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    Parasitic worms live in the soil and water where they can constantly reinfect people. EPA/Jane Hahn

    Deworming has become a common practise across the world. It has proved very successful reducing the burden of parasitic worms among children by more than 50%.

    The success of the last 17 years has been driven by deworming initiatives where school-going children get deworming tablets once to twice a year – and could have been greater if there was a vaccine.

    But parasitic worms – found mainly in tropical and subtropical areas particularly in sub-Saharan Africa, the Americas, China and East Asia – remain a challenge. The World Health Organisation’s latest figures show that across the world, there are close to 1.5 billion people– about one fifth of the world’s population – infected with parasitic worms.

    The persistence of parasitic worms shows that deworming is not enough to interrupt the worms’ transmission. One part of the problem is that they live in the soil and water where they can constantly reinfect people even after they have been treated. Another part of the worm problem is that diagnoses are poorly efficient, anti-worm drugs are limited and tightly overlapping geographics and ecologics render co-infections with other diseases like HIV, malaria or tuberculosis frequent.

    But most importantly, communities are not educated about the dangers. This means that even when they are treated they continue activities that result in them being reinfected.

    The WHO has set a goal to eradicate the burden of parasitic worms in children by 2020. To do this, it’s advocating mass deworming campaigns. But the only way to achieve the 2020 goal is to combine deworming with other tools such as education campaigns.

    We learnt some refreshing lessons in rural Cameroon on how this should be done. Our study looked at a campaign against schistosomiasis – more commonly known as snail fever. Part of the campaign involved educating children, teachers and legal guardians in rural Cameroon about the dangers.

    The data we collected showed that mass drug administration alone had a questionable efficiency in halting schistosomiasis transmission. But that coupling mass drug administration of praziquantel to children with information about risk factors of infection might produce better outcomes. In fact, another recent study in Côte d’Ivoire unequivocally found that repeatedly informing communities how parasitic worms are transmitted and giving them a set of safe practices considerably helped to avoid reinfection.

    This underscores the importance of including - among other complementary measures - extensive population awareness campaigns in the deworming strategies to reduce the burden of these diseases. Such health education ventures that are low-cost clearly constitute a necessary tool for creating the enabling environment for mass drug administration campaigns to thrive.

    The challenges

    There are four main challenges when it comes to managing parasitic worms. All are particularly visible in tropical and sub-tropical countries where sanitatory conditions are insufficient and people’s lifestyles undermine attempts to interrupt the transmission of parasitic worms.

    The first challenge is diagnosis. The diseases caused by parasitic worms are generally asymptomatic. This means that the early signs of infection are usually missed. In cases where people develop severe disease, they usually have symptoms like diarrhoea, abdominal pain, blood loss that can result in anaemia, cognitive deficit and tissue destruction. On rare occasions, these diseases can result in death.

    But because people don’t show symptoms, most do not know that they have the worms in their body until the parasites proliferate.

    The second problem is reinfection. Even after populations receive treatment, they can still be reinfected.

    The third challenge is that there is a limited repertoire of anthelminthic drug therapies. These have been repeatedly administered for decades raising concerns about drug resistance in areas targeted for frequent campaigns.

    And the fourth is the problem of co-infections with major communicable diseases such as HIV, malaria or tuberculosis. In many instances the parasitic infections accelerate the course of these diseases and worsen their burden.

    Tackling the problem

    Creating awareness in communities is critical and arguably the most cost-effective tool in an anti-worm strategy.

    It is important to educate and involve infected people in mass deworming campaigns. There are some examples of success. Kenya, for example, has managed to eradicate Guinea worm disease as a result of deworming campaigns being complemented by health education. Guinea worm disease is caused by Dracunculus medinensis– a long, thread-like worm.

    Educational campaigns should include three vital messages. The first must explain how parasitic worms are spread, the second must explain the importance of sanitation in preventing transmission and the third should stress the limitations of mass drug treatments.

    These campaigns should include messages on how to protect water sources and sanitation and hygiene practices.

    Unless these health awareness campaigns are incorporated into strategies that target parasitic worms, there won’t be much improvement in trying to sustainably reduce the burden of parasitic worms and achieve the elimination rather than the control of these diseases.

    The Conversation

    Justin Komguep Nono receives funding from the National Research Foundation of South Africa, the Merck Global Health Institute, the International Centre for Genetic Engineering and Biotechnology (CRP/CMR15-05) and the European Union via the European & Developing Countries Clinical Trials Partnership (EDCTP2) programme through funds TMA2016CDF-1571

    Hlumani Ndlovu receives funding from Medical Research Council of South Africa (MRC-SA).


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    A girl gets tested for HIV in Uganda where attempts to integrate HIV services with general health service have failed. Shutterstock

    In many countries in sub-Saharan Africa, HIV services are still offered separately within health facilities. These HIV clinics have their own dedicated staff and infrastructure such as waiting areas, a separate patient flow system and they typically run on designated days of the week. This is known as a vertical model and was touted as a pragmatic emergency strategy to overcome sub-Saharan Africa’s weak health systems in the quest to rapidly enrol millions on HIV treatment.

    Vertical HIV clinics are very common in sub-Saharan Africa. Studies conducted in Kenya, Swaziland and Zambia suggest that stand-alone HIV clinics are the rule rather than the exception in the region.

    Stand-alone HIV clinics have depended substantially on donor aid especially from the US’s President’s Emergency Plan for Aids Relief (PEPFAR). But over the past five years, there have been persistent reports of declining international assistance to scale up HIV services in sub-Saharan Africa. This has been one of the main drivers of calls for integrating HIV services with non-HIV services to avoid duplication and promote long-term programme sustainability.

    Numerous studies have been done evaluating the integration of HIV services with other health services such as sexual and reproductive health service or those for non-communicable diseases. In addition, several policies, including World Health Organisation guidelines, have outlined ways in which HIV services can be integrated into general health services.

    But, research we conducted across eight geographic sub-regions in Uganda shows that the country is not prepared for this integration. This is because general clinic staff don’t have specialist HIV knowledge, as well as the fact that sheer numbers of HIV clients will make it difficult. We argue that a more nuanced approach should be taken.

    Why not

    Our study identified a number of potential challenges in doing away with stand-alone HIV clinics.

    Firstly, we found that HIV-related stigma was widespread among health workers. For example, we found that some health workers in the labour ward of a public health centre refused to touch HIV positive expectant women.

    Secondly, we found that HIV-positive patients were discriminated against. In one large hospital we visited, the pharmacy prioritised patients who paid for their medication while HIV patients were treated last because they don’t pay.

    Thirdly, health workers maintained that HIV disease management is a speciality skill. They argued that requiring all health workers to learn how to manage HIV treatment overnight was not feasible because of continuous updates in HIV treatment protocols. Also, the one-on-one touch by clinicians in HIV care would be hard to maintain in general clinics.

    Fourthly, there’s the problem of numbers. HIV clinics in Uganda were described as “a hospital within a hospital” because of the large patient volumes. Uganda has 1.6 million people living with HIV with 898,200 enrolled on antiretroviral therapy in 2016. This suggests that the sheer volume of HIV clients at health facilities is too large simply to be merged with the general pool of patients.

    What we found

    Most studies evaluate integrating HIV with non-HIV services under experimental settings. Our study is different in that the majority of health facilities we surveyed had actually experienced having specialist HIV clinics, as well as been through the experience of integrated care.

    Several hospitals we visited had reverted back to a stand-alone clinic model after failed attempts at integrating HIV with non-HIV services. Health workers and patients cited a number of reasons for this happening. These included:

    • The chaos that ensued when all hospital laboratory services were brought under one roof. This included multiple accounts of HIV patient samples being lost.

    • The increased workload while implementing an integrated package of services.

    • A shortage of physical space.

    • The ability of health facilities to conduct HIV and non-HIV laboratory tests concurrently.

    • The absence of counselling rooms when facilities were integrated into general out-patient services. This affected the ability to offer HIV positive patients’ privacy.

    • Increased waiting times in integrated facilities.

    What next

    Our study suggests that a wholesale switch to integrated health services is not feasible and a more incremental approach is advisable. From our findings it is clear that the health system in Uganda is unprepared for integrated care.

    Retraining health workers, preparing people for the changes and shortages of space are among the issues that need to be addressed. Blanket integration policies are impractical and need to be tailored to country context.

    The Conversation

    Henry Zakumumpa received funding from The Wellcome Trust (UK) through the Consortium of Advanced Research Training in Africa (CARTA).


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    Suicide is increasingly recognised as a global health challenge.Love the Wind/Shutterstock

    Suicide is increasingly recognised as a global health challenge by the World Health Organisation who call for society-wide efforts to prevent suicide.

    In a recent study, we set out to understand the drivers of suicide for young men in Meru county, in central Kenya. We wanted to know whether young men in the region were more at risk of contemplating suicide if they have more friends and family who have attempted, or committed, suicide.

    Previous research has found that incidents of suicide and emotional states contribute to suicidal thoughts passing among networks of friends and within families. Part of the familial link may be genetic, but evidence shows that social pathways – like the transmission of considering suicide as a viable option and devaluing one’s own life as a result of a peer’s self destructiveness – also exist.

    If we identify factors that predict why young men consider suicide as an option, we can potentially stop suicides before they happen.

    Contemplating suicide

    Using surveys, we randomly interviewed 514 young men (aged 18-34 years) in the Igembe sub-counties of Meru County. We used the Modified Scale of Suicide Ideation– a scale that assesses the presence or absence of suicidal thoughts and how severe suicidal ideas are – and coded for only the most severe cases.

    We found that, over two days, around 12% of men engaged in severe suicide ideation – they prepared a plan to end their lives, and considered their own death with concerning intensity or frequency. Though global lifetime estimates of considering suicide range between 14%-33%, our survey specifically screened for more severe suicide ideation, as opposed to more common passing thoughts about ending one’s life.

    Among young men who reported that none of their friends had completed suicide, the percentage who had contemplated suicide was 5%. This is much lower than the percentage of respondents who engaged in severe suicidal ideation if they had one friend who completed suicide (17%), and higher still if respondents knew two or more friends who completed suicide (32%).

    Similarly, the prevalence of suicidal thoughts increases with the number of friends who attempt, but don’t complete, suicide. If a family member completed suicide during the respondent’s first 18 years of life, the risk for present suicidal thoughts increases by 20% in the respondent’s young adulthood. These patterns are consistent regardless of education, age and household wealth.

    Explanations

    Consistent with other studies, we found a relationship between self-esteem, loneliness and suicide that may explain this pattern. Men who reported more suicide among friends and family, reported lower social self-esteem, a predictor of suicide behaviour. Men who reported lower self-esteem also reported more loneliness – described as the pain felt when they believed they didn’t belong socially and emotionally.

    The image is therefore that men who have experienced suicide in their social groups think their social groups are less valuable and experience loneliness. They then experience less meaning in life and thoughts of ending their own life can begin to form.

    Prior research also finds that our thoughts about ourselves are influenced by the self destructive behaviours of our peers. We can internalise their emotions and behaviours as though these emotions and behaviours were our own through a process called projective identification.

    Peer suicide doesn’t affect the majority and identifying social and psychological factors that lead to resistance needs more investigation, and likely includes making meaning from the tragedy.

    Implications

    The implications of this research are multi-fold.

    As with many countries, Kenya lacks enough mental health resources to meet the demand for services. Resources to prevent suicide in the future should target young men who are friends or children of those who have attempted or completed suicide in the past. This includes identifying and following-up with friends of suicide attempters who come to emergency health centres.

    Efforts should focus on group support and gratitude interventions which encourage people to remember at least one thing they are thankful for each day by writing or drawing it down. Gratitude interventions can improve one’s sense of meaning in life and reduce suicidal thoughts.

    Faith, community, education and other leaders should be sensitised to the challenges faced by those who remain behind after a loved one’s suicide.

    And finally, media campaigns should be promoted that improve awareness and reduce stigma related to mental health issues.

    The Conversation

    Michael Goodman receives funding from the University of Texas Medical Branch in Galveston, TX. He is affiliated with Sodzo International.


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    Roasted mopane caterpillars are eaten in Livingstone, ZambiaRainer Lesniewski/Flickr

    Insects could be a game changer in the race to combat food insecurity and achieve zero hunger – the theme of this year’s World Food Day.

    Eating insects can help fight hunger and food insecurity. They are a fantastic source of nutrients – like protein – and food at times when the production of commonly eaten staple African food crops, like maize, fails due to the changing climate, droughts, or insect pest damage.

    Eating insects is an ancient practice which is still prevalent today. About two billion people, more than a quarter of the world’s population, eat insects. Most live in Africa, Asia and Latin America.

