Challenges remain in HIV care in Africa

Barriers to diagnosis and lack of access to modern medications have combined to place caregivers and HIV-positive patients in sub-Saharan Africa between a rock and a hard place. A new study shows that physicians are often forced to choose between controlling seizures, which can occur if the disease goes undiagnosed for too long, or treating the underlying HIV infection.

The study was led by Gretchen Birbeck, M.D., M.P.H., the Edward A. and Alma Vollertson Rykenboer Professor in Neurology at University of Rochester Medical Center (URMC). Birbeck also serves as director of the Epilepsy Care Team at Chikankata Hospital in rural Zambia and is an honorary lecturer at the University of Zambia.

While the study, which appears in the journal Neurology, was undertaken for the purpose of identifying risk factors for seizures in HIV-positive patients and thereby providing physicians with a blueprint for care, it has instead highlighted the difficult decisions that providers and patients must confront.

Seizures are a common symptom in individuals with advanced stage HIV. At least 11 percent of people with the infection will have a seizure at some point if the disease is undiagnosed and not treated.

In many parts of Africa there are still significant social and economic barriers that prevent people from being tested for HIV. Consequently, for some individuals the first time there are diagnosed with the disease is after they have been brought to the hospital following a seizure.

Once this occurs, caregivers are forced into a no-win situation. Because the HIV infection is often advanced, the appropriate course of action is to aggressively start a treatment of combined antiretroviral therapy (cART). However, at the same time there is a sense of pressure and urgency to treat the seizures as well, which represent a significant health risk if left unaddressed.

The dilemma exists due to limited treatment options. Most African regions with high rates of HIV infection continue to rely largely on older, enzyme-inducing antiepileptic drugs (AED) for seizure management. Unlike newer anti-seizure treatments, these AEDs are known to interfere with cART, making the HIV treatment less effective. Not only does this interaction place the patients at greater risk from death from the disease – a third of the patients were dead within a year of their first visit to the hospital – but it could also give rise to drug-resistant strains of HIV.

While the long term solution is to increase access to newer anti-seizure drugs, the authors believe that the priority should be to reconstitute the immune system by getting patients on cART as soon as possible. They acknowledge that a treatment approach that omits AEDs leaves patients vulnerable to a reoccurrence of seizures, but believe that the HIV infection poses the far greater health risk in the long term.

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Additional co-authors include Omar Siddiqi and Igor Koralnik with Beth Israel Deaconess Medical Center, Melissa Elafros with Michigan State University, Christopher Bositis with the Greater Lawrence Family Health Center, William Theodore with the National Institutes of Health, Jason Okulicz with the San Antonio Military Medical Center, Lisa Kalungwana with the University of Zambia, Izukanji Sikazwe with the Centre for Infectious Disease Research in Zambia, and Michael Potchen with URMC Department of Imaging Sciences. The study was supported with grants from the Fogarty International Center and the National Institute of Neurological Disorders and Stroke.

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