Study reveals substantial misdiagnosis of malaria in parts of Asia

The authors warn that with more than two billion people at risk of malaria in this part of Asia – larger than that of Africa - this is a major public health problem which needs to be confronted.

The study was published in the BMJ.

Malaria remains one of the most important infectious diseases of poverty. Recent global malaria treatment guidelines recommend that patients are treated with anti-malaria drugs only when a diagnostic test positively identifies malaria parasites in the patient's blood.

In Africa, many patients are treated for malaria even when the parasite test is negative, resulting in other severe infections being missed and drugs being wasted. Yet the extent of this problem in south and central Asia is relatively unknown.

A team of researchers from the School therefore set out to assess the accuracy of malaria diagnosis and treatment for over 2,300 patients with suspected malaria at 22 clinics in northern and eastern Afghanistan.

Some clinics used microscopic diagnosis, while others relied on clinical signs and symptoms to diagnose malaria.

Blood sample slides were collected for every patient as a reference slide which was read by two independent experts who recorded whether the slide was positive or negative for malaria. This reference result was compared to the result of the diagnosis at the clinic and the treatment given to each patient.

In clinics using clinical diagnosis where malaria is rare, 99% of patients with negative slides received a malaria drug and just over one in 10 (11%) received an antibiotic.

This compares with clinics using newly introduced microscopy, where 37% of negative patients received a malaria drug and 60% received an antibiotic. In clinics with established microscopy, 51% of negative patients received a malaria drug and 27% received an antibiotic.

Almost all cases were due to vivax malaria, a relatively less serious form of malaria. However, only one in six cases of the rarer but potentially fatal falciparum malaria were detected and appropriately treated.

Compared with clinical diagnosis, microscopy improves the targeting of malaria drugs, but only by half, and it increases the prescription of antibiotics, say the authors.

They argue that misdiagnosis and treatment is caused in equal part by inaccurate microscopy and by the clinicians' tendency to treat with malaria drugs even when a test result is negative, resulting in a 40-50% loss of accuracy in treatment. The results are comparable to findings from Africa, confirming that inaccurate diagnosis and treatment of malaria is a worldwide problem.

Lead author Dr Toby Leslie, Lecturer at the London School of Hygiene & Tropical Medicine and Project Manager of the ACT Consortium in Afghanistan, said: "Improving malaria diagnosis and treatment is central to present day efforts to reduce malaria mortality and morbidity. Our research contributes to an emerging picture of suboptimal services across the malaria endemic world. Not only does this waste limited resources but also means that many patients are not correctly treated. This has to be corrected through improving coverage and quality of diagnosis and changing practice amongst prescribers." (healthcanal.com)

The Global Perspective on HIV/AIDS and Mental Health

blog.aids.gov - As AIDS 2012 (the XIX International AIDS Conference) continues in Washington, DC, we are reminded of the numerous, multiple, and far-reaching impacts this epidemic has had in the past 30-plus years. The burden of being HIV positive, or caring for loved ones living with the disease, is not restricted to the physical toll. For many people, there are equally important mental health needs (PDF). We at HHS understand that addressing HIV means addressing the whole person.

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Breaking The Cycle Of HIV, Hunger and Poverty

trust.org - Hunger and malnutrition are significant obstacles to the global fight against the HIV virus. A growing consensus of experts at the International AIDS Conference in Washington DC (AIDS 2012) agreed that helping patients with HIV meet their nutritional needs can make the difference between life and death.

WASHINGTON DC — The connection between food and HIV treatment is not an obvious one, but for millions of people around the world, this connection is vital to both lives and livelihoods.

When high health care costs mean that a family can't put food on the table, when malnutrition means an HIV patient has a greater risk of dying or when not having enough to eat means experiencing intolerable side effects from treatment, food and nutrition can make the difference between life and death.

"Fortunately, we've seen both scientifically and in our own programmes, that when we help people living with HIV overcome hunger and malnutrition, we also help them to fight off illness and regain their health and strength," said WFP Chief of Nutrition and HIV Policy Martin Bloem.

AIDS 2012

At the International AIDS Conference in Washington DC (AIDS2012), Bloem moderated a discussion of health and policy experts from around the world to discuss the impact of food assistance in the fight against HIV.