    Insects should be tapped into as an excellent tool to fight hunger and malnutrition because they are abundant, healthy, have less of a carbon footprint to produce and can offer a range of business opportunities.

    Why eat insects

    Abundant: Insects are abundant in Africa. The continent is home to over 1900 edible insect species – mostly beetles, caterpillars, grasshoppers, wasps and ants.

    And insects reproduce quickly and have high growth rates. Insects can attain maturity in less than a month. Most insects take three weeks or less to complete their life cycle. At the same time, farming insects doesn’t require much land and water as traditional agriculture does.

    Insect farming is already happening in Africa. In Kenya, for example, crickets are produced in buckets and crates where female adults lay fertilised eggs under a wet cotton wool. After a month, the eggs hatch into nymphs that feed on vegetables, soy flour and water. It takes three months for crickets to mature into adult stage. In Zimbabwe, Mopane Worm Enterprises grow trees on to which the moth lays its eggs. These then hatch and the larvae feed on the leaves. It’s at this stage that the Mopane worm is harvested.

    Healthy : Insects can serve as sustainable alternative sources of proteins and other nutrients. Insects are rich in essential amino acids and protein. They are sometimes superior per ounce, to traditional protein sources including beef, chicken, goats and sheep. Nutritional benefits can vary from one insect species to another. For example, the Orthoptera group of insects, that contains grasshoppers, yields the highest protein content.

    Better for environment: Agriculture and livestock, are major sources of greenhouse gas emissions. Unlike agriculture, insects produce far fewer greenhouse gases: one-tenth the methane and one-three-hundredth of nitrous oxide.

    Money makers: Insects, provide an opportunity for entrepreneurs to think outside the box. Millions of Africans are already eating them and new businesses could be developed. They can be eaten as they are, or processed – for instance into protein powders to serve as supplements. Several start-up businesses have been launched focusing solely on producing insects for human food and animal feed. These range from countries like Netherlands to South Africa and Kenya.

    Evidence

    Insect eating is widespread in Africa.

    In Cote d’Ivoire, a recent survey reported that over 59% of the surveyed respondents were eating insects. Similarly, in Zimbabwe, a recent survey reported most of the people surveyed had eaten insects. Consumption happens mainly in rural areas, rather than in the cities.

    In South Africa, insect eating is normal. Topping the list is the Mopane caterpillar – a delicacy that’s eaten in other African countries too, such as Zimbabwe and Namibia.

    In Kenya, farmers and entrepreneurs are increasingly turning to eating insects to fight hunger. Termites, for instance, are being eaten by small-holder farming families to supplement meals due to failed harvests. Farmers are also rearing insects to sell in local markets. A recent survey in Kenya, showed that over 80% of respondents said they ate insects, with termites, and lake flies topping the list. Others eaten include grasshoppers, locusts, ants and crickets.

    Rolling it out

    Tapping into insects to fight hunger, food insecurity and malnutrition doesn’t come without some challenges.

    As an entomologist – that has maintained insect colonies in the laboratory – I know firsthand about what these are. Managing insects needs careful attention and management. This includes regulating temperature, humidity and observing high hygiene standards, since insects are highly susceptible to microbial and bacterial infections. At the moment there aren’t any laws governing this. New legislation must also be put in place to ensure that entrepreneurs that decide to venture into insect farming maintain proper food and hygiene standards.

    As challenges, like droughts linked to climate challenge, continue to exacerbate food security challenges, insects provide an opportunity for innovation.

    The Conversation

    Esther Ndumi Ngumbi does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.


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    Tik users' teeth are often damaged by their habit. Shutterstock

    Crystal methamphetamine is the most widely used synthetic drug in the world, according to the United Nations Office on Drugs and Crime. It’s an extremely addictive stimulant that dramatically affects the central nervous system.

    The drug is widely used in South Africa, with particular hotspots in the Western Cape province where it is referred to as “tik” due to the “ticking” sound it produces when smoked. Cape Town appears to be the tik capital of South Africa; about 98% of methamphetamine patients seen across the country come from this city. Tik is used as a recreational stimulant and can be swallowed, snorted, injected or smoked. In its smoked form it is often referred to as ice, crystal, crank and glass. Smoking is the most dangerous way of consuming the drug, as it provides quicker access to the brain and bloodstream.

    People who use the drug experience feelings of wakefulness, energy, a sense of well-being, and euphoria. But crystal methamphetamine abuse has devastating effects: it can cause lung disorders, kidney damage, hyperthermia, stroke and cardiac arrest. But, one of the least researched areas is the extensive tooth decay and gum disease that it causes.

    A team at the Tygerberg Oral Health Centre at the University of the Western Cape’s faculty of dentistry traced how tik affects users’ teeth and gums. Tik causes serious mouth and teeth problems commonly known as “meth mouth” – that presents as extensive tooth decay and gum disease. Once the damage begins, it is virtually impossible to stop and in many cases leads to multiple tooth extractions. Based on our findings we recommend early diagnosis to prevent the rapid and extensive deterioration.

    Education is also key – not only within communities and for the users, but also the education of other health care workers (nurses, social workers and medical practitioners) so they can recognise the oral and dental signs of methamphetamine use.

    The effects

    My colleagues and I at the Tygerberg Oral Health Centre noticed an increase in the number of young adult patients presenting with multiple badly decayed teeth. We saw an unusual pattern of tooth decay. These patients presented with cavities on the smooth surfaces of the teeth, leading eventually to total destruction of the tooth.

    One of the side effects of tik is hyposalivation (causing a dry mouth). This lack of saliva has serious consequences. The ducts of the salivary glands produce saliva that is the primary defence in fighting bad bacteria in the mouth, buffering acids and protecting the teeth. The enzymes in saliva keep the mouth moist and in a state of homeostasis; that is, a pH balance with just the right amount of acid in the mouth.

    Meth mouth is one of the devastating effects of abusing tik.Author supplied

    In mechanisms still being studied and debated, the use of tik affects the actions of the salivary glands and inhibits the secretion of saliva, causing a dry mouth. One theory is that the drug causes a narrowing of the blood vessels in salivary glands, decreasing the flow of saliva. Others argue that the use of the drug affects those parts of the brain that control the salivary glands.

    But the consequences of a dry mouth go even further. To counteract the very dry mouth, tik users consume vast amounts of sugary, fizzy drinks. With no or very little protective saliva in the mouth, this creates the perfect acidic conditions for rapid wear and tooth decay by weakening the teeth’s surface enamel.

    To exacerbate matters, tik users often grind their teeth because of drug-induced hyperactivity, anxiety and nervousness. This causes accelerated tooth wear. Furthermore, they lose interest in basic personal and dental hygiene. A tik “high” can last for days; users don’t bother brushing their teeth for extended periods causing plaque to accumulate and the bacteria to continue metabolising sugars into acids. The acidic environment often leads to erosion and when mouth pH drops below critical levels, tooth decay is the result.

    What we found

    The research team recruited a sample of over 300 Cape Town patients between the ages of 21 and 29 years, making their study one of the largest of its kind. The study confirmed the harmful effects of tik use on oral health, as well as highlighted the impediments to treatment. Methamphetamine users are not easy patients to treat as they are often paranoid and unpredictable.

    Users usually seek dental care for pain. But by that stage, most of the teeth are already badly decayed and need extraction or several sessions to repair. But, once the pain is gone, most patients don’t attend repeat appointments.

    Dental disease is a distinct comorbidity in tik users and requires the development of comprehensive treatment plans that address both its abuse and the oral and dental health problems.

    Dentists should be trained to identify users presenting in their clinics, as should other health care workers (nurses, doctors, community health workers) and addiction specialists who need to be aware of oral health problems among tik users. Combating the public health problem and social nightmare of tik abuse requires buy-in from government, industry and society. And perhaps seeing images of a “meth mouth” might go some way in putting anyone off drug use for life.

    The Conversation

    Sudeshni Naidoo does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.


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    Rift Valley fever is a disease passed from mosquitoes to animals then to people.Shutterstock

    The concept of One Health is deceptively simple: it’s the recognition that human, animal and environmental health are all inherently linked.

    Put into practice, it means approaching global health issues such as disease outbreaks and antibiotic resistance with the combined force of doctors, veterinarians, environmental scientists and civil society to tackle them more effectively across multiple fronts.

    Taking on health issues from different angles simultaneously has the benefit of saving time, money and lives, rather than addressing a challenge in one area only to later find it emerge in another.

    While this concept has proven particularly popular among veterinarians, the wider implementation of One Health practices has remained relatively low. For instance, our team reviewed more than 1 800 scientific articles on One Health published since I coined the term in 2003. Only seven papers describe an effort to measure the benefits of the approach.

    Research coordinated by EcoHealth Alliance, a global environmental health organisation, set out to show how we can better anticipate disease outbreaks by joining forces. This can allow us to keep ahead of new public health threats and take preventative measures to protect people and animals.

    Focus on Rift Valley Fever

    We focused on Rift Valley Fever, a viral and zoonotic disease, as a test case to demonstrate the value of adopting a One Health approach, and found both scientific and resource efficiency advantages.

    Passed from mosquitoes to animals and from animals to humans with no known treatment, Rift Valley Fever is one of the World Health Organisation’s eight priority diseases and has all the elements that could quickly turn it into a global public health emergency.

    In humans, mild cases can cause flu like symptoms that last from four to seven days. Rift Valley Fever can also cause severe illness such as hemorrhagic fever with symptoms ranging from vomiting blood, passing blood in the faeces, or bleeding from the nose or gums. Almost half of the people who get this form of the disease die.

    Rift Valley Fever causes severe illness in animals. Around 90% of lambs that get infected die. The abortion rate among pregnant ewes that get infected is almost 100%.

    Recent outbreaks in Kenya, Rwanda and South Africa have put health authorities on high alert. Some authorities restricted the movement of livestock and even temporarily banned the sale of meat. And there is increasing concern that Rift Valley Fever could spread to Europe.

    Rift Valley Fever is an ideal candidate for a One Health approach because of its complex overlapping human, animal and environmental elements.

    Given there is as yet no cure for the virus, the better equipped we are to preempt outbreaks, the quicker we can mobilise to prevent them from spreading and putting animals and people at risk.

    Our research found that by tracking a disease with a combined, One Health approach, we could get a bigger, more accurate picture of the way it was spreading. This would allow us a greater opportunity to take preventative measures to protect people and animals, and save lives.

    Modelling disease interactions

    To show how this could work, we built a computer model of the complex disease interactions in people, cattle and mosquitoes based on real-world data from our field project to demonstrate possible outcomes.

    We then ran simulations to compare two approaches: a One Health surveillance system with joint human-animal sampling at the same time and place, and the more traditional approach of independent human and animal surveillance conducted separately.

    Our simulations demonstrated that the One Health sampling approach could detect associations in disease transmission between animals and people that would have been missed in typical, non-integrated study designs.

    Our research in the field also found that a One Health approach saved up to 35% in spending on staffing and resources when compared to conducting separate surveillance or studies.

    We also found that engaging the private sector, such as ranchers, farmers and their associations, which are often left out of One Health efforts, dramatically improved the efficiency and impact of the work.

    Engaging small-scale farmers was particularly important. But, in Kenya, where Rift Valley Fever was first detected, and throughout sub-Saharan Africa, convincing smallholder farmers to keep their flocks and herds vaccinated can be challenging if they do not see an imminent risk.

    In many parts, outbreaks happen once every five to six years. So many farmers do not see the return on the cost of vaccinating animals annually as well as with every new lambing and calving season, which can be up to three times a year.

    Ultimately, the only way for us to reduce the risk of Rift Valley Fever ever becoming a pandemic is to vaccinate livestock.

    We can be better prepared to tackle diseases before they take hold and avoid the devastating consequences, but only if environmental scientists, veterinarians and doctors work together and with the public. This is no easy or inexpensive task but our findings indicate that the returns on investment are manifold, for all of us who share one health.

    The Conversation

    William B Karesh receives funding from U.S. Agency for International Development. The US Dept. of Defense Biological Threat Reduction Agency funds the research on Rift Valley Fever.


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    The WHO recommends HIV viral load testing to monitor people on ARVs. Shutterstock

    A United Nations initiative backed by global experts has set its sights on an ambitious programme to bring an end to the AIDS epidemic by 2030.

    The 90-90-90 strategy aims to do this by reaching three targets: 90% of all people with HIV must know their status, 90% of those diagnosed with HIV must receive antiretroviral therapy, and 90% of people receiving antiretroviral therapy must be virally suppressed. When a person is virally suppressed it means the virus in their blood is undetectable. The last goal is informed by evidence that people with a suppressed viral load are less likely to transmit HIV to others.

    But a couple of steps still need to be taken before these goals can be met. The first is large scale community based HIV testing that aims to get people tested on an annual basis at the very least. The second is linking testing to care. This is critical because it addresses the gap between a person being diagnosed with HIV to when they start antiretroviral therapy.

