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Test and Treat; cautioning on the conundrum of treatment compliance in chronic diseases

It has recently been announced that it is now recommended by WHO, other Agencies and Global Health Initiatives that countries should now move to a policy of putting all people living with HIV on Anti-retroviral therapy (ART) irrespective of their CD4 count. We should recall that criteria for treatment have changed over time, the main one being the level of CD4 count, but also based on viral loads and on presence of AIDS defining conditions (diseases such as TB, Pneumonia (PCP) or Herpes zoster conditions).  The CD4 criteria are the ones that have changed most over time, starting with 200, then 350 and now the recommendation being to start ART irrespective of CD4 count or any other criteria for that matter.

This decision to treat all HIV positive individuals is scientifically sound. It has the greatest potential to control HIV/AIDS in the long term, because it can reduce HIV related disease and AIDS to a minimum, and most importantly, in reducing viral loads to undetectable or very low levels, would render most people living with HIV non-infectious. This is the scientific basis.

There are however negative unintended complications to think of. The one that people talk about most is the cost; can Botswana, with its high HIV prevalence rate (the second highest in the world), afford to have such a large number of people on ARVs? This is despite the fact that the price of the drugs has been falling. Already, even with the current treatment criteria, the impact on the fiscus is being felt, with many people regarding the ARV treatment as unsustainable.

The other unintended consequence, which worries those like me more that the fiscal sustainability, is the question of treatment compliance.  Human beings don’t like taking tablets for long periods of time. We all know that many people can hardly complete a 5-day course of antibiotics. We have seen what happens to compliance in cases of chronic diseases, such as TB, diabetes, hypertension, and indeed in ART itself. Many patients simply get tired and stop taking treatment; they either get lost to follow-up, or in some cases they continue collecting the drugs but don’t actually ingest them.

The idea of “Test and Treat” is indeed very attractive and exciting, and that is why some in the press in Botswana are already asking when Botswana is going to implement it. But we have to learn from experience in other chronic diseases to predict its chances of success. It is, as indicated above, a scientifically solid idea, but its success in entirely dependent on human behaviour.

And we know that in the fight against HIV/AIDS, (and other diseases), it is the human behaviour, not the effectiveness or ineffectivess of drugs that has been the source of failure. In the fight against HIV/AIDS itself, we know that in the last three decades that we have been fighting the disease, human sexual behaviour in Botswana has changed very little. Multiple concurrent partnerships, intergenerational sex, transactional sex, early sexual debut, non-use of condoms, and other negative behaviours have persisted despite intensive education. There are still a lot of teenage pregnancies, resulting in a high school drop-out rate. Behavioural change communication has not been a roaring success.

We also know that whereas initially treatment compliance with anti-retroviral drugs (ARVs) was good, now there are many lost to treatment, either by simply defaulting and not coming any more for treatment, taking treatment irregularly, or collecting the tablets and simply not ingesting them. This deterioration of compliance over time can be attributed to the fact that whereas early in the treatment with ARVs the patients started treatment when they were very sick, and could see that without treatment they were going to die (some were rescued from death at the last moment – sometimes described as the Lazarus phenomenon) now a large number of patients, because of new treatment criteria, start treatment when they don’t really feel sick, and therefore have little motivation to continue the treatment. We know also that some end up being persuaded by traditional healers or religious practitioners to stop their treatment. This does not only happen in HIV but also in Diabetic patients, TB patients and others.

This is the reason I am urging so much caution in the adoption of the new criteria of treating all HIV positive individuals, the so called “Test and Treat”. I have worked for almost four decades in Tuberculosis control, here at home and internationally, and nothing has challenged TB control like patient compliance. That is why WHO and its partners, especially the International Union Against Tuberculosis and Lung Disease (IUATLD), adopted supervised treatment in the 1980s, which later came to be known as DOTS (Directly Observed Treatment, Short Course) in the 1990s. It is the recommended way of delivering TB treatment internationally, especially in high burden countries, because when left to self-administer treatment, patients generally do not comply, resulting in low cure rates or treatment completion rates, and the rise in drug resistance.