"By providing a safety net for families that have lost a source of income and who face rising expenses, we encourage people to come to clinics to receive and stay on treatment," he said.

Speaking at the event, which was co-hosted by Harvard Medical School and Partners In Health, Rwandan Minister of Health Agnes Binagwaho remarked on the situation in her country.

"Food is a human right. But most people living with HIV don't have enough food, and they need more food. So the only thing to do is to give it to them."

Case in point

One of the countries where WFP has been doing this for several years is Ethiopia. In a recent interview for WFP.org, Belaynish Dabe said that she used to struggle to provide for her family of eight.

When Belaynish and her husband, both of whom are HIV-positive, started receiving nutritious food from WFP, they felt healthier and were better able to adhere to their treatment.

Belaynish also participated in community activities, like urban gardening, to supplement her irregular income. Now, more than a year later, Belaynish and her husband are again strong enough to grow their own food and no longer rely on food assistance to survive.

In 2011, WFP provided food and nutrition support for 2.3 million people living with HIV and TB—the number one killer of people with HIV—moving one step closer to the goal of universal access to treatment.

Fighting AIDS: US donates an extra $150 million

WASHINGTON (AP) — Science now has the tools to slash the spread of HIV even without a vaccine — and the U.S. is donating an extra $150 million to help poor countries put them in place, the Obama administration told the world's largest AIDS conference Monday.

"We want to get to the end of AIDS," declared the top U.S. HIV researcher, Dr. Anthony Fauci of the National Institutes of Health.

How long it takes depends on how quickly the world can adopt those tools, he said — including getting more of the millions of untreated people onto life-saving drugs that come with the bonus of keeping them from infecting others.

"No promises, no dates, but we know it can happen," Fauci told the International AIDS Conference.

Part of the challenge will be overcoming the stigma that keeps high-risk populations from getting needed AIDS treatment and services.

"We have to replace the shame with love," singer Elton John told the conference. "We have to replace the stigma with compassion. No one should be left behind."

Some 34.2 million people worldwide are living with HIV, and 2.5 million were infected last year.

Secretary of State Hillary Rodham Clinton said the goal is an AIDS-free generation. That would mean no babies would be born infected, young people would have a much lower risk than today of becoming infected and people who already have HIV would receive life-saving drugs so they wouldn't develop AIDS or spread the virus.

"I am here today to make it absolutely clear the U.S. is committed and will remain committed to achieving an AIDS-free generation," Clinton told the more than 20,000 scientists, people living with HIV and policymakers assembled for the conference.

But it will require smart targeting of prevention tools where they can have the greatest effect. "If we want to save more lives, we need to go where the virus is," she said.

First, Clinton said it's possible to virtually eliminate the transmission of HIV from infected pregnant women to their babies by 2015, by getting the mothers onto anti-AIDS drugs. HIV-infected births are rare in the United States and are dropping steadily worldwide, although some 330,000 children became infected last year. Clinton said the U.S. has invested more than $1 billion toward that goal in recent years and is providing an extra $80 million to help poor countries finish the job.

Much of the AIDS conference is focused on how to get treatment to all people with HIV, because good treatment can cut by 96 percent their chances of spreading the virus to sexual partners. Fauci pointed to South Africa, where healthy people who live in a region that has increased medication now have a 38 percent lower risk of infection compared with neighbors in an area where HIV treatment is less common.

Drugs aren't the only effective protection. Fauci said male circumcision is "stunningly successful," too, at protecting men from becoming infected by a heterosexual partner. Clinton said the U.S. will provide $40 million to help South Africa reach its goal of providing voluntary circumcision to half a million boys and men this year.

A tougher issue is how best to reach particularly high-risk populations: gay and bisexual men, sex workers and injecting drug users. In many countries, stigma and laws that make their activities illegal drive those populations away from AIDS programs that could teach them how to reduce their risk of infection, Clinton said.

"If we're going to beat AIDS, we can't afford to avoid sensitive conversations, and we can't afford not to reach the people who are at the highest risk," she said.

So the U.S. will spend an additional $15 million on research to identify the best HIV prevention tools to reach those key populations in different countries, and then launch a $20 million challenge fund to support country-led efforts to implement that science.