    The third step is the close monitoring of people taking antiretroviral medication. The World Health Organisation (WHO) recommends viral load testing as the primary method of monitoring people on antiretroviral therapy. Viral load is the measure of the amount of HIV in a person’s blood and is used as a measure of how well a person is responding to HIV treatment. The lower the viral load the better the health outcomes.

    WHO guidelines advise that all patients on antiretroviral therapy receive a viral load test at six months and 12 months, and annually thereafter if the patient is stable. But very few patients receive that level of care.

    The main barrier is the time it takes to get test results back from laboratories that are often situated great distances from clinics. One way round the problem is to enable viral load testing to take place at primary health care level – what’s known as point-of-care viral load testing. This would be a game changer. Results would be known immediately and health workers could intervene swiftly by evaluating antiretroviral treatments in real time. This would, in turn, improve treatment outcomes.

    But achieving this requires innovation. A new approach is being piloted. The idea is to test if point-of-care viral load monitoring is in reach.

    Testing

    Monitoring the viral loads of people on antiretroviral therapy is an essential part of HIV management. Viral load testing helps doctors determine if a person is taking their medication as prescribed. It also helps to determine if patients are on the correct combination of antiretroviral drugs.

    It’s a key part of the arsenal against HIV because research shows that people who are virally suppressed are less likely to pass on the virus to someone else. That makes it a key factor in breaking the cycle of transmission.

    The most efficient way of doing this is through point-of-care testing sites. These are based within the community so that patients don’t have to travel long distances to get tests done as well as to receive treatment. This new model is being piloted with the aim of providing convenient access to care for patients.

    Currently nearly all viral load testing is conducted in centralised and designated laboratories. This means that there can be lags in getting results back to the field. Patients can wait for weeks.

    Laboratory based viral load testing is also expensive. Point-of-care testing is also cheaper than lab-based viral loads: health care workers could do the test rather than highly paid technicians.

    Small steps have been made in the direction of enabling viral load monitoring to be done at point of care.

    But additional equipment is also needed. Pilots evaluating point-of-care viral load testing are ongoing. A pilot is being run using a portable testing machine – the m-PIMA HIV1/2 – that fits on a desk top and can provide an accurate reading of viral load in under 70 minutes.

    The machine is being tested to establish whether it meets WHO standards. Once it is given the stamp of approval by the WHO, ministries of health can start the implementation at all sites.

    Closing the gap

    All countries still struggling to bring the HIV pandemic under control are focused on achieving the 90-90-90 goals.

    South Africa, which still has the biggest HIV epidemic in the world, with 7.9 million people living with HIV, is no exception, and is making significant progress.

    It is edging closer to the target of having 90% of people with HIV knowing their status. And it’s made significant progress on the second target that 90% of people with HIV should be on treatment.

    But it has some way to go on the third. While the country is on track to meet the goal that 90% of people on treatment be virally suppressed, it’s advances on this front haven’t been uniform. Some regions of the country still lag behind others. Being able to roll out point of care testing would go a long way in helping close these gaps.

    The Conversation

    Glenda Gray is the deputy chairperson of the Orange Babies Charity in South Africa, director of HCRISA, president and CEO of the South African Medical Research Council and a board member at the NRF. She is writing this article in her personal capacity.


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    Nigerian children receiving the polio vaccine in Lagos. EPA

    Polio is a disease that struck fear into the hearts of parents just a generation ago.

    Poliomyelitis, known as polio, is a viral illness which spreads through faeces and respiratory secretions. Polio causes sudden onset of weakness, often permanent paralysis, in otherwise healthy individuals. One arm or leg can become useless, or the whole body from the neck down can be paralysed. Often multiple children in the same household would die of the disease, with survivors left in wheelchairs. South Africa still had polio cases well into the 1980’s, with the last case of wild poliovirus in 1989.

    The Global Polio Eradication Initiative has not gone according to plan. The first eradication target date of 2000 was missed. 2018 is the latest target that we are about to miss. This is due to hard-to-reach areas of instability, unrest and fundamentalism in Nigeria, Pakistan and Afghanistan where it’s a struggle to achieve the high vaccination coverage required to eliminate the disease. Health workers in these areas risk their lives to conduct vaccination programmes amid hostile communities.

    Unfortunately, pockets of polio transmission provide reservoirs for resurgence at any time, with even one traveller able to bring polio back to a polio-free country.

    Polio is targeted to be the second human disease ever eradicated through vaccination. Smallpox was the first success story in 1974. Other diseases, like measles, wait in the wings to be selected for third place. Eradication initiatives are too labour intensive for the world to commit to more than one at any given time.

    In South Africa, the National Institute for Communicable Diseases investigates every child with sudden neurological weakness for polio – processing hundreds of samples from South African children annually, despite not having a wild polio case for almost thirty years. Such a situation is unsustainable for more than one disease at a time.

    The poliovirus has biological characteristics which have proven harder to combat than smallpox. Polio is a tough and hardy organism that can survive in the environment even when not carried by a human host. It’s stealthy, and can infect a hundred individuals silently before resulting in even one case of paralysis. This makes it difficult to trace and contain.

    The big successes

    Despite the setbacks, triumphs of the programme have been notable. Globally, polio caused more than 350 000 cases of paralysis in 1988 when the global polio eradication initiative was launched. In comparison, in 2017, there were only 21 people paralysed by wild poliovirus. Of three viral strains, poliovirus type 2 has been eradicated, with wild poliovirus types 1 and 3 remaining.

    But it’s too early to celebrate. Hotspots of wild poliovirus and related strains remain detectable. For this reason, a global public health emergency of international concern was declared for polio in 2014, the same level of threat given to the Ebola crisis the same year.

    Ebola eclipsed polio in public perception. Despite the fear that strikes parents when hearing of Ebola, we have forgotten the potential devastation wreaked by polio. Unlike the gusto with which novel Ebola vaccines were embraced for Ebola epidemics, vaccination for polio has become “bread and butter”. Mothers take their children for vaccination with a sense of duty and purpose, hardly realising that they are participating in the largest social movement in the history of mankind.

    Vaccination is a powerful example of social change; demonstrating impact of purpose united across geography and sustained through multiple generations. Every caregiver is participating in the most ambitious social endeavour in human history – to systematically eradicate dreaded diseases through immunisation.

    What happens to the diseases waiting in the wings if the polio programme fails?

    Cynics will ask if the smallpox success was merely a lucky break. Critics will query whether systematic disease eradication is an attainable human goal. The global polio eradication initiative comprises billions of dollars, hundreds of millions of children, millions of health workers and 30 years of work in hundreds of countries. We have gone too far to go back. It has been said that the global polio eradication initiative will be either a spectacular success or a spectacular failure.

    Failure is unthinkable.

    The Conversation

    Dr Suchard discloses having received funding, administered through her university, for speaker honoraria and consultancy work from Aspen GSK, Prepex Circ Med Tech ltd and Paediatric Management Group. She has administered conference funding sponsored by Sanofi Pasteur and been a sponsored delegate to Vaccinology congresses. As part of her responsibilities at the National Institute for Communicable Diseases, she engages regularly with the World Health Organisation and the National Department of heath regarding issues related to the Expanded Programme on Immunization and is a member of the National Advisory Group on Immunization..


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    False positive results have raised questions about home pregnancy tests.flickr/Rebecca

    Recent media reports revealed that digital home pregnancy tests being sold at leading pharmacies in South Africa and the UK were consistently giving false positive results. Both countries acted quickly. The home pregnancy kits, reportedly manufactured by a large international manufacturer were immediately recalled.

    The incident led to lots of questions being asked about home tests and what had gone wrong. These included whether the tests were well regulated and whether or not they were safe.

    Home pregnancy tests measure the hormone human chorionic gonadotropin in the urine of pregnant women as early as seven to 10 days after conception. A false positive is rare but it can happen. The reasons are usually because the user didn’t follow the manufacturer’s instructions, the kits had expired or the user was on medication that affected the outcome.

    In this case it’s clear that the device itself was at fault.

    Home pregnancy kits are just one of a range of point-of-care medical diagnostic tests. These include tests used by health care professionals in a small clinic, hospital, or at a patient’s bedside as well as those sold over the counter and used at home by the patient themselves or a caregiver.

    Diagnostic tests performed in rural clinics or at the bedside have huge advantages, and can result in improved clinical decisions and treatment. Consequently, the market for point-of-care testing is expanding rapidly and is now worth billions of dollars.

    One of the main challenges has been the quality and accuracy of the final results. To fix this, organisations such as the World Health Organisation and the International Federation of Biomedical Scientists have published guidelines for the validation and use of a range of tests, particularly those used by health care facilities.

    But there are very few guidelines for over-the-counter diagnostic tests. And regulation is patchy – in South Africa as well as in other countries. So it’s not surprising that false results happen.

    In the absence of proper regulation of over-the-counter medical tests, patients need to take extra care when using them. They need to follow the manufacturers instructions closely. But they also need to confirm the result at an accredited laboratory and consult with a health care practitioner.

    And governments need to take action to improve regulations so that faulty kits don’t get sold. In South Africa this would require consultation with all role players and the expansion of the current regulations to include all home based tests being sold at retailers.

    A wide array of tests

    The demand for over-the-counter diagnostic tests, performed by patients themselves, is increasing. These include tests for pregnancy, glucose and HIV.

    In 2017 the first home test kit for HIV became available in South Africa. The kits were welcomed because they increased the number of individuals who could simultaneously know their status and present for early treatment. This could ultimately result in a reduction in the spread of the virus.

    Guidelines for HIV home testing have been included in the South African National Strategic Plan for HIV, sexually transmitted infections and tuberculosis. The guidelines emphasise that test kits should be approved by a regulatory body similar to the Food and Drug Administration in the US and meet international quality standards.

    In addition, the South African Health Products Regulatory Authority has published regulations covering medical devices and in vitro diagnostic medical devices. These include issues such as their importation, transportation, registration and manufacture.

    But, with the exception of HIV, home test kits are not adequately monitored and managed.

    Where to next

    The era of individuals taking control of their own medical decisions is here to stay. Home based diagnostic tests should be accepted.

    Although guidelines for HIV home testing have been developed, there are huge gaps when it comes to other testing kits. This includes pregnancy tests. Authorities in South Africa – and in other countries – should up their game and provide guidelines and regulations on the quality, training and use of all point-of-care testing.

    The Conversation

    Glenda Mary Davison does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.


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    There are concerns that Africa may be excluded from advances in genetic brain research brain.Shutterstock

    Over the past two decades, mental health research has advanced markedly. But most mental health studies haven’t included African people – either as researchers or as participants. This raises an all too familiar concern that Africa could be a bystander as advances in molecular and genetic research of the brain proceed at a breakneck speed.

    A turning point in this disparity has been the realisation that the involvement of Africa in mental health research is vitally important. This is true for two reasons. Firstly, science that doesn’t include diverse population groups risks being biased, inaccurate and incomplete. Secondly, African populations are genetically the most diverse due to the continent’s unique position as a land of origins.

    Missing this diversity has held back the progress of mental health genetics research.

    A dedicated group of African and non-African researchers, clinicians and institutions are working to reverse this trend and make up for lost time.

    But, the challenges are formidable.

    The first is that there’s been a bias in medical research in Africa towards communicable diseases. This includes HIV, tuberculosis and malaria. The need to eradicate these diseases can not be over emphasised. But this shouldn’t be at the expense of issues such as mental health and its associated repercussions.

    The second problem relates to budgetary constraints. Mental health disorders account for approximately 19% of the overall years lived with a disability in African countries. But less than 1% of the health budgets of countries is attributed to mental health.

    Thirdly, not many clinical trials and genetic studies have been done on the continent. Often, policymakers consider genetics a distraction to the more urgent problems faced on the continent.

    Lastly, government agencies and institutions find it difficult to justify allocation of funds to genetics studies and mental health research. But given the pace of technical and analytic developments in the field, African scientists can no longer afford to ignore the possibility that the opportunities may outweigh the perils of genetic research.

    Breaking down barriers

    So what can be done?

    One initiative that’s trying to break down some of the barriers is the Human Heredity and Health in Africa (H3Africa). This organisation is invested in understanding health and disease in African populations by providing research opportunities to study the interplay between environmental and genetic factors that affect the spread of diseases.

    The initiative is also leading efforts to get the public, institutions and governments engaged on genetic research in mental health disorders. This is part of an effort to close the knowledge gap so that insights from genetics are more accessible and understandable.

    Another initiative, designed to address the problem of a lack of expertise, is being driven by the Global Initiative for Neuropsychiatric Genetic Education in Research. Genetics research is highly complex and requires knowledge in areas ranging from computational sciences to ethical studies. The initiative is bridging the training and capacity gaps of mental health genetic research in Africa through online classrooms and onsite visits for early-career African researchers.

