Letter from the Editor
Having just returned from a trip to visit the University of Mali Medical School, hospital (Point G) and research center (the NIH-funded MRTC) in Bamako, Mali (West Africa), I'm looking at the enormous contrast between HIV practice, here and there, from a new perspective. As there is still only limited access to antiretroviral agents, and the cost of the medication is still prohibitive despite a dramatic pricing reduction, patients are reluctant to get tested for HIV (why test, if treatment is inaccessible). Therefore, most patients only present to clinicians in the very late stages of AIDS -- literally on death's door. The real tragedy is yet to come, when the effect of AIDS on the economic stability of sub-Saharan Africa becomes more apparent. The average age of the AIDS ward patients when I visited was 23.
I saw cases of severe cryptococcal meningitis, wasting disease, and miliary tuberculosis, the likes of which I have not seen in years in my practice here in the US. Screening for and treatment of CMV is unheard of; Mycobacterial subtyping (MAI vs M.tb vs M.bovis) is not possible. Prophylaxis for opportunistic infections is not feasible, due to the cost of the medications. And, to put the conditions for patients in sharp contrast with the treatment for HPV that is outlined in this issue of HEPP News by my colleague A.K. Goodman, Pap testing is not the standard of care -- at all. Thus, cervical cancer is one of the top cancer causes of death in Africa.
I am pleased to report that antiretroviral medication ("ARV" to Malian doctors) is becoming more accessible due to the advocacy of clinicians and governments in Africa, and Malian physicians are eager participants in any AIDS training courses that are available. I hope we may help our colleagues avoid some of the costly errors we have made in the course of the US epidemic. How would we structure HIV/AIDS care now, if we had a chance to start over now that so many different treatment options are available?
Our tradition to address sexually transmitted diseases in our January issue of HEPP News is done by A.K. Goodman, a gyn-onc specialist who provided care contemporaneously with me in a MA DOC institutions in the late 1980s. In this issue, Dr. Goodman provides a roadmap for the diagnosis and treatment of HPV. After reading this article, readers should understand the transmission of HPV, the relative risk of the various subtypes, and the current gynecological standard of care for HIV-positive women. In keeping with the STD theme, we also bring you a spotlight on the issue of condom distribution in prison and jail settings from across the border (Canada). And, since the use of combination therapy is expanding, we decided to re-run our "Abacavir Hypersensitivity Syndrome (AHS)" algorithm, which clinicians can use in order to recognize the symptoms of AHS and to identify the antiretroviral medications that contain abacavir.
Anne S. De Groot, M.D.
This article was provided by Brown Medical School. It is a part of the publication HEPP News.