Better prevention for gay and bisexual men is a huge issue in the U.S. as well — and a striking study presented Monday added evidence that those men are especially at risk if they're young and black.

Government-funded researchers tracked black gay and bisexual men in six U.S. cities and found that 2.8 percent a year are becoming infected, a rate 50 percent higher than their white counterparts. Worse, the rate was nearly 6 percent a year in those men who are 30 or younger.

International health panel says treat all HIV infections

(Reuters) - An international health panel has recommended for the first time that all HIV patients be treated with antiretroviral drugs, even when the virus's impact on their immune system is shown to be small.

The nonprofit International Antiviral Society-USA cited new evidence that untreated infection with the human immunodeficiency virus that causes AIDS can also lead to a range of other conditions, including cardiovascular disease and kidney disease. In addition, data have shown that suppressing HIV reduces the risk of an infected person passing the virus to another person.

"We are no longer only focused on traditional AIDS-defining infections. We know that HIV is doing damage to the body all the time when it is not controlled," said Dr. Melanie Thompson, principal investigator of the AIDS Research Consortium of Atlanta and a member of the Antiviral Society panel.

The recommendations are global, but mainly aimed at "resource-rich" countries who can cover the cost of the medications, she said. The guidelines were published in the Journal of the American Medical Association at the start of the International AIDS Society's 2012 conference, which runs from Sunday through Friday in Washington, DC.

In addition to studies showing that treatment with antiretroviral drugs reduces the risk of HIV transmission, trials have shown a protective effect when the drugs are used by at-risk people who are not already infected with the virus.

U.S. health regulators earlier this month approved use of Gilead Sciences' (GILD.O) Truvada for HIV-negative adults who are at risk of acquiring the virus. Like other antiretroviral drugs, the Gilead pill is designed to keep the virus that causes AIDS in check by suppressing viral replication in the blood.

"The drugs are convenient, have very little side effects and their benefits are becoming clearer and clearer -- both for the infected person and from a public health standpoint," said Dr. Paul Volberding, director of the Center for AIDS Research at the University of California, San Francisco and another member of the panel.

CHECKING WHITE BLOOD CELL LEVELS

The guidelines echo those issued in March by the U.S. Department of Health and Human Services, which also cited improved drugs and new studies showing patients benefit from treatment regardless of their level of infection-fighting white blood cells.

Previous recommendations called for antiretroviral drugs to be started for only patients whose CD4 cell counts had fallen below 500 per cubic millimeter of blood.

A normal CD4 count in a healthy adult varies between 500 and 1,200, according to HHS.

Earlier guidelines were based largely on the potential for health complications associated with initial antiretrovirals as well as concerns that patients without symptoms might not adhere to the therapy.

"The risk/benefit of the kinds of therapies we had available led us to be more restrictive in terms of when to start treatment," Dr. Thompson said.

The availability of new multidrug combination pills has made it easier for patients to take them consistently and has lessened the risk of drug resistance, she said.

"We were really focusing on the treatment aspect of it and didn't have the prevention data, which we now have," Dr. Volberding said.

The United Nations estimates that around 34 million people are living with HIV, including more than 1.2 million Americans.

The World Health Organization recommends that people diagnosed with HIV start taking antiretroviral therapy when their CD4 cell count hits 350 or less. It said this week that it is reviewing recent studies pointing to the potential benefits of giving the drugs earlier, before the immune system starts to weaken.

(Reporting By Deena Beasley; Editing by Michele Gershberg and M.D. Golan)

Physical inactivity kills 5.3 million a year globally

cbc.ca - Lack of physical activity could be causing as many deaths worldwide as smoking and obesity do, say researchers who are calling on people to take at least a 15-minute brisk walk each day.

This week's issue of the medical journal The Lancet includes a series of studies leading up to the London Olympics to highlight how little physical activity most people worldwide actually get and how dire the health consequences are.

I-Min Lee from Brigham and Women's Hospital in Boston and her co-authors estimated that worldwide, physical inactivity causes six per cent of the burden of disease from coronary heart disease, seven per cent of Type 2 diabetes, 10 per cent of breast cancer, and 10 per cent of colon cancer.

What's more, physical inactivity was blamed for nine per cent of premature mortality — more than 5.3 million deaths of the 57 million deaths globally in 2008.