    In addition to analytic experience, the curriculum teaches a range of skills including time management, communication, networking, and building interpersonal relationships. All are designed to help fellows become independent researchers.

    The programme is committed to producing the next generation of African researchers. And to set the foundation for these fellows to mentor, train and produce a second generation of scientists.

    The hope is that the programme will also spearhead a new level of collaboration between African institutions and overseas collaborators. This too can help overcome the shortage of skilled genetic researchers in Africa.

    Two other initiatives are also helping advance mental health research, though they aren’t specifically focused on the genetics of mental health. These are the African Mental Health Research Initiative and the Friendship Bench Project. Both have paved the way for increased funding, collaboration and understanding of mental health in Africa.

    Additional hurdles to overcome

    Even after the research hurdles have been cleared, other challenges will have to be addressed.

    Chief among these is the need to assuage people’s fears about taking part in genetic studies. Misconception, stigma, and socio-cultural prohibitions have hampered genomic research in Africa. Participants tend to feel uneasy about the long-term use of their blood and tissue samples in genomic research.

    This means that a lot of work still needs to be done to encourage people to take part in studies by contributing biological samples and clinical data.

    On top of this, methods need to be found to extract samples that are both affordable and non-invasive. And finally, participants must be afforded the chance to make informed decisions about taking part in research. In particular, those with diminished or impaired autonomy need special protection.

    Some work has already been done to address these issues. For example, H3Africa developed guidelines on the export of samples from African countries. But it’s unclear if all institutions adhere to them.

    And there are still big gaps. Most African countries don’t have policies for health-related research so harmonisation isn’t possible. There’s also no comprehensive framework to guide mental health neuropsychiatric genetics research in Africa. This needs to be developed and should take into account how best to mobilise local and international resources.

    Our continent provides incredible diversity and a wealth of knowledge that needs to be tapped.

    _Fellows from the Global Initiative for Neuropsychiatric Genetic Education in Research (GINGER) contributed to this article: Felicita Omari, Benedict Akimana, Melkam Alemayhu, Shareefa Dalvie, Abebe Ejigu, Michelle Hoogenhout, Allan Kalungi, Symon M. Kariuki, Nastassja Koen, Lerato Majara, Jackline Mmochi, Emmanuel K. Mwesiga, Linnet Ongeri, Abigiya Wondimagegnehu Tilahun _

    The Conversation

    Dr Nathaniel McGregor receives funding from the National Research Foundation (NRF) (Thuthuka). Additionally Dr McGregor is affiliated with the Schizophrenia Research Group in the Department of Psychiatry at Stellenbosch University, a member of the SU/ UCT MRC Unit on Risk and Resilience in Mental Disorders housed in the Department of Psychiatry at Stellenbosch University, co-founder of the Systems Genetics Working Group in the Department of Genetics at Stellenbosch University, and an inaugural member of the Global Initiative for Neuropsychiatric Genetics Education in Research (GINGER) programme hosted by the Stanley Center for Psychiatric Research, Broad Institute, Harvard T.H. Chan School of Public Health and MIT.

    Benyam Worku Dubale and Celia van der Merwe do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.


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    Scientists analysing data at the South-South Malaria Research Partnership project laboratory in Kenya. Flora Mutere-Okuku

    Malaria is still a major problem in Africa. There are over 200 million clinical cases each year and approximately half a million deaths.

    There are different ways in which malaria can be controlled. Preventive measures include use of insecticides in bed nets or indoor spraying programmes. Medicines can also be used to prevent or treat malaria, but resistance often develops and drugs lose their effectiveness.

    The World Health Organisation reported that progress in controlling malaria has stalled.

    As an immunologist, I dream that one day we will have an effective vaccine that will help eliminate malaria. I think this is possible because for over a century, we have known that humans do become immune to malaria. In places where there is lots of malaria adults don’t succumb to the disease, but their young children do.

    In experiments conducted over 50 years ago, researchers showed that blood could be taken from adults who had become immune and used to treat children admitted to hospital with malaria.

    Antibodies in the blood were responsible for this effect; in other words, antibodies could treat malaria. Researchers have been trying to isolate the exact antibodies that do this. The challenge is that our bodies make millions of antibodies, so pulling out those with the antimalarial activity has been difficult.

    One way to identify these “good” antibodies is to compare the blood samples of people who get malaria with those who don’t with the aim of identifying the differences. This type of research has been going on for about 30 years, but the results have been inconclusive.

    Part of the reason is that in almost every study, the investigators do things differently.

    It’s like cooking your favourite dish. You may have a particular recipe but if you check in with friends and ask how they prepare the very same dish, you will find that each of them does something slightly differently. In the same way, differences in the way scientists have conducted their experiments have contributed to a lack of clarity in the results.

    We’ve embarked on a project that breaks this cycle.

    The project

    In experiments conducted over 50 years ago, researchers showed that blood could be taken from adults who had become immune and used to treat children admitted to hospital with malaria.

    We used the latest technology to analyse our samples. We designed a small glass slide on which we stuck over 100 carefully selected proteins from the malaria parasite. With less than a drop of blood, we were able to simultaneously measure antibodies to all these proteins.

    This was a major step-change. When I started this research 14 years ago, I used to measure antibodies to one parasite protein at a time, using a lot more blood, and in samples from one area in Kenya.

    Developments in technology now mean that it’s possible to do this much more efficiently. And we’re really excited that we have been able to exploit these new innovations in Africa.

    My team analysed antibodies in over 10,000 samples in three months. We are now working through the statistical analysis of this data to understand how people who are immune to malaria do it.

    My team is also working on understanding how antibodies kill malaria parasites. It’s still unclear if the antibodies attack the parasite from different angles or whether different antibodies are synergistic in their actions.

    We also don’t know how much antibody is necessary.

    What we know

    So far, our studies suggest that having a bit of one antibody is not good enough, and we may need high concentrations of antibodies against combinations of parasite proteins.

    We are also learning that antibodies kill parasites in many ways, and that studying any one of these in isolation may not adequately reflect reality.

    I believe the key to making a better malaria vaccine is right here with us. With patience, perseverance and continued hard work, we will find the recipe required to make a really good malaria vaccine.

    The Conversation

    Faith Osier receives funding from the Wellcome Trust, the MRC/DFID African Research Leader Award, the European and Developing Countries Clinical Trials Partnership (EDCTP), the Sofja Kovalevskaja Award from the Alexander von Humboldt Foundation and TIBA - Tackling Infections to Benefit Africa. She is Vice-President/President-elect of the International Union of Immunological Societies.


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    X-ray of the lungs in a 5-year-old child who has pneumonia. Shutterstock

    Pneumonia is a respiratory infection that affects the lungs. The viruses and bacteria that cause the disease are spread through airborne droplets from a cough or sneeze. An infection can cause the lungs to fill with pus and fluid, making breathing and oxygen intake difficult. And while anyone can get pneumonia, children with weakened immune systems or underlying illnesses are more susceptible. That’s why, pneumonia kills more than a million children every year across the world.

    There have been some critical advances in preventing and treating the disease. These include vaccines, antibiotics and providing supplemental oxygen. In 2009, South Africa became the first African country to include the pneumococcal conjugate vaccine in its routine infant immunisation programme. By 2012 an estimated 81% of one-year-old babies had received three doses of the vaccine.

    South Africa has also reduced its pneumonia burden through the mass roll-out of antiretroviral therapy and the HIV prevention of mother-to-child transmission programme. This has made a difference because children born to HIV-infected mothers have a significantly increased risk of pneumonia disease and death.

    But much work remains. In 2016 influenza and pneumonia were the second leading cause of death in children younger than five years in South Africa. That’s why we at the country’s National Institute for Communicable Diseases are monitoring key areas related to the cause and effects of pneumonia.

    There is reason to be optimistic: a number of advances currently in development will almost certainly strengthen our artillery in the fight against pneumonia. Some of these are complicated and expensive, such as developing additional and more effective vaccines. But there are also many tools that don’t involve expensive, complicated medical interventions such as providing adequate nutrition, clean air and water.

    There is an argument to be made for getting back to basics in a bid to tackle pneumonia. The answer to stopping children dying from preventable diseases may simply lie in basics such as reducing poverty and inequity.

    Advances

    As with any other disease, data is crucial when it comes to understanding and, ultimately, controlling pneumonia. At the institute, we examine what pneumonia-causing pathogen strains are circulating at any given time. We also keep a close eye on population groups at risk of infection and death (such as children) and monitor the effect that existing vaccines have on the disease.

    All this data helps to detect increases in disease. This helps us to prepare rapid responses and work towards containment should an outbreak occur.

    The information we collect can also help those who are trying to develop new pneumonia vaccines and improve current vaccine schedules. For instance, immunisation of women in their third trimester of pregnancy to provide protection to their babies in their first few months of life when they are most vulnerable.

    In addition, vaccine candidates targeted against one of the viruses responsible for a significant proportion of childhood pneumonia – the respiratory syncytial virus (RSV) – are in the late stages of development.

    Other advances are being made to improve pneumonia diagnosis. These include improved radiological methods, point-of-care tests which are used at or near patient care to speed up diagnosis, and the use of host biomarkers that examine the type of immune response a person develops to identify the cause of infection.

    Back to basics

    We know that malnutrition, indoor household air pollution, poverty, poor hygiene and sanitation all significantly increase a child’s risk of infection and death.

    In South Africa, about 30,3 million people were living below the poverty line in 2015. Two-thirds of children younger than 18 years were living in poverty.

    It is critical to provide children with basic human needs like adequate nourishment, access to clean water and air, and equitable access to vaccines and basic healthcare.

    The costs associated with improving children’s living conditions must be evaluated against the high costs associated with the clinical management of childhood pneumonia. The residual burden of pneumonia can be reduced by prioritising child health through simple interventions. These include improving living conditions and accessibility to affordable medication, vaccines and care.

    The Conversation

    Nicole Wolter receives funding from National Research Foundation, Bill and Melinda Gates Foundation, Centers for Disease Control and Prevention, Pfizer and Sanofi Pasteur.


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    New toilet blocks in Mathare Valley informal settlement in Nairobi.Samantha Winter

    About 2.3 billion people around the world lack access to basic toilets. This leads to poor sanitation and about 280,000 people per year die as a result. But the global sanitation crisis isn’t equally distributed. Women in developing countries are disproportionately burdened by the persistent lack of access to sanitation in their homes, communities, schools and public spaces.

    Women and girls who rely on shared toilets, at schools or in densely populated urban settlements, lack privacy, safety and hygiene to comfortably manage their daily toilet and menstruation needs.

    This threatens their health. Exposure to harmful bacteria in unsanitary environments puts women at risk of urinary tract infections, toxic shock syndrome and vaginal infections. Holding in their urine and faeces also puts them at risk of dehydration and haemorrhoids.

    We carried out a study in Mathare Valley informal settlement in Nairobi, Kenya to better understand women’s daily sanitation practices and what influences their decision to use facilities in the settlement.

    Seven years ago there were about 144 public toilet facilities in Mathare. Anywhere from 17 to 232 people relied on a single toilet and over 70% of residents had to walk more that 50 meters to reach a toilet.

    Since then, there’ve been concerted efforts by non-governmental organisations and the government to increase the number of toilets in Mathare. For instance Sanergy, a social venture, has launched more than 140 toilets in Mathare. But many of the existing toilets still require payment to use, between KES 3 and KES 10 per use (USD$0.03 - USD$0.10).

    Despite the growing availability, many women still don’t always use them.

    In our study we found that about one-third of women relied on a bucket, plastic bags or open defecation at least once during the day and over two-thirds rely on those methods at night.

    This means that its not just access that’s the issue. Many women aren’t using the new facilities because of concerns over their safety, privacy, health and ability to pay to use them.

    Future interventions must address these problems – and not just supply toilets – if sustainable gains in this important public health area are to be achieved.

    Informal settlements

    About 6.5 million of Kenya’s 45.5 million people live in urban informal settlements. The population living in these settlements increased by more than three times, from 1.5 million to more than 6.4 million between 1990 and 2014 and is still expected to keep growing. This will exacerbate the challenges women face when it comes to sanitation.

    We collected data in two phases between 2015 and 2017. During the first phase we partnered with representatives from the University of Nairobi and female residents from Mathare to conduct in-depth case studies with 55 women living in Mathare. In the second phase we worked with female residents in Mathare to carry out 550 household-level surveys with women.

    We found that, about 40% of women relied on public toilets for some of their sanitation needs during the day, but are unable to rely solely on these toilets. Within 24 hours, 75% of women relied on plastic bags or buckets at least once for their ablutions. They then dispose of these in open drains or rivers near their homes.

