Some thirty features of AIDS in Africa
In 1987 I visited sixteen African countries to acquaint myself with the AIDS situation on the continent. I obtained information from doctors and health workers about many of the countries I could not visit. 1 was refused a visa to go to Zaire.
A synoptic overview of clinical and other features of AIDS in Africa as I learnt on my sub-Saharan tour is here presented, making mention of some of my teachers. Those not referred to are being protected because the authorities forbade them to take any foreigner on a ward round. What I learnt from the prostitutes is to be published elsewhere.
Aids is not uniform over the 50 countries in Africa. In most it is now in the introductory phase. In 5 or 6 countries AIDS is in the propagation phase with the highest incidence in some French speaking (but not necessarily French related) regions and countries bordering them.
Age block gap. No patients were found between infancy and teens except the blood trans-fused, thus excluding insect vectors in transmission (Dr. Miriam Duggan and Dr. Sewankambo of Uganda, Professor McLarty. Tanzania; Dr. Fleming. Zambia.)
Repatriation AIDS. In my Krobo tribe in Ghana, all patients had been sent home to die from Ivory Coast (1). Most of West Africa is like that.
100 % Female preponderance. In certain tribes in West Africa males have yet to manifest the disease (1-4).
Perineal devastation easily visible from the foot of the bed with undressed patient lying prone (Dr. Mate-Kole, Korle Bu Teaching Hospital, Ghana.)
Virgins and the nulliparous can get AIDS from the first intercourse due to tears (Dr. Mate-Kole, Korle Bu Teaching Hospital, Ghana).
Pervisemos i.e. ‘persistent virus secreting mothers’ who are asymptomatic