological treatment by developing a strategy for health authorities and guidelines for practitioners in these countries.”
ROADMAP FOR NEUROLOGY
Dr. Aarli, Professor of Neurology at the University of Bergen and Haukeland Hospital, in Bergen, Norway, told Neurology Today in a telephone interview that the WFN and the WHO “roadmap for neurology” in Africa will be the federation's “leading vision” for the next four years.
“In the Atlas survey, less than half of African countries have a national neurological organization or association. But they all have a central health authority, and through these, the WFN and WHO hope to improve neurological outreach and care,” he said.
Although sub-Saharan Africa has the greatest number of AIDS patients receiving treatment and the second-highest rate of treatment coverage of developing countries overall, the region still accounts for 70 percent of the world's unmet treatment need for neurological services, he said.
The new initiative will target HIV-related neuroinfections, such as meningitis, as well as parasitic disorders and neurological problems associated with malnutrition. Using the report, the organizations also hope to develop a set of specific recommendations on priorities for improving neurological education of health workers.
He noted that only 10 percent of HIV antibody-positive people in sub-Saharan Africa know whether they have been infected. “We are not acting in isolation on this,” Dr. Aarli said. “Many people are involved. We're developing a report designed for politicians and public health planners, a set of operational guidelines to help them expand access to provider-initiated testing and counseling for neurological disorders. We hope to have these completed by the end of this year, or early in 2007.”
Because of the paucity of neurologists in most sub-Saharan countries, Dr. Aarli explained that the guidelines will include educational priorities and directions for training nurses and other health care workers to recognize and treat AIDS neurological disorders, especially in rural clinics.
“This program will take time to develop, and WFN's contribution is only a small part, but the problem is enormous and we have to start somewhere.”
BARRIERS TO PROGRESS
While the WHO and WFN are developing recommendations and priorities, there is skepticism about how much effect any guidelines can have, given the social, political, and demographic barriers to improve neurological care, even in South Africa with its established health care infrastructure, said WFN's South Africa Delegate Kevin Rosman, MD, a neurologist at Morningside Mediclinic in Rivonia, SA.
“It's a disaster – as bad as it gets,” he told Neurology Today in a telephone interview. “In South Africa the health care system is divided into public and private sectors, and I don't see a lot of progress at all in public hospitals,” he said.
“It's horrendous. If you walk though a neurology ward, a good seventy percent of patients are HIV-positive. And they're the lucky ones,” he said. “We don't see much help from the government at all – just factions arguing about the best way to roll out antiretroviral treatment. There's a lot of tension between [medical] groups and the government right now, and the only people who seem to be doing anything at all are the AIDS activists. I get the feeling there's a lot of foot-dragging.”
For example, South Africa Health Minister Manto Tshabalala-Msimang and President Thabo Mbeki have repeatedly expressed doubts in public statements about the efficacy of Highly Active Antiretroviral Therapy (HAART); recommending instead garlic, beetroot, and olive oil to fight the disease. At the International AIDS Conference in Toronto, in mid-August, protestors broke up South Africa's exhibition stall, which displayed beetroot and garlic alongside antiretroviral medications.
Nonetheless, at the plenary session of the International AIDS Conference in Toronto on August 16, WHO HIV/AIDS Director Kevin De Cock, MD, reported that the number of people receiving HIV antiretroviral therapy in sub-Saharan Africa has surpassed 1 million for the first time, a ten-fold increase in treatment access in the region since December 2003.
However, on the last day of the meeting, Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa, strongly criticized the South African government for its failure to expedite distribution of modern drugs to underserved victims.
“It is the only country in Africa … whose government is still obtuse, dilatory, and negligent about rolling out treatment,” he charged.
Highly Active Antiretroviral Therapy (HAART) can ameliorate some neurological symptoms, but cognitive impairment eventually develops in about 30 percent of people with AIDS and frank dementia in about another 15 percent.
AIDS DEMENTIA AND HAART
Ned Sacktor, MD, Associate Professor of Neurology at Johns Hopkins Bayview Medical Center in Baltimore, MD, recently returned from Uganda, where he was helping to validate the International HIV Dementia Scale (IHDS), a screening instrument that has now been tested in Kampala (Uganda), Zimbabwe, and elsewhere (AIDS 2005;19(13):1367–1374).
“Right now, what we know about the extent of the problem is quite limited,” he told Neurology Today in a telephone interview. “We're seeing a frequency rate of about 30 percent in patients with advanced infection, which is high but similar to frequency in the pre-HAART era 15 years ago in the U.S.”
There have been a handful of AIDS-dementia incidence studies at different sites over the past 15 years showing a wide range of frequency – from 5 percent to 65 percent, he noted.
“What we really need is a study of frequency across sites. Basically we need to evaluate the frequency, establish screening instruments … and get access to [HAART] as soon as possible. It's an area that hasn't been studied in great detail, but if the frequency is 30 percent in HIV-positive patients, then AIDS dementia is up there with Alzheimer disease and vascular dementia in terms of the general population, and that needs to be recognized.”
Dr. Sacktor is also lead author of a new study testing HAART in a small group of patients with AIDS-dementia in Uganda, the results of which were published in the August 8 issue of Neurology (2006;67:311–314).
He and his colleagues reported improvement in cognition and function in 23 African HIV patients with dementia after six months of treatment.
“Some patients returned to normal status on cognitive and executive function tests, and others continued to have mild impairment,” he said.
Several organizations are already involved in efforts to improve the diagnosis and treatment of patients with AIDS-related neurological disorders and dementia in Africa, and to increase the availability of antiretroviral therapy. These include the Gates Foundation, the Neurological AIDS Research Consortium, and the Academic Alliance for AIDS Care and Prevention in Uganda.
THE STIGMA OF AIDS
However, Dr. Aarli told Neurology Today that HIV-dementia is often “overlooked” in Africa, partly because both HIV and dementia generate a stigma that keeps many from going for help.
“Most patients never reach a hospital or doctor because there's still reluctance to seek treatment,” Dr. Aarli said. “We need more neurologists, but also better education and outreach in addition to many more trained nurses and health care workers – all are absolutely critical. These countries face a daunting challenge, but world health leaders are concerned about the issue. The crisis is so important that all neurologists need to become involved just to start.”
If the rate of progress in getting HAART to the general public in South Africa is any indication, however, there is a long, long road ahead, according to Dr. Rosman. “Some people are getting treatment here, but it is mostly those with insurance and access to private medical care. There's very little help in the countryside, where the only care available is at understaffed rural clinics.”
As for dementia, he said, “Most AIDS patients I see don't live long enough to develop it.”
ARTICLE IN BRIEF
- ✓ The World Federation of Neurology and World Health Organization are collaborating on a new initiative to target HIV-related neuroinfections in Africa, such as meningitis, as well as parasitic disorders and neurological problems associated with malnutrition.