Workers in HIV/AIDS should take the TB experience to heart. Although there is a vaccine used against TB (BCG which in Botswana is given at birth), the vaccine is not effective in controlling TB because it does not prevent the infectious form of the disease. In fact it is used only to prevent severe forms of the disease in childhood (such as meningitis and miliary TB). So the major way of preventing TB is the effective treatment of those suffering from the infectious form of the disease i.e. pulmonary (lung disease)TB in adults. So if patients default from treatment, they continue to be infectious, and in many cases, they develop the drug-resistant form of the disease because the microbes become resistant to the drugs; and they then spread the resistant organisms.  This has been the experience in many countries, including Botswana. Multidrug resistant TB is now a major problem in Eastern Europe and in Southern Africa among other places. This could happen to HIV.

Treatment of TB is relatively long but it is not for life. TB is curable. Up to the 1980s, treatment of TB took 18 to 24 months. After new more potent drugs came into the market in the 1970s, treatment of TB was reduced to six months. In Botswana we changed to these new drugs in 1984, far ahead of other African countries. The drugs were very expensive, and there was an international agreement that they were to be given only under full supervision, i.e., every dose the patient took had to be supervised and documented by a health worker. The critical drug for this was Rifampicin, so this new treatment was called Rifampicin-containing drug regimens, and it reduced the treatment time to six months, hence it was referred to as Short-Course Chemotherapy.  
Adopting fully supervised Short-Course Chemotherapy helped Botswana to drastically reduce the level of non-compliance with treatment (defaulting).  In a paper published in the British Medical Journal in 1992, titled “Case holding in patients with Tuberculosis in Botswana”, Kumaresan and Maganu (myself) demonstrated the dramatic impact of Short-Course Chemotherapy and daily supervised treatment. Treatment compliance rose to 92.3% and defaulting dropped to 7.7%. Before the introduction of Short-Course Chemotherapy and supervised treatment in 1984, treatment compliance was only 60%.

In fact, when I took over the National TB programme in 1979, there was no compliance to talk about; hardly any patient completed treatment.  Patients defaulted either by disappearing or collecting the tablets regularly but not ingesting them or ingesting them irregularly. Health workers used to visit patient’s homes and find large numbers of anti-TB tablets stored under beds and in similar places. Urine tests also used to prove that many patients were simply not ingesting their anti-TB drugs. So, few were cured. In a situation like that many TB patients either died or became chronic excretors of the TB organisms, infecting large numbers of people.

So the dramatic effect of introducing Short –Course Chemotherapy and supervised treatment was very obvious. Botswana introduced this form of treatment when only a few countries in Africa were doing it under sponsorship from donors as pilot projects; in our part of Africa it was Tanzania and Malawi that piloted the treatment. The treatment was adopted internationally under WHO leadership in the early 1990s and was called “DOTS” (Directly Observed Treatment, Short Course).  Unfortunately, the adoption of DOTS in Southern Africa, including Botswana, coincided with the HIV/AIDS epidemic, which resulted in a rapid rise of HIV-associated TB. Consequently the impact of DOTS in Southern Africa was not as good as in other parts of the world because of the HIV/AIDS epidemic. However, treatment outcomes improved dramatically because of great improvements in patient compliance. The percentage of TB patients classified as “Treatment success rate” (cured or completed treatment) rose drastically and was well documented as part of the DOTS monitoring system.

I have related the TB experience to illustrate the negative effect that can result from poor patient compliance with treatment. Putting large numbers of HIV positive people on ARV treatment when they are not ill needs to be approached with caution. In Botswana this implies well over 10% of the population on ARV drugs. TB treatment has a problem with compliance although its treatment is only six months. ARV treatment is life-long; how much more compliance problems are likely to occur? The effect of widespread defaulting from ART would be large-scale drug resistance and a need to use more and more expensive drugs. Morbidity and mortality would actually not be reduced.

The Government of Botswana should only adopt universal treatment of those who are HIV positive (the so-called Test and Treat) if new ways of promoting or ensuring compliance are found.

The TB establishment came up with DOTS; HIV workers don’t have to follow DOTS, but have to find a similarly innovative way of ensuring compliance before embarking on this new internationally promoted initiative.

The new treatment criteria for HIV, including the “Test and Treat” movement, is an integral part of the triple 90 initiative. It is all very scientific and noble, but if Botswana embarks on the initiative without taking care of the concerns mentioned above, it could end up in a very terrible disaster.