    This is surprising. Over the last few years there have been efforts to increase access to toilets in Mathare. Notable among them are Sanergy’s fresh life toilets, Grand Challenge Canada’s funded Banza toilets and a government effort under the National Youth Service’s slum improvement project. Each of these projects focused on some aspect of increasing access to sanitation, from provision of innovative toilets to household rubbish collection, drainage cleanup, and toilet construction and management.

    A number of factors prevent women from regularly using the facilities.

    Women fear victimisation – like sexual assault, rape, or theft – poor cleanliness and a lack of privacy. On average, toilets in Mathare are shared by 70 people, with many being used by hundreds of people. This makes it very difficult to maintain them.

    We found that one or more of the stalls at public toilets have missing doors or locks, are flooded or blocked, or aren’t cleaned well. Several of the public toilets, which have separate sections for men and women, aren’t always open or have closed one of the gender sections. Having to share facilities is a factor that makes women feel insecure, particularly at night.

    The women didn’t see the toilets as safe spaces. They also don’t feel safe in the settlement. Participants said they felt unsafe leaving their homes at night, even if the toilets were located within a short walking distance.

    Another reason women wouldn’t use the facilities is because most charge them, and they can’t afford to pay. Most toilets in Mathare charge a pay-per-use fee between KES 3 and KES 10 per use (USD$0.03 - USD$0.10). If they can afford the “family fee” (a bulk payment), then they can pay KES 100 to KES 150 per month (US$1 - US$1.50). The average household income in Mathare is about KES 8500 (USD$85), and estimated monthly expenditures often exceed this amount. This leaves little or no money for spending on sanitation.

    On top of this, we found that some women don’t have the decision making power or control over household spending to allocate additional funds to sanitation.

    Interestingly, many of the community toilets in Mathare have separate urinals for men that are free to use but there’s no setup like this for women.

    Solutions

    When we asked the participants what would work for them, some suggested they needed more access to free urinals – one or two stalls in a public toilet facility – that they could use for urination and to change menstrual pads.

    We also suggest that policymakers need to start accounting for other challenges to sanitation access, like strategies that increase women’s safety and privacy, especially at night. For example, better lighting in and around public toilets or community or technological innovations to help women feel safer when accessing public toilets.

    The Conversation

    Samantha Winter received funding for this project from the National Security Education Program in the United States as a Boren Fellow, PEO International, and the Rutgers Global Health Institute.


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    Bed nets treated with insecticide have been effective in fighting malaria in Africa.Shutterstock

    Current strategies to prevent malaria using bed nets and insecticides protect millions of people from malaria-transmitting mosquitoes. Last year 175 million bed nets treated with insecticide were delivered across sub-Saharan Africa. Between 2000 and 2015 bed nets are estimated to have prevented an estimated 450 million malaria cases.

    But these measures offer only limited protection. According to the latest World Malaria Report, 44% of people in African countries with high malaria rates don’t have access to bed nets and insecticides. Even when they are available, they’re not failsafe. For example, the use of bed nets has been linked to an increase in mosquitoes biting outdoors, and they can also develop resistance to the insecticide.

    Worldwide there were 435,000 deaths last year from malaria. Over 90% were in Africa. This means that scientists need to redouble efforts to develop new, complementary measures to eliminate the disease.

    One promising solution includes reducing the population of malaria mosquitoes through genetic modification to help reach the target of ending transmission.

    Target Malaria, a research consortium working across the USA, Europe and Africa, is in the early stages of developing a genetically modified mosquito that can either produce only male offspring or reduce female fertility in subsequent generations.

    Where I work in Mali, we are currently studying local mosquito populations to help inform work on genetic modification.

    Though the scientific research often gets the limelight, the process also involves working side by side with local communities from the very beginning. This engagement helps us get not only the communities’ feedback but also their active participation.

    Genetic modification

    Our work in Mali involves trying to understand the mosquito species that are responsible for malaria transmission and to gather as much baseline data as possible on the local malaria mosquitoes. These data include: abundance, biting and resting behaviour, migration, effective population size. This is a crucial first step that will be the basis for further work in our country.

    Genetic modification could be achieved in one of two ways.

    The first is to bias the sex ratio so future offspring would be all males. This is done by fragmenting the X chromosome in the males so they only pass on a Y chromosome. As a result, their offspring is male (XY), as a female would need to inherit an X from each parent (XX).

    The second way is to reduce female fertility. This is achieved by targeting the gene responsible for fertility in females. A female that has one copy of this fertility gene disrupted will be able to reproduce normally, but when both copies within her chromosomes are disrupted, the female cannot produce viable offspring, reducing the mosquito population.

    But as the science to make this possible gets closer, we must ensure that the public debate around such a novel and potentially transformative technology also keeps up.

    This means not only exploring what we can do in a laboratory, but exploring and understanding what is acceptable to the communities most affected by such innovations. We need to ensure that any new malaria control method fully meets their needs.

    Involving communities

    In Mali, where Target Malaria has been working since 2012, there is an ongoing dialogue at national, regional and community levels.

    Our teams visit the communities around our in-sectary where insects are kept and studied, as well as field sites nearly every week and community members visit our laboratories. We also get permission from individual households to collect mosquitoes from homes or compounds. And we ask communities before we catch mosquitoes in swarms.

    But engagement is not just about information and acceptance, it’s also about collaboration. Our “relay” staff, who live in the communities, can provide information even when we are not there.

    On top of this we respect the decision-making processes of each individual village regardless of how different the processes can be.

    We will continue following this way of doing things for each subsequent phase of our work.

    The reason for such extensive and transparent engagement is clear.

    As researchers, our role is not only to determine whether the genetic alteration of mosquitoes to stop malaria is scientifically possible. It is also to ensure that this can be done ethically and responsibly to meet the needs of the affected population. We can only do this by involving them.

    The Conversation

    Mamadou Coulibay no recibe salario, ni ejerce labores de consultoría, ni posee acciones, ni recibe financiación de ninguna compañía u organización que pueda obtener beneficio de este artículo, y ha declarado carecer de vínculos relevantes más allá del cargo académico citado.


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    The life expectancy improvements in sub-Saharan Africa vary between men and women.Shutterstock

    People in sub-Saharan Africa are now living longer than ever before. A child born in the region today is expected to live up to 64 years on average. This is a remarkable increase of 11 years since the year 2000, when life expectancy at birth was only 53 years in sub-Saharan Africa.

    Life expectancy at birth is the average number of years that a newborn is expected to live, if current mortality rates hold steady. Changes in life expectancy can be used to track the impact of population-wide health threats, such as the HIV epidemic in sub-Saharan Africa. The monitoring of life expectancy can also provide crucial information that’s needed to deploy resources and effective interventions on the ground.

    The life expectancy improvements in sub-Saharan Africa vary between men and women, within sub-regions and between countries.

    We know all of this, and much more, because of an extensive study we recently published in The Lancet. We drew from the Global Burden of Disease study, which is a systematic effort to gather and analyse a huge amount of data on health loss due to diseases, injuries and risk factors by age, sex and geography over time. This allowed us to look at trends in mortality and life expectancy in the region from 1950 to 2017. It’s the most comprehensive look at these issues that’s ever been published.

    Our research shows that the average life expectancy for men in sub-Saharan Africa is 62 years. For women it’s 66 years.

    There are regional variations too. For example, men in central Africa will live to 60; those in eastern Africa to 63. Women in central Africa will reach 64 years; in southern Africa the figure is 68 years. The lowest life expectancy among men in sub-Saharan Africa is 49 years in the Central African Republic. The highest – 73 – is in Cape Verde. The corresponding life expectancy for women in those countries is 55 and 79 years.

    There has been a huge decrease in mortality among children younger than five in sub-Saharan Africa. As a portion of total deaths, the number of deaths before the age of five has decreased from 45% in 1950 to 10% in 2017.

    This is likely linked to a number of interventions such as the scale-up of vaccination programmes, improved water and sanitation, and mass distribution of insecticide-treated bed nets. Mothers’ increased education levels and rising individual incomes have also contributed to the decrease in child deaths.

    But caution is necessary. It’s not inevitable that death rates will keep falling. Rising epidemics of high blood pressure, high blood sugar, and obesity in some African countries could lead to shifts over time in the opposite direction.

    Falling death rates

    Overall, death rates have been dropping in sub-Saharan Africa since the beginning of the 21st century. There were 702 deaths per 100 000 people in 2017, down from 1366 deaths per 100 000 in 2000.

    For all ages, it’s estimated that one-third of life expectancy improvements are because of rising income per capita, one-third can be attributed to improvements in educational attainment, and one-third are a result of changes that have happened over time. These include technological improvement such as new vaccines. We have also learned more about diseases and how to control them.

    There may be additional reasons for the reductions in mortality over time. These would include social factors like availability of job opportunities and good working conditions, existence of social support networks, and safe housing.

    Causes of death

    The five leading causes of death in sub-Saharan Africa for adults between the ages of 15 and 49 years in 2017 were AIDS, tuberculosis, malaria, maternal disorders, and road injuries.

    The leading causes of death differed when we looked at mortality for each of the sexes over time. There were major changes in the leading causes of death between 1990 and 2017.

    Interpersonal violence was the seventh leading cause of death among men in 1990. Now it’s number five. Liver cirrhosis was the eighth leading cause of death; now it’s the sixth.

    The main changes in causes of death among women were cervical cancer, which moved from 10th in 1990 to seventh. Breast cancer was the 17th leading cause of death among women – today it is eighth.

    For people between the ages of 50 and 69, the three leading causes of death in 2017 were tuberculosis, heart attacks and stroke among men; and stroke, heart attacks and tuberculosis among women.

    This shows that non-communicable diseases are already wreaking havoc in many countries across the continent.


    Read more: People in Africa are living longer but lifestyle diseases are rising


    Impending epidemic

    High blood pressure, high blood sugar, and obesity are the top risk factors for death in women aged between 50 and 69. The top risk factors for men in the same age group are high blood pressure, high blood sugar, and alcohol use (with obesity in sixth position).

    These risk factors are warning signs of an impending, widespread epidemic of non-communicable diseases in sub-Saharan Africa. Some non-communicable diseases such as diabetes, heart attacks, and stroke are already projected to be major killers in the region soon.

    The Conversation

    Charles Shey Wiysonge does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.


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    Ghana's newspapers are largely doing a good job when it comes to mental health reporting.Francisco Anzola/Flickr, CC BY-ND

    If you want to know how a country views mental illness, take a look at the way its media reports on the issue. That is the view of some scholars who argue that newspapers, television and radio influence negative ideas about mental health. Others suggest it’s the other way around: the media merely reflects what society already believes.

    With these debates in mind, we wanted to explore the role that Ghana’s print media plays in shaping public opinion and disseminating knowledge about mental health disorders.

    To do this we studied articles about mental health that appeared in the country’s newspapers between 2000 and 2015. There were a number of developments around mental health in Ghana during this period, particularly in terms of legislation.

    Our analysis suggests that Ghana’s newspapers are largely doing a good job when it comes to reporting about mental health. Many articles showed a commitment to educating readers about the issue. Articles also highlighted how those with mental health disorders are still stigmatised in society.

    Our findings are encouraging given the crucial role the media plays in informing and educating people.

    There were, however, areas of concern. There were some instances in which we found newspapers were not disseminating accurate information about mental health. This needs to be addressed. Perhaps mental health experts could be brought into Ghana’s newsrooms to train journalists about how to report on the relevant issues. These experts could also be better used as resources for fact checking.

    What we found

    We chose newspapers because they are a popular source of information for Ghanaian’s.

    Working with 164 articles from six Ghanaian newspapers – The Chronicle, Daily Graphic, Ghanaian Times, Mirror, Spectator, and Times Weekend – we were able to identify several themes related to mental health. These were awareness, advocacy, opinion, suicide, donations (and funding), and religion. Here is what we found.

    Awareness: The articles in this category sought to provide information about mental health disorders and available treatment options. The problem was that some made false claims or misidentified mental health issues. It’s important to point out that only 1.8% of articles in our sample provided misinformation. Still, it is a problem that must be addressed.

    In one piece, headlined “This is Killing Me Softly,” an advice columnist responded to a request for help about combating severe shyness around women. While the columnist’s advice challenged the writer to interact with women, it failed to acknowledge mental health implications – namely anxiety.

    Advocacy: Articles in this category aimed to rally public support around mental health policy. One example, “Ghana’s Population in Psychological Distress,” called for the implementation of Ghana’s Mental Health Law.

    These articles highlighted barriers to implementing mental health policies, and the administrative hurdles that prevent mental health services from being expanded.