Eliminating physical inactivity could increase life expectancy by 0.68 years. That may seem small, they said, but the gains are for the whole population, not just inactive people who start moving more.

Canadian health authorities recommend that adults get 2½ hours of physical activity a week.

Tanya Berry holds a Canada Research Chair in physical activity promotion at the University of Alberta in Edmonton. Berry said her research suggests half of Canadians think they're moving enough, but they're mistaken.

"If you actually put a little accelerometer or pedometer on people, something that actually objectively measures how active they are, it's closer to 15 per cent are actually active and 85 per cent of Canadians are not active enough to achieve health benefits."

The Lancet researchers said people need to be told about the dangers of being sedentary, rather than just the benefits of exercise. They urged governments to find ways to make physical activity more convenient, affordable and safer.

"This series emphasizes the need to focus on population physical activity levels as an outcome, not just decreasing obesity," Harold Kohl, a professor of epidemiology at the University of Texas and one of the Lancet authors, said in a release.

Kohl recommended prioritizing physical activity across sectors including health, transportation, sports, education and business.

Min-Lee and her co-authors acknowledged that not everyone is capable of being physically active.

"This summer, we will admire the breathtaking feats of athletes competing in the 2012 Olympic Games," the researchers concluded.

"Although only the smallest fraction of the population will attain these heights, the overwhelming majority of us are able to be physically active at very modest levels — 15 to 30 minutes a day of brisk walking — which bring substantial health benefits.

Fighting Depression, One Village at a Time

Nytimes.com - What is the most burdensome disease in the world today? According to the World Health Organization, the disease that robs the most adults of the most years of productive life is not AIDS, not heart disease, not cancer. It is depression.

This is especially true in places that have experienced war, disaster or crushing deprivation. Yes, in many poor countries the bonds between people are much stronger than they are in wealthier, more individualistic societies, and this is a good thing for mental health. But it can hardly counteract the fact that a lot of people have an awful lot to be depressed about. Violence — whether war or high rates of crime — produces widespread post-traumatic stress. The constant worry that a crop failure or serious illness will throw a family into poverty is a source of extreme anxiety. Seeing your children go hungry creates paralyzing guilt.

According to the World Health Organization, three-quarters of the world's neuropsychiatric disorders are in low-income or low-middle income countries.

In troubled places, depression's impact is more severe. Most families have no cushion or safety net — they are running very hard just to stay in one place. A parent who is too depressed to work can bring a family to ruin.

In wealthy countries, we grasp how debilitating mental illness can be, and we treat it. (Unevenly — the disparity in access to mental health care between rich and poor in America is enormous.) In poor countries, attention to mental health has been close to zero. The conventional wisdom is that treating depression in countries where there are myriad other problems is a luxury. Besides, how could it be done? Drugs are expensive, and the vast majority of poor countries have virtually no psychiatrists or psychologists outside of private clinics.

Until a few years ago, no one was even asking this question. Today, not only is mental health getting global attention, mental health care is successfully expanding in many poor countries, including India, which announced a new national mental health care plan at the end of June. The strategy is the same one that is preventing and curing disease all over the world where health care professionals are few: task shifting. That means training and supporting people with lower levels of education to do the work of doctors and nurses.

~~~~~

Amadi was inside her hut, sitting in the semidarkness, when C.N. came to her door to invite her to do something that would have been unheard-of in her Ugandan village before: join a therapy group for depression. She was 59, and had lost five of her nine children in the last 10 years, three of them to AIDS. She was numb and passive, sad and irritable. She could not care for her family, work in her garden, or do her mat-weaving.

At first Amadi had no use for any therapy — "all the treatment in the world won't bring my children back," she told C.N. But at C.N.'s urging, she joined the group.

The group consisted of eight women, with C.N. as facilitator. They met weekly, first spending their time describing their problems, but gradually comforting one another and suggesting steps to take. Together they visited the graves of their loved ones and held a formal mourning service. The women all became active in the community, and each talked to her own family members about H.I.V. infection and how to prevent it.

All the women, including Amadi, gradually got better. Eighteen weeks after starting therapy, Amadi had no more symptoms of depression. She was once again, to use her husband's words, the fierce, loving, strong woman she had been.

Amadi's story was described by Helena Verdeli, an assistant professor of clinical psychology and director of the Global Mental Health Lab at Columbia University's Teachers College. (Amadi is not her real name.) Verdeli was one of the organizers of a study designed to test whether interpersonal therapy, which has proved as effective as medicine at curing major depression in Western settings, can work in a rural village.

By accident, the study did something else just as significant. The researchers were working with the Christian humanitarian organization World Vision, and had intended for the groups to be led by World Vision's trained health workers — nurses and health counselors. "But they couldn't spare any," Verdeli said. "They said, 'don't worry, we're going to hire their younger brothers and sisters.'" Some were in college. Some, including C.N., had only a high school degree. Yet the treatment was overwhelmingly successful: six months after beginning therapy, only 6 percent of the people treated still had major depression. This study, which took place in 15 villages, was proof that effective therapy for depression could be delivered in the poorest of settings, by lay people.

There have been other studies confirming that when done correctly, community members with minimal education can effectively treat depression. One of them took place in Goa, India. Nearly 3,000 people with symptoms of depression or anxiety were randomly assigned to receive normal services in their usual public or private clinics, or to be treated by young local women who had taken an 8-week course in interpersonal psychotherapy. Six months later, 66 percent of the patients in the public clinic who had gotten that therapy had improved. Of those who didn't get the therapy, only 42 percent had improved. (At the private clinics, where patients normally had their own doctors and better care, the doctors and the lay workers did equally well.)

Another study in Pakistan gave community health workers — women who had completed secondary school — a two-day course in listening and basic cognitive behavioral therapy. They were shown how to integrate these things into their regular visits to pregnant women and new mothers. Even that brief training made a huge difference: a year later, only a quarter of their depressed patients were still depressed, compared to 59 percent of the control group.

Interest in global mental health care was awakened by a World Bank-commissioned study in the early 1990s looking at the global burden of disease. While most research had concentrated on what causes death, this one examined disability — and found the shocking burden of depression.

The World Health Organization got involved, devoting its world health report to mental health in 2001. Four years ago, the W.H.O. started the Mental Health Gap Action Program.It pushes for greater attention to mental health in poor countries and provides technical support and guidance, mainly about how to include mental health care in primary care clinics, and train community health workers.

The tremendous prevalence of depression also caught the attention of organizations making big investments in child health and treating AIDS, tuberculosis and other diseases. It was clear that depression was keeping these programs from working as well as they could. "People on the ground realized that adherence to treatment is important," said Mark Van Ommeren, the director of mental health in emergencies at W.H.O. "But people with mental health problems are less likely to adhere."

"The question was how do you close treatment gaps where there are hardly any professionals," said Vikram Patel, a psychiatrist at the London School of Hygiene and Tropical Medicine, who also works in Goa with the nongovernmental mental health group Sangath and was the lead researcher on the Goa study. "It got people thinking: how have other people closed treatment gaps in maternal and child health for the last 15 years?" They used taskshifting — Patel prefers to call it tasksharing. "So we can do it for mental health," he said. He has been extremely influential in shaping India's plan, which includes a new cadre of community mental health workers.

Task shifting is happening even in wealthy countries to close treatment gaps; hence the rise of the nurse practitioner as physician substitute. But it's very widespread in poor countries. Across Africa, nurses and clinical officers do the work of doctors in treating AIDS. In Africa and Asia, a few days or weeks of training enable barely literate women to improve the health of their villages. When doctors are present — if they are present — their role has changed; they now supervise the others and see only the really hard cases. "It became very clear it was possible to train lay members of the community to do fairly specific things and do them well," said Harry Minas, a psychiatrist who directs the Center for International Mental Health at the University of Melbourne.

But new programs required new money, and this was present only in a few countries — usually as a result of crisis. Sri Lanka and Indonesia's province of Aceh both had long-running civil conflicts that traumatized much of the population. But they started getting access to treatment for that trauma only after the tsunami of 2005. "The number of people affected by the tsunami pales in comparison to the people who had trauma from the conflicts," said Greg Miller, who reported on mental health care in Aceh for Science magazine. "But in both places mental health care didn't exist — nothing there. With the tsunami, there was a huge outpouring of support specifically geared towards improving the mental health of survivors."

In the past, perhaps, international aid might have paid for stand-alone treatment centers that would last only a few months, the therapy delivered by outsiders, with little local training or participation. Now, instead, most of the money was employed to build mental health care into the government's health system, using task shifting. The visiting psychologists and psychiatrists were there to train locals.

Lay people in Aceh learned how to identify symptoms of depression, and how to work with patients' families and support their treatment in the community. Nurses were trained in psychotherapy. Doctors learned how to treat patients with a limited number of psychiatric drugs.

Now 85 percent of health centers in Aceh have some staff with mental health training, Miller wrote. Sri Lanka, which has a similar system, is now expanding it beyond zones hit by the tsunami.

Kosovo, building a health infrastructure after the end of Slobodan Milosevic's war, found a different and very creative solution. Serbia had barred Albanians in Kosovo from getting formal medical education, and after the war Kosovo had only five clinical psychologists and 19 psychiatrists for its two million people.

"Our needs were very high, and the human resources to respond were very low," said Ferid Agani, a psychiatrist who led the construction of the new mental health system, and today is Kosovo's health minister. "The natural answer was to rely on family structure. Families are very strong here, very connected. Before, our model was centered on medication. We wanted to train teams in providing complete services based on family resilience. What could be better than having this resource?"

With advice and training from a group of doctors from the American Family Therapy Academy, Kosovo set up workshops for patients and their families, where they learned about the patient's disease and how to help. Several families were trained together, creating support groups. Meanwhile, the medical schools graduated professionals — now there are 60 psychiatrists and 600 clinical psychologists. Agani said that hospitalization is down by 60 percent and results are better.

Why did it take so long for health experts to see what now seems obvious: just as all people need access to health care, we all need access to mental health care. If depression can paralyze people who have everything, how could we ever have thought that it didn't affect people who have nothing? "There's an assumption that after you bury five of your kids you get used to it, and it doesn't hurt as much," said Verdeli. "People don't realize you don't get used to it. You just give up

WHO gives Chinese health minister award for battling smoking in country addicted to tobacco

BEIJING — The World Health Organization is giving China's health minister an award for battling smoking in a country whose people and government remain prodigiously addicted to tobacco.

China has stepped up efforts to curb tobacco use in recent years. The Health Ministry released the country's first official report on the harms of smoking in May, banned smoking in its office building and hospitals, and is lobbying for airports and other indoor public facilities to do the same.

WHO said Health Minister Chen Zhu will be presented a certificate of recognition at a ceremony on Wednesday attended by WHO chief Margaret Chan.

Tobacco control is a difficult task in a nation where huge revenues from the state-owned tobacco monopoly hinder anti-smoking measures. Nearly 30 percent of adults in China smoke — about 300 million people, roughly equal to the entire U.S. population — a percentage that has not changed significantly.

The tobacco monopoly's influence is pervasive, with cigarette companies sponsoring schools, sports events and fostering close ties with the academic community.

In December, a tobacco scientist who specializes in adding traditional Chinese herbs to cigarettes in an attempt to reduce their harmful effects was appointed to the prestigious Chinese Academy of Engineering in a move that was criticized by other academics, several of whom sent letters to the academy in protest.

Despite the many challenges that remain in stamping out tobacco use, anti-smoking activists welcomed the WHO award.

"Among the government departments, the Health Ministry is the one that has made the biggest efforts in promoting tobacco control," said Xu Guihua, vice president of the government-affiliated Chinese Association on Tobacco Control. "On many occasions, Minister Chen Zhu has told the public that tobacco is harmful and asked people to give up smoking. He also called on the government to step up tobacco control legislation."

Xu said China still needs to issue a national tobacco control plan, raise prices of cigarettes and better educate the public on the health risks of smoking.

She criticized the apparent conflict of interest in the dual role that China's State Tobacco Monopoly Administration plays as both tobacco policymaker and overseer of the China National Tobacco Corp. — the world's largest cigarette maker.

Health officials have warned that smoking-related deaths could hit 3 million per year by 2030 without greater efforts.

Last year's certificate for anti-smoking efforts was awarded to Australian Attorney General Nicola Roxon, who as health minister led a campaign to make Australia the first country in the world to require cigarettes to be sold in plain packages with large, graphic warnings.