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Opinions

The Taiwan Question: China ramps up military exercises to rebuff US provocations

18th August 2022

US House Speaker Nancy Pelosis visit to Taiwan has violated the One-China policy, and caused the escalation of tensions across the Taiwan Strait. Experts and political observers across the spectra agree that Pelosis actions and subsequent pronouncements by US President Joe Biden gave impetus to an already simmering tension in the Taiwan Strait, provoking China to strengthen its legitimate hold on the Taiwan Strait waters, which the US and Taiwan deem as international waters.

Pelosis visit to Chinas Taiwan region has been heavily criticised across the globe, with China arguing that this is a serious violation of the one-China principle and the provisions of the three China-US Joint Communiqus. In response to this reckless move which seriously undermined China’s sovereignty, and interfered in China’s internal affairs, the expectation is for China to give a firm response. Pelosi visit violated the commitments made by the U.S. side, and seriously jeopardized peace and stability across the Taiwan Strait.

To give context to Chinas position over Taiwan region, the history behind gives us perspective. It is also important to note that the history between China and Taiwan is well documented and the US has always recognized it.

The Peoples Republic of China recognises Taiwan as its territory. It has always been the case even before the Nationalist Republic of China government fled to the previously Japanese-ruled Island after losing the civil war on the mainland in 1949. According to literature that threat was contained for decades first with a military alliance between the US and the ROC on Taiwan, and after Washington switched diplomatic recognition to the PRC in 1979 by the US One China policy, which acknowledges Beijings position that Taiwan is part of One China. Effectively, Taiwans administration was transferred to the Republic of China from Japan after the Second World War in 1945, along with the split between the Peoples Republic of China (PRC) and the Republic of China (ROC) as a consequence of the Chinese Civil War. Disregarding this history, as the US is attempting to do, will surely initiate some defence reaction on the side of China to affirm its sovereignty.

However, this history was undermined since Taiwan claimed to democratise in the 1990s and China has grown ever more belligerent. Furthermore, it is well documented that the Biden administration, following the Trump presidency, has made subtle changes in the way it deals with Taipei, such as loosening restrictions on US officials meeting Taiwanese officials this should make China uneasy. And while the White House continues to say it does not support Taiwanese independence, Bidens words and actions are parallel to this pledge because he has warned China that the US would intervene militarily if China attacked Taiwan another statement that has provoked China.

Pelosi, in her private space, would know that her actions amount to provocation of China. This act of aggression by the USA seriously undermines the virtues of sovereignty and territorial integrity which has a huge potential to destabilize not only the Taiwan Strait but the whole of the Asia- Pacific region. The Americans know very well that their provocative behavior is deliberately invoking the spirit of separatism masqueraded as Taiwan independence. The US is misled to think that by supporting separatism of Taiwan from China that would give them an edge over China in a geopolitics. This is what one Chinese diplomat said this week: The critical point is if every country put their One-China policy into practice with sincerity, with no compromise, is going to guarantee the peace and stability across the Taiwan Strait. Therefore, it was in the wake of US House speaker Nancy Pelosis visit to Taiwan, that China, in a natural response revealed plans for unprecedented military exercises near the island, prompting fears of a crisis in the Taiwan Strait and the entire Asia-Pacific region. The world community must promote and foster peace, this may be achieved when international laws are respected. It may also happen when nations respect the sovereignty of another. China may be in a better space because it is well capacitated to stake its territorial integrity, what about a small nation, if this happens to it?

As to why military exercises by Beijing; it is an expected response because China was provoked by the actions of Pelosi. To fortify this position, Chinese President, Xi signed a legal basis for Chinas Peoples Liberation Army to safeguard Chinas national sovereignty, security and development interests. The legal basis will also allow military missions around disaster relief, humanitarian aid and peacekeeping. In addition the legal changes would allow troops to prevent spillover effects of regional instabilities from affecting China, secure vital transport routes for strategic materials like oil, or safeguard Chinas overseas investments, projects and personnel. It then follows that President Xis administration cannot afford to look weak under a US provocation. President Xi must protector Chinas sovereignty and territorial integrity, of which Taiwan is a central part. Beijing is very clear on One-China Policy, and expects all world players to recognize and respect it.

The Peoples Liberation Army has made it clear that it has firepower that covers all of Taiwan, and it can strike wherever it wants. This sentiments have been attributed to Zhang Junshe, a researcher at the PLA Navy Research Institute. Zheng further said, We got really close to Taiwan. We encircled Taiwan. And we demonstrated that we can effectively stop intervention by foreign forces. This is a strong reaction from China to warn the US against provocation and violation of the One-China Policy.

Beijings military exercises will certainly shake Taiwans confidence in the sources of its economic and political survival. The potential for an effective blockade threatens the air and shipping routes that support Taiwans central role in global technology supply chains. Should a humanitarian situation arise in Taiwan, the blame would squarely be on the US.

As Chinas military exercises along the Taiwan Strait progress and grow, it remains that the decision by Nancy Pelosi to visit Chinas Taiwan region gravely undermined peace and stability across the Taiwan Strait, and sent a wrong signal to Taiwan independence separatist forces. This then speaks to international conventions, as the UN Secretary-General Antnio Guterres explicitly stressed that the UN remains committed to the UN General Assembly Resolution 2758. The centerpiece is the one-China principle, namely, there is but one China in the world, the government of the Peoples Republic of China is the sole legal government representing the whole of China, and Taiwan is a part of China. It must be noted that the US and the US-led NATO countries have selectively applied international law, this has been going on unabated. There is a plethora of actions that have collapsed several states after they were attacked under the pretext of the so-called possession of weapons of mass destruction illuminating them as threats – and sometimes even without any valid reason. to blatantly launch military strikes and even unleash wars on sovereign countrie

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Opinions

Internal party-democracy under pressure

21st June 2022

British novelist, W. Somerset Maugham once opined: If a nation values anything more than freedom, it will lose its freedom; and the irony of it is that if it is comfort or money that it values more, it will lose that too.

The truism in these words cannot be underestimated, especially when contextualizing against the political developments in Botswana. We have become a nation that does not value democracy, yet nothing represent freedom more than democracy. In fact, we desire, and value winning power or clinging to power more than anything else, even if it harms the democratic credentials of our political institutions. This is happening across political parties ruling and opposition.

As far as democracy is concerned, we are regressing. We are becoming worse-off than we were in the past. If not arrested, Botswana will lose its status as among few democratic nations in the Africa. Ironically, Botswana was the first country in Africa to embrace democracy, and has held elections every five years without fail since independence.

We were once viewed as the shining example of Africa. Those accolades are not worth it any more. Young democracies such as South Africa, with strong institutions, deserves to be exalted. Botswana has lost faith in democracy, and we will pay a price for it. It is a slippery slope to dictatorship, which will bring among other excess, assault on civil liberties and human rights violations.

Former President, Festus Mogae once stated that Botswanas democracy will only become authentic, when a different party, other than the Botswana Democratic Party (BDP) wins elections, and when the President of such party is not from Serowe.

Although many may not publicly care to admit, Mogaes assertion is true. BDP has over the years projected itself as a dyed-in-the-wool proponent of democracy, but the moment its stay in power became threatened and uncertain, it started behaving in a manner that is at variance with democratic values.This has been happening over the years now, and the situation is getting worse by the day.

Recently, the BDP party leadership has been preaching compromise and consensus candidates for 2024 general elections. Essentially, the leadership has lost faith in theBulela Ditswedispensation, which has been used to selected party candidates for council and parliament since 2003. The leadership is discouraging democracy because they believe primary elections threaten party unity. It is a strange assertion indeed.

Bulela Ditswewas an enrichment of internal party democracy in the sense that it replaced the previous method of selection of candidates known as Committee of 18, in which a branch committee made of 18 people endorsed the representatives. While it is true that political contest can divide, the ruling party should be investing in political education and strengthening in its primary elections processes. Democracy does not come cheap or easy, but it is valuable.

Any unity that we desire so much at the expense of democracy is not true unity. Like W. Somerset Maugham said, democracy would be lost in the process, and ultimately, even the unity that was desired would eventually be lost too. Any solution that sacrifice democracy would not bring any results in the long run, except misery.

We have seen that also in opposition ranks. The Umbrella for Democratic Change (UDC) recently indicated that its incumbent Members of Parliament (MPs) should not be challenged for their seats. While BDP is sacrificing democracy to stay in power, UDC is sacrificing democracy to win power. It is a scary reality given the fact that both parties ruling and opposition have embraced this position and believe democracy is the hindrance to their political ambitions.

These current reality points to one thing; our political parties have lost faith in democracy. They desire power more than, the purpose of power itself. It is also a crisis of leadership across the political divide, where we have seen dissenting views being met with persecution. We have seen perverting of political process endorsed by those in echelons of power to manipulate political outcomes in their favour.

Democracy should not be optional, it should be mandatory. Any leader proposing curtailing of democracy should be viewed with suspicion, and his adventures should be rejected before it is too late. Members of political parties, as subscribers of democracy, should collectively rise to the occasion to save their democracy from self-interest that is becoming prevalent among Botswana political parties.

The so-called compromise candidates, only benefits the leadership because it creates comforts for them. But for members, and for the nation, it is causing damage by reversing the gains that have been made over the years. We should reject leaders who only preach democracy in word, but are hesitant to practice it.

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Opinions

The Big Deal About Piracy

21st June 2022

Piracy of all kinds continues to have a massive impact on the global creative industry and the economies of the countries where it thrives.

One of the biggest misconceptions around piracy is that an individual consumers piracy activities, especially in a market the size of Botswanas, is only a drop in the pool of potential losses to the different sectors of the economy piracy affects.

When someone sitting in Gaborone, Botswana logs onto an illegal site to download King Richard online, they dont imagine that their one download will do anything to the production houses pocket or make a dent in the actors net worth. At best, the sensitivity towards this illegal pirating activity likely only exists when contemplating going about pirating a local musicians music or a short film produced locally.

The ripple effects of piracy at whatever scale reach far beyond what the average consumer could ever imagine. Figures released by software security and media technology company, Irdeto, show that users in five major African territories made approximately 17,4 million total visits to the top 10 identified piracy sites on the internet.

The economic impact of this on the creative industry alone soars to between 40 and 97.1 billion dollars, according a 2022 Dataprot study. In addition, they estimate that illegally streamed copyrighted content consumes 24% of global bandwidth.

As Botswanas creative industry remains relatively slight on the scale of comparison to industries such as Nollywood and Nilewood where the creative industry contributes a huge proportion to West and East Africas respective GDPs, that does not imply that piracy activities in Botswana do not have a similar impact on our economy and the ability of our creative industry to grow.

When individuals make decisions to illegally consume content via internet streaming sites they believe they are saving money for themselves in the name of enjoying content they desire to consume. Although this is a personal choice that remains the prerogative of the consumer, looking beyond the fact that streaming on illegal content sites is piracy, the ripple effect of this decision also has an endless trail of impact where funds which could be used to grow the local creative industry through increased consumption, and revenue which would otherwise be fed back into Botswanas economy are being diverted.

Why cant our local creative industry grow? Why dont we see more home-grown films and shows in Botswana? are questions constantly posed by those who consume television content in Botswana. The answer to this lies largely in the fact that Botswanas local content needs an audience in order for it to grow. It needs support from government and entities which are in a position to fund and help the industry scale greater heights.

Any organisational body willing to support and grow the local creative industry needs to exist and operate in an economy which can support its mandates. Content piracy is a cycle that can only be alleviated when consumers make wiser decisions around what they consume and how.

This goes beyond eradicating piracy activities in so far as television content is concerned. This extends to the importation and trade in counterfeit goods, resale of goods and services not intended for resale across the border, outside its jurisdiction, and more. All of these activities stunt the growth of an economy and make it nearly impossible for industries and sectors to propel themselves to places where they can positively impact society and reinvest into the countrys economy.

So what can be done to turn the tide here in Botswana in order to see our local production houses gain the momentum required to produce more, license more and expand their horizons? While those who enforce the law continue to work towards minimizing piracy activities, its imperative that as consumers we work to make their efforts easier by being mindful of how our individual actions play a role in preventing the success of our local creative networks and our economys growth.

Whether you are pirating a Hollywood Blockbuster, illegally streaming a popular Motswana artists music, or smuggling in an illegal decoder to view content restricted to South Africa only, your actions have an impact on how we as a nation will make our mark on the global landscape with local creative productions. Thembi Legwaila is Corporate Affairs Manager, MultiChoice Botswana

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