    Opinion: These pieces offered one writer’s perspective on mental health issues. One example was an opinion piece about an ongoing investigation into psychiatric hospitals. It showed how newspapers can be used as a platform to provide social commentary on mental health related matters, and to remind readers that mental illness is part of everyday life.

    Opinion pieces also illustrated the press’s role in holding public agencies accountable on issues which would otherwise be suppressed.

    Suicide: Most articles in this category were investigative reports that identified the victims and the alleged circumstances that led to suicide. Other articles aimed to raise awareness about suicide.

    We also found that columnists played an important role in the lives of their readers as authorities about suicide. For example, one anonymous reader wrote to an advice columnist saying that he felt like committing suicide because he was not able to provide financially for his sextuplet newborns. The columnist offered useful resources and services for the writer.

    Collectively, these articles illustrated the reality of suicide in Ghana.

    Donations: a subset of articles reported on donations by individuals and organisations to psychiatric hospitals. These involved donations of time, cash or in-kind services.

    The trend of local philanthropy reflected the low funding available to support the operation of psychiatric hospitals, the public recognition of this funding gap, and the public’s willingness to provide resources.

    Religion: Other articles explored Christianity as a means of mental health self-care. The intersection of religion with mental well-being is not surprising given that many Ghananians are religious.

    Lessons

    This certainly was not an exhaustive overview of public knowledge sources about mental health in Ghana. Similar research could focus on radio or television coverage, for instance.

    That said, it provides a useful starting point for understanding the sort of messages many Ghanaians are getting about mental health. The analysis could be used to get journalists and media houses to think differently about how they report on these issues, and to plug the gaps where necessary.

    Author’s note: Graduate students Alexis Briggs and Christina Barnett contributed to this article and to the research it is based on.

    The Conversation

    The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.


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    The theme for World Aids Day is "know your status". EPA

    In recent years, more emphasis has been placed on testing for HIV. The idea behind this drive is that if people know their status, they’ll be able to seek treatment and support. One approach that’s become fairly common is self-testing, or self-screening.

    This is when a person collects their own specimen (blood or oral fluid), performs a rapid diagnostic test and interprets the result themselves. This type of test can also be done by a health provider or peer educator. The blood is obtained by pricking one’s finger; the oral fluid is swabbed from the inside of your cheek.

    The rapid diagnostic test detects HIV antibodies in the blood or oral fluid. If the result is positive, people are encouraged to go and get their blood tested by a professional for confirmation.

    Self-screening for HIV has been touted as a disruptive innovation: one that can help to close the HIV testing gap by reaching key and under-tested populations who won’t necessarily want to visit a doctor or clinic for testing. These under-tested populations include sex workers, men who have sex with men and young women aged between 15 and 24.

    Research shows that HIV self-screening yields highly accurate results even when carried out by untrained lay people. Two years ago the World Health Organisation published guidelines recommending that self-screening be included in countries’ existing testing services. So far, 59 countries have implemented HIV self-screening policies and 53 others developing these policies.

    Access to HIV testing is an important factor in reaching the United Nations’ “90-90-90” goal: by the year 2020, 90% of people with HIV must know their status, 90% of people with HIV must be on antiretroviral treatment, and 90% of people on treatment must be virally suppressed.

    It’s estimated that only 75% of people around the world know their HIV status. This figure is higher in South Africa where an estimated 85% of people with HIV know their status.


    Read more: HIV, AIDS and 90-90-90: what is it and why does it matter?


    To help South Africa reach this first “90”, my colleagues and I at the University of the Witwatersrand, Wits Reproductive Health and HIV Institute are collaborating with a number of organisations to scale up HIV self-screening among under tested populations. These include men, who have lower testing rates than the general population, young people, sex workers and their networks (clients, partners and peers).

    Self-screening

    From November 2017 to September 2018, we distributed HIV self-screening kits to primary recipients (clients directly receiving the kit) and secondary recipients (people related to primary recipients, for example their sexual partners). These were distributed in four of the country’s nine provinces.

    The kits were handed out in a number of different places including existing HIV testing mobile services, and selected spaces in communities such as shopping centres. HIV self-screening kits were also distributed in workplaces, taxi ranks, and at health facilities for partners of pregnant women and people living with HIV. Participants in our sex worker programmes were also given self-screening kits to share with their networks.

    As part of the initiative, follow-ups were done telephonically with a randomly selected and representative sample of people who received kits in communities, workplaces and taxi ranks. We also followed up with everybody who received self-screening kits at health facilities and through our sex worker programmes.
    The aim is to encourage people to use the HIV self-screening kits and interpreting the results themselves. If the results are positive, the person must have the results confirmed by a health professional. If the results are still positive, the person should start HIV treatment immediately.

    By the end of September 2018, we had distributed 505 836 kits. A majority – 62% – went to men; 12% were received by people who had never tested for HIV before; and 45% of the recipients had not tested in the last year. The WHO recommends testing for HIV every six to 12 months.

    In less than a year we were able to reach the target populations. Our project is ongoing and forms part of a Unitaid-funded HIV self-testing Africa initiative, which is evaluating HIV self-screening around the continent.

    Our findings, is informing the implementation of HIV self-testing in South Africa, and other countries. The findings will also be published in open access journals early next year.

    Mohammed Majam, technical head of HIV Self-Testing at the Wits Reproductive Health and HIV Institute contributed to this article.

    The Conversation

    Joel Msafiri Francis received funding from HIV Research Trust, UK, THRiVE consortium, Global Fund Round 8 (HIV-Initiative), HIV Implementation Science fellowship, NIH grant through Harvard School of Public Health, Global Health Department.


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    More than a year after a groundbreaking liver transplant doctors still can't say if the recipient is HIV-positive or not.Shutterstock

    A lifesaving partial liver transplant from an HIV-infected mother to her uninfected child – the first of its kind – was conducted last year at the University of the Witwatersrand’s Donald Gordon Medical Centre in Johannesburg. More than a year later, both mother and child are doing well.

    But the crucial question of the child’s HIV infection status remains unanswered. And we don’t expect to have a definitive answer any time soon.

    Despite this uncertainty, the story of the transplant is inspiring. To date there have been no published reports of a living organ donation by a person with HIV, or of an intentional transplant from an HIV-positive to HIV-negative individual. The operation was driven by a number of factors. These included life-threatening liver failure in the child, no available deceased or suitable live HIV-uninfected donors, and an HIV-positive mother’s continued pleas to be allowed to save her child.


    Read more: Liver transplant from HIV+ living donor to negative recipient: key ethical issues


    We’ve learned a great deal from the operation and during the subsequent year. Most importantly, the success of this transplant provides a new therapeutic option for similar cases in high burden HIV countries where deceased donor organs are limited in number, or where access is limited.

    But there are still gaps in our knowledge. The biggest is what the long term effect of the transplant will be on the child, and particularly whether the mother’s virus was transferred with the liver.

    The journey

    The child was 13 months old when the transplant happened. The liver has a remarkable ability to regenerate and grows back to its normal size in the donor in about six weeks.

    Although born to an HIV-positive mother, the child did not have HIV. The mother was on antiretroviral therapy during pregnancy, and the child received standard preventative treatment.

    The mom had an undetectable virus ahead of the transplant. The child also received antiretrovirals ahead of the transplant to try and prevent infection. Both mom and child are still on HIV treatment today. The child is also on immunosuppressive therapy to prevent liver rejection.

    After the transplant, the child was tested for HIV. No virus was detected. Very sensitive tests also couldn’t detect traces of the virus within cells. This means that, one year on, there is no direct evidence of virus in the blood or blood cells.

    But there is a caveat. Just because we can’t detect the virus doesn’t mean it isn’t hiding in very small amounts.

    There’s another reason we can’t conclusively say whether the child is infected or not: 43 days after the operation HIV antibodies were detected in the child using standard diagnostic tests. But these antibodies have since decreased in amount. Normally, the presence of HIV antibodies means a person has been infected. But in this case, we can’t tell if these antibodies belong to the child or the mother (or both) because of the donor cells in the liver.

    Because of these uncertainties, treatment is being continued for the moment. Whether this will be lifelong remains one of many open and unanswered questions.

    Unanswered questions

    The operation, and subsequent events, have put us on the cusp of new insights and understanding about HIV and its transmission.

    We’ve been able to get some insights from previous events. For example, the transfer of HIV through liver transplantation has accidentally happened where deceased donors unknowingly had HIV. In all cases there was clear evidence of HIV infection in the recipient.

    There are lots of other examples – not HIV related – of the transfer of specific immune responses from a donor to the recipient. An interesting one is the transfer of an allergic reaction to peanuts in cases where the recipients had no prior history of peanut allergy but developed reactions following transplantation. Such transfer of donor immune responses is why we can’t use our standard HIV antibody tests for a conclusive diagnosis of recipient HIV infection in the setting of transplantation.

    Two factors make the situation we find ourselves in unique: it’s the first time that liver tissue from an HIV positive living person has been transplanted to a HIV-negative person. The second is that the liver is very different to other organs.

    The liver is the major draining organ for substances passing through the gut. Because of its role in metabolism, nutrient storage and detoxification it needs to distinguish foreign particles that are good (food) from those that are bad (pathogens). That’s what makes it immunologically tolerant. Tolerance means the immune system is geared to prevent an overreaction to good molecules.

    It’s not known how this tolerance might affect the risk of HIV infection. Studies on monkeys have shown an absence of actively infected cells in the liver compared with other organs. The presence of antiretrovirals in our transplant mom-child case would make the presence of actively infected cells even less likely.

    On the other hand, latent or “silently” infected cells which are very difficult to detect could be present in small numbers and pose a potential risk of sparking an infection if antiretroviral treatment were ever stopped.

    The way forward

    There are still many gaps in our knowledge. For example, we need to understand HIV in the liver of patients who are on antiretrovirals and virally suppressed.

    We also need to have a better understanding of this novel type of HIV exposure so that we can inform best practice in the setting of HIV-positive donor liver transplants.

    Studies of this case and of further transplants of this nature will help us to fill in these knowledge gaps.

    The ultimate aim is to have the best of both worlds – a life-saving intervention together with successful prevention of HIV infection in the transplant recipient.

    The Conversation

    Caroline T. Tiemessen receives research funding from the South African Medical Research Council (MRC) Strategic Health Innovation Partnerships (SHIP) programme, Department of Science and Technology/National Research Foundation (DST/NRF) South Africans Chair Initiative (SARChI) programme, Poliomyelitis Research Foundation (PRF), and the US National Institutes of Health (NIH).


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    The largest number of HIV-exposed but uninfected children are in South Africa.Shutterstock

    One of the most remarkable public health successes of the last decade in southern Africa has been the reduction in the number of babies born with HIV. This was achieved through the provision of antiretroviral therapy to pregnant and breastfeeding women living with HIV. For example, the number of new HIV infections in children in South Africa has come down from a peak of 70 000 in 2003 to 13 000 in 2017.

    Nevertheless, worldwide there are still an estimated 14.8 million children under the age of 15 who were born HIV uninfected but have been exposed to their mother’s HIV during pregnancy.

    The largest number of HIV-exposed but uninfected children – 3.2 million– are in South Africa.

    A staggering 30% of pregnant women in South Africa have HIV. Their infants are exposed to both HIV and antiretroviral drugs during pregnancy and breastfeeding. HIV-exposed but uninfected children don’t have HIV, so what’s the big deal?

    It is a big deal because HIV-uninfected children born to mothers with HIV are prone to infections that are more severe, are at almost two times greater risk of dying before their first birthday, and are more likely to be born prematurely than children born to mothers without HIV.

    In our recent study we set out to try and quantify the contribution of deaths in HIV-exposed but uninfected infants to the overall infant mortality rates in Botswana and South Africa.

    What we found was that because children born to mothers with HIV make up almost 1 in every 4 infants in Botswana and South Africa, and because they die more often than children born to mothers without HIV – even when they are HIV-uninfected themselves – this contributed to a higher infant mortality rate in both countries.

    The risks

    Even when they’re not HIV infected, children born to women with HIV experience a complex package of detrimental exposures.

    For example, HIV-exposed but uninfected infants are still more often born preterm or of low birth weight. This increases their risk for complications and death early in life.

    They are also exposed to more infectious pathogens in the home such as tuberculosis.

    There are other problems too. Breastfeeding has enormous nutritional and immunological benefits, but has often been avoided in infants born to women with HIV. Maternal access to antiretrovirals has made it safer but sustained breastfeeding is still low. One study in South Africa showed that, irrespective of HIV-status, women stopped breastfeeding their babies on average when the infants were eight weeks old.

    On top of this, HIV-exposed infants more often have mothers who are unwell or who have died. And HIV-affected households experience challenging socioeconomic circumstances that can make children more vulnerable. These exposures in the first 1000 days of life can be detrimental to early childhood development and have life-long consequences.

    In addition, infants born to women with HIV are subject to factors during pregnancy that unexposed infants aren’t. These include exposure to HIV particles, that may make their immune systems develop differently. And these infants are exposed to at least three antiretroviral drugs given to the mother during pregnancy.

    What the research found

    To estimate the contribution of deaths in HIV-exposed but uninfected infants to the overall infant mortality rates we used previously published research comparing the mortality risk in HIV-exposed uninfected infants to risk of mortality in unexposed infants, as well as United Nations estimates of infant mortality in Botswana and South Africa.

    In Botswana, HIV exposed uninfected infants accounted for 26% of the infant population but 42% of all infant deaths. Similarly, in South Africa HIV exposed uninfected infants accounted for 23% of the infant population but 38% of all infant deaths.

    Putting this into actual numbers, this extra mortality in HIV exposed uninfected infants increased the overall HIV-uninfected infant mortality rate in both Botswana and South Africa from around 30 deaths per 1000 infants to 35 deaths per 1000 in the year 2013.

    Botswana and South Africa have adopted the World Health Organisation’s recommendation to provide lifelong antiretrovirals to all pregnant and breastfeeding women with HIV. But there’s a lack of research comparing the mortality of HIV-exposed to unexposed infants under these new guidelines. Our calculations are therefore based on the year 2013, the most recent year before policy shifts in both countries. There is emerging evidence though of a persisting increase in mortality in HIV-exposed infants even with maternal antiretroviral therapy.

    What next

    With 1 in every 4 children in Botswana and South Africa being HIV and ARV-exposed, robust systems need to be put in place to monitor the long-term safety of these exposures during pregnancy. Countries need to invest in research to understand why HIV-exposed children still have an increased risk of dying. And countries need to ensure that routine child health interventions, such as immunisations and promotion of optimal durations of breastfeeding, are uniformly reaching HIV-exposed children.

    Most critically, countries like South Africa and Botswana with high HIV infection rates need to find responsible, transparent and accurate ways of sharing what is known and being done about the risks of HIV-exposure with HIV-affected families and involve them in finding solutions.

    The Conversation

    Amy Slogrove receives funding from research funding agencies on a competitive funding basis including the US National Institutes of Health and the International AIDS Society.

    Kathleen M. Powis receives funding from the National Institute of Health and from the Collaborative Initiative for Pediatric HIV Education and Research.

    Mary-Ann Davies receives funding from research funding agencies on a competitive basis including the National Institutes of Health and the International AIDS Society.


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    The WHO recommends testing for HIV every 6 to 12 months.Shutterstock

    There was a time when HIV was untreatable, heavily stigmatised, and the benefits of testing weren’t as clear as they are now. But that was 25 years ago.

    HIV testing remains the crucial entry point for all HIV services, including both prevention and treatment.

    When someone tests and learns that they are HIV positive, there is an opportunity to access life-saving treatment, ensure their own well-being and that of their intimate partners. When someone tests and learns they are HIV negative, there is an opportunity to evaluate their risk and assess which HIV prevention options are the best fit for them.

    UNAIDS estimates that 76% of people living with HIV in eastern and southern Africa know their status. While an HIV-positive diagnosis can still provoke fear among some, 85% of people with HIV in South Africa know their status.

    The goal is that by 2020, 90% of people with HIV should know their status. Increasing the uptake of testing is an essential first step in this quest, which is part of a package of goals aimed at ending the epidemic.


    Read more: HIV, AIDS and 90-90-90: what is it and why does it matter?


    Many people still struggle to overcome real and perceived barriers to testing. These include access to testing and the stigma related to testing. However many of the hurdles still in place might not be as big as once thought.

    What’s standing in the way of 90%

    Access: HIV testing is free in South Africa in all public clinics and health facilities, but for many people just getting to the clinic can seem like a major barrier. Whether this is because of long walking distances, the need to take time off work, or simply not prioritising or having the time to build testing into their health care routine.

    One solution lies in the advent – and increasing availability – of HIV self-testing kits. Now getting an HIV test can be as simple as going to the pharmacy and following the instructions.

    Being judged: A common concern is around confidentiality and being judged. This is especially evident among young people who are at risk of HIV infection, but may feel as if they would be judged for being sexually active. It’s estimated that 2000 adolescent girls and young women in South Africa are infected every week.

    This problem needs to be tackled by helping young people access testing. This can be done by providing youth friendly services where health care professionals are friendly, non-judgemental and supportive. Testing must be normalised and seen as an appropriate, responsible and acceptable thing to do. Many clinics already undergo training and accreditation for the provision of adolescent and youth friendly services. But it’s not universal.

    Stigma: Aside from stigma around HIV, many high-risk groups (such as sex workers, men who have sex with men, and injecting drug users) still face enormous barriers to accessing traditional services due to stigmatisation, discrimination and even criminalisation. This is especially true in sub-Saharan Africa where anti-LGBTI laws are rife and few protective mechanisms exist.

    The way this can be solved is by ensuring that testing campaigns and environments encourage everyone to test. More work must be done to combat bad laws and policies, stigma and discrimination. The fight should be against the virus, and not the people it targets.

    Low risk perception: The World Health Organisation and the South African government recommend testing every six to 12 months. But most people only test when they feel they have been at risk. Risk perception is highly subjective and sometimes incorrect. In a South African context, where the prevalence of HIV is so high – 20.6% of adults aged 15 to 49 years have HIV – everyone is at risk and should get tested every year.

    To encourage people to test more frequently, campaigns should continue to focus on the fact that HIV doesn’t discriminate. HIV testing also increases the opportunity to screen for multiple conditions, such as tuberculosis and other sexually transmitted infections, at the same time. This integration of HIV testing services with other health services is seen as a way of reducing stigma, increasing access, and is a move towards achieving universal health care.

    The Conversation

    Linda-Gail Bekker receives funding from various research agencies both local and international. She is the immediate past president of the International AIDS Society.


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    Restrictive laws mean that women resort to unsafe meansjbdodane/Flickr

    The Kenyan Medical Practitioners and Dentists Board has stopped the NGO Marie Stopes International from performing abortions in Kenya. Marie Stopes is a global organisation that provides contraception and safe abortion to women in urban and rural communities. Abortion is illegal in Kenya, unless a trained medical professional judges that there’s a need for emergency treatment, or that a woman’s life or health is in danger.

    The Conversation Africa’s Moina Spooner spoke to Michael Mutua about the Marie Stopes ban and its implications.

    How did the ban come about?

    According to the Kenya Medical Practitioners and Dentists Board, they banned abortion services provided by Marie Stopes following complaints from the general public. The public claimed the organisation was running pro-choice media campaigns. These adverts specifically sought to provide women with a solution when faced with crisis pregnancies.

    The adverts were also criticised by the Kenya Film Classification Board, which ordered Marie Stopes to pull them down for allegedly promoting abortion.

    The Kenya Medical Practitioners and Dentists Board is the only body within the Ministry of Health that has the mandate to regulate and set policies on medical training and service provision in the public and private sectors.

    Aside from closing down the abortion services, the board also ordered that Marie Stopes file all its service reports with them for two months. This is a way for them to keep track of what services the NGO is providing.

    Under what circumstances are abortions legal or illegal in Kenya?

    Abortion in Kenya is guided by two laws.

    Kenya’s 2010 Constitution prohibits abortion unless, in the opinion of a trained health professional, there is need for emergency treatment, or the life or health of the mother is in danger. Health can refer to complete physical, mental, and social wellbeing; it’s not just related to physical factors. So factors like social pressures and the psychological and emotional distress associated with unwanted pregnancies are taken into account.

    But there continues to be confusion over this for women, medical practitioners and legal bodies. That’s because, since this constitution came into effect, no policy guidelines have been created about the provision of safe legal abortion in Kenya. These guidelines would clearly define the circumstances under which the medical practitioner can do an abortion and what type of medical practitioner is authorised to perform the procedure.

    These guidelines used to exist – but they were withdrawn soon after the launch of the constitution following an outcry from religious groups. The Ministry of Health also argued that the guidelines were prone to misuse by quack medics.

    Without these guidelines, the older penal code law comes into effect. This law practically criminalises the act of seeking or securing abortion. It is harsher on the service provider than on the woman who terminates a pregnancy. The law can penalise the service provider with up to 14 years in jail. The patient can get seven years.

    The penal code does allow surgical intervention when the life of the mother is in danger. But this is very invasive and doesn’t accommodate improved procedures like manual vacuum aspiration and medical abortion.

    How many abortions happen in Kenya every year, and how?

    The impact of these laws means that women often turn to backstreet clinics and unsafe abortion services. Abortion is highly stigmatised within communities and at health facilities so women prefer to take a risk to assure their privacy.

    A recent study by the Ministry of Health, in conjunction with the African Population and Health Research Center, revealed that about 465,000 unsafe abortions take place in Kenya every year.

    As a result, nearly 120,000 women are treated in health facilities each year for complications arising from unsafe abortions. These include incomplete abortion, infection, excessive bleeding and injury to the internal organs.

    The risk of maternal mortality is high. Over 77% of these cases presented are “moderate or severe” and the women are at a high risk of death.

    What will the impact of the ban be?

    Each year the government spends over US$5million to treat women in government facilities who have complications from unsafe abortion. This cost is high. But it’s actually an underestimation: it excludes social costs – like the loss of working hours – and out-of-pocket expenses covered by the patient or their friends and relatives.

    Non-governmental players – like Marie Stopes – that provide safe abortions make a significant contribution in preventing the risks of maternal morbidity and mortality. One of the main roles they play is in preventing unintended pregnancies by providing contraception.

    These organisations also provide quality counselling to patients who intend to secure abortion. However some patients, given their social situations and because of the stigma of an unintended pregnancy, will resort to unsafe abortion when safe options aren’t available.

    I anticipate that by curtailing safe abortion services, without a commensurate investment in the prevention of unintended pregnancies, there will be an increase in the incidence and magnitude of complications from unsafe abortion in Kenya.

    The Conversation

    Michael Mutua is affiliated with African Population and Health Research Center.


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    It's important for kids to move and play.Monkey Business Images/Shutterstock

    Most of us would agree that we want to encourage children to be physically active, get enough sleep, and keep their screen time at healthy levels. But did you know that this starts from birth? And, what is enough sleep for young children? Also, given the ubiquity of screens, what is a healthy level of screen time?

    South Africa has just launched 24-hour movement guidelines for children from birth to five years, integrating physical activity, sitting behaviour, screen time and sleep. These guidelines intend to answer these and other questions, providing guidance that can help put young children on the best trajectory for their growth, health and development.

    The country is following the example of others that have recently updated or are busy updating their movement behaviour guidelines for the early years – Canada, Australia, and the UK. It’s the first low- and middle-income country to bring out movement behaviour guidelines for this or any age group.

    These developments represent a shift towards integrated guidelines for children’s physical activity, sitting and sleep behaviours. These guidelines take into account the natural and instinctual integration of these behaviours across a 24-hour period, and are intended to provide a more cohesive message for parents, caregivers, teachers and practitioners.

    Research shows that children from birth to five years who receive support to meet these movement guidelines are likely to grow up healthier, fitter and stronger. They may also have greater motor skill abilities, be more prepared for school, manage their feelings better, and enjoy life more.

    The guidelines

    The development of the guidelines was supported by the Laureus Sport for Good Foundation South Africa which brought together a panel of stakeholders, practitioners and academics (local and international) from the field of early childhood. The panel considered the best available scientific evidence, the South African context and how the guidelines would be received across the country’s very diverse settings.

    The guidelines recommend that children from birth to five years should participate in a range of play-based and structured physical activities that are appropriate for their age and ability, and that are fun and safe. Children should be encouraged to do these activities independently as well as with adults and other children. For caregivers, activities that are loving and involve play and talking with children are best.

    These guidelines also emphasise that the quality of what is done when sitting matters. For children younger than two years, screen time is not recommended. Sitting activities that are screen-based should be limited among children aged two to five years. The quality of sleep in children from birth to five years is also important, and screen time should be avoided before bed.

    While the educational benefits of screen time receive much attention in the media, there’s little scientific evidence to support the claims of these benefits. And the long-term, potentially negative, impacts of replacing “traditional” games and books with screen-based versions are not yet known.

    The World Cancer Research Fund recently highlighted the link between childhood screen time to 12 deadly cancers and short-sightedness. There is also a trend emerging among technologists in Silicon Valley to keep their children away from screens. This should surely be causing us to think twice about the easy role that screens play in little ones’ lives.

    Early childhood represents a key window of opportunity to lay down a healthy foundation for children’s movement behaviours, setting them up for a win as far as their growth, health and development are concerned.

    The guidelines can help build this foundation and can be used by anyone who has an interest in the health and development of all children from birth to five years – parents and family, educators, caregivers, health professionals, and community workers.

    The Conversation

    Catherine Draper receives funding from the British Academy for the Humanities and Social Sciences. She has an honorary affiliation with the Division of Exercise Science at the University of Cape Town


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    The leading causes of child injury in Ethiopia are road traffic crashes, burns, and drownings.Ikpro/Shutterstock

    Children in poorer countries are far more at risk of death and disability from injuries than their developed-world peers. These injuries include; road traffic injuries, drownings, poisoning, falls, burns and intentional injuries – like harm caused by another person.

    Take Ethiopia as an example. Previous data shows that each year Ethiopia has a high number of injury-related deaths and disabilities among children. Out of the country’s 83,516 total injury deaths in 2015, 13,550 children were younger than five; 11,684 were children aged between five and 14. This is similar to other countries in the region.

    But these are just figures. There needs to be a better understanding of the situation so that Ethiopia can implement effective, evidence-based action plans to tackle the problem.

    My colleagues and I set out to provide a more robust estimate of just how many children in Ethiopia are being fatally injured and what is causing these injuries. We also predicted what would happen without any targeted interventions by 2020 and 2030.

    We reviewed a huge variety of data from different sources and consulted with relevant government ministries like those dealing with health. We found that, unlike other model-based estimates which show a decline, the number of child injuries is growing. The leading causes of child injury in Ethiopia are road traffic accidents, burns, and drownings.

    With this information, we hope that government and development agencies will be better informed in how to prevent children from getting injured. The results also serve as a rallying cry for an injury surveillance system at health facilities to keep monitoring the situation.

    The study

    Our work involved reviewing data both to understand what is already happening, and to project what might happen in the future if there are no interventions. Ultimately, the study focused on fatal and non-fatal child injuries from 2015 to 2030.

    We did an extensive search for data, studies and government reports on injuries among children from birth to the age of 14. One of our major sources was the Ethiopian central statistical agency. We also did an extensive literature review.

    The study covered all types of injury, which can be categorised into intentional and unintentional injuries. Road traffic crashes, drownings, and burns are the most common types of unintentional injuries; intentional injuries include self-harm, harm caused by another person and collective violence – like terrorism or violent protests.

    These were our key findings.

    • Injuries caused about 25,000 deaths among 0 to 14-year olds in Ethiopia in 2015. Our estimate is close to that from the World Health Organisation and more than two times higher than that from the global burden of disease project.

    • The leading cause of fatal, unintentional injuries among children was road-traffic injuries (25%). This is consistent with the country’s rapid motorisation during this period.

    • Next came fire, heat and hot substances (13%), followed by drowning (12%). The high incidence rate of injuries caused by fire, heat and hot substances may be because that many children in Ethiopia help their parents with cooking, and open flame cook stoves are commonly used.

    • The death rate due to injuries among 0–14 years olds was about 50% higher in males than females. This may be because boys were exploring new things and taking more risks than the girls.

    • Rural children were at greater risk of injury than their urban peers. This is because the rural areas could be a more hazardous environment, with the children exposed to more water or fires, and the children have less supervision.

    In terms of future trends, the annual mortality caused by injuries among children younger than five is projected to increase from 10,697 in 2015 to 11,279 in 2020 and 11,989 in 2030. The number of deaths among 0-14-year olds will be 26,463, 27,807, and 30,364 respectively in 2015, 2020, and 2030. These took population growth into account.

    Without proper interventions, the problem is only going to get worse.

    Increasing the risk

    Next, we examined the risk factors associated with these injuries.

    Unfortunately only a small number of risk factor studies were located in our literature review, mostly on child abuse, which is anecdotally considered the most common form of child injuries in Ethiopia. Children were more at risk of injury if the prevalence of child sexual abuse was high (68.7%).

    Being poor was another major risk factor for fatal and non-fatal injuries. Age was also a factor: burns were common among children aged between five and nine. Caregiver depression and maternal depression were also linked to child injuries, particularly intentional physical injuries.

    In consultation with Ethiopian government and other stakeholders, we propose starting an injury surveillance system at health clinics and hospitals and building an intervention package based on existing platforms, like the country’s health extension program - an initiative which expanded health facilities across the country.

    The Conversation

    Qingfeng Li ne travaille pas, ne conseille pas, ne possède pas de parts, ne reçoit pas de fonds d'une organisation qui pourrait tirer profit de cet article, et n'a déclaré aucune autre affiliation que son poste universitaire.


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    At about 21 million strong, nurses make up half of the world’s health workforce. SIM USA/Shutterstock

    Nurses in Kenya are threatening to strike, protesting that the government had failed to increase their salaries in spite of an agreement which ended a five-month strike last year. If they strike this would be the second time in two years and it could create another public health crisis because of the huge role that nurses play.

    Kenya’s almost 16,500 nurses work across all levels of health care; from primary care dispensaries and clinics to major hospitals. In some settings they may be the highest qualified, or only health professional, there. This means they provide essential public health prevention, health treatment and emergency services.

    My colleagues and I put together a report for the recent world innovation summit for health. We worked with a team of experts to review global evidence and explain why to quickly, and cost-effectively, expand universal health coverage, there must be proper investment in nurses.

    Nearly one billion people around the world can’t access or afford basic health care. At about 21 million strong, nurses make up half of the health workforce. If they are properly resourced and empowered, they could help to quickly spread universal health care, expanding services to under-served communities.

    One of President Uhuru Kenyatta’s “four pillars” is universal health care. Ksh44.6 billion (about USD$420million) was allocated into the sector so that all Kenyans could have access to critical health care services.

    But unless proper investment is made in the workforce, it won’t work. While increasing allowances is important, nurses must be empowered to reach their full potential. Also worrying is the recent redrafting of the Kenyan Health Act which limits the leadership potential and opportunities for nurses within the public health system.

    The steps

    Kenya currently has about 1.6 practicing nurses to 1,000 people, significantly less than western countries like Canada (9.8) and Australia at (12.9). Not enough nurses are joining the force, about 600 leave the country each year and many are retiring, or close to retirement.

    Their low numbers mean they often attend over 100 patients per day, and in many rural health centres they are the only professional care available. And yet they could offer a solution to Kenya’s challenges of making health care accessible and affordable.

    There are three reasons to invest in nurses and midwives:

    Rapid expansion

    By investing in nurses, Kenya can quickly expand quality medical services because of the availability of nurses.

    Doctors are important members of the health care team but there’s not enough of them to make a major impact on the rapid scale-up of universal health care. In Kenya there’s 1.6 nurses and midwives for every thousand people, while just 0.1 doctors. Nurses and midwives are able to provide care of equal value to doctors when it comes to the basics of primary health care prevention and follow-up. This includes prevention, early detection and support for longer term chronic disease.

    To take advantage of this, Kenya must adopt a strategy that combines investment in nurses with changes in service delivery and practice. Investment would mean more people go into nursing schools, graduate nurses get full employment and there are increased pathways for upgrading the current nursing workforce. For instance programmes, like the one we offer at Aga Khan University, which allows nurses to upgrade their qualifications while still working.

    Changes in service delivery would include the creation of more nurse-led clinics, and more specialist nurses and midwifery services.

    Cost-effective expansion

    Because there are at least three times more nurses and midwives than doctors, it will be more cost-effective for Kenya to increase their skills.

    There is enormous potential for nurses to expand their scope of practice through task-sharing with doctors. One study in the report estimates that some nurses can complete approximately 70% of a general practitioner’s workload. This would free up doctors so they can attend to patients that need more intensive medical care.

    High-quality expansion

    High quality expansion involves moving nurses and midwives into more advanced, speciality roles.

    There is evidence that an approach centred on nurses and patients will have a positive impact on access and satisfaction. Studies show that nurses generally achieve equivalent health outcomes as doctors for long-term non-communicable diseases management.

    Nurses often also score higher for patient satisfaction and for treatment adherence. Patients are more likely to return for follow-up appointments and take prescribed medicines. Because they have so much contact with patients, nurses are well-positioned to provide simultaneous health-promotion and disease prevention advice. They also take on roles in coordinating and supporting teams of primary health care workers.

    These factors all give a powerful case for why, in order to achieve universal health care, governments must invest in their nurses.

    The Conversation

    Sharon Brownie does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.


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    Since 2014 the Ebola outbreak in Liberia killed over 4,800 people.UNMEER/Flickr

    Ebola in the Democratic Republic Congo (DRC) has now spread to urban areas. The Conversation Africa’s Moina Spooner spoke to Mosoka Fallah who was head of case detection during Liberia’s outbreak in 2014 and 2015 about his experience, and what lessons it offers.

    What can you tell us about the spread of Ebola in the DRC?

    The situation is very serious. So far there have been 458 cases, including 271 deaths, in two of the country’s provinces. This could get much worse. In Liberia’s case, over two years, 4810 people lost their lives to ebola.

    I think it could be a matter of days before DRC’s epidemic spreads to more urban centres or spills over into neighbouring countries.

    I say this because of how the outbreak is unfolding.

    First, health care workers are being infected. In our experience in Liberia, and in most outbreaks, infected health care workers can be super spreaders. They can infect the people they treat or those taking care of the sick.

    Second, there are now cases (live and dead) reported in communities that were not on the contact list. This is a list of people that may have come into contact with an infected person. If there are people that are infected who weren’t on the list, it means that proper tracking isn’t happening. It also implies that people don’t trust, or are afraid, of the ebola response and are turning to home treatments, including traditional remedies or prayers. These could expose a larger population to infection.

    To contain an ebola outbreak, it’s crucial that 100% of the contact list is documented and tracked. If this is broken, then a spread should be expected.

    Why has the country been unable to contain the spread this time round?

    The failure to control this outbreak is due to a variety of factors.

    Because of the civil war and with huge numbers of people living in abject poverty – as was the case in Liberia – there is widespread distrust in the government and its institutions. This means it will be hard for people to trust the Ebola response team.

    This is a major problem because Ebola containment is based on trust. Response workers can’t be in every house and so they rely on individuals in communities to alert them. But if they’re not trusted, cases won’t be reported. Mistrust can also lead to violence – as we’ve seen in the frequent attacks against response workers in the DRC. These attacks delay response when speed is critical.

    These reactions are because the Ebola response goes against the normal tendency for families and friends to take care of their sick. Instead they are isolated and kept away. To help people accept this requires them to trust the health workers. People who are very poor, and have been neglected by the state, don’t trust the authorities. And they aren’t likely to accept the radical changes required. This, in turn, results in resistance and violence.

    What steps need to be taken immediately?

    The first steps must be to address some of the fundamental needs of the people. For example, at risk communities should be provided with food and useful tools and services – like water pumps and functional clinics. But these must be distributed through locally trusted leaders.

    Second, some of the Ebola response must go to the local community. The first step would be to identify key, trusted leaders who can lead the response. They can also be invited to propose solutions, and be supported in getting these implemented. In addition, local youths and religious and traditional leaders need to drawn in and paid to do active surveillance and community sensitisation.

    They must share the resources (financial and logistics) the resources (financial and logistics) in the Ebola response.

    What lessons are there from Liberia?

    The one big difference is that there’s an active war on in the DRC. Apart from that, however, there are some clear parallels between the outbreak in Liberia and this one.

    The first case of ebola in Liberia was reported in March 2014. Five months later, we accounted for 51% of all cases in West Africa – it had spread across Liberia, Guinea and Sierra Leone. But we shifted the epidemic curve and, in September 2015, became the first country in the region to be declared ebola free.

    This was because of our work with the community. I cofounded the community-based initiative with support from the Ministry of Health, the United Nations Development Fund and the World Health Organisation. We were advocates for the communities and got support to them quickly and efficiently. We held daily meetings with national response workers and international partners organised under the national emergency operation centre.

    These are the steps we took:

    • We engaged local communities in meetings to allow them to express their concerns and propose solutions.

    • We then asked them to map out all the households in their communities and recruited members of the community to cover 40 households. They would need to pass on messages, search for the sick, the dead and visitors. This information would then be passed on to us

    • Local community chairs were given visitor log books. This allowed us to see where visitors came from and if they were at risk

    • Precautionary observation was encouraged. Here those who could be infected stayed home and restricted their movement for 21 days. During this time they were provided with food and comforts - like electricity

    • A mobile app was deployed on the phones of community members who reported cases of infection or death to us. This allowed us to analyse and respond quickly

    • Culturally sensitive burial teams - for example observing Muslim traditions - were developed and rolled out

    • We recruited over 5700 community members. By the end of the response they had earned nearly $3million for their daily work.

    Many of these steps could be replicated. But time is of the essence.

    The Conversation

    Mosoka Fallah-consults for MERCK/MSD as an Expert from Africa on the process of the Ebola vacine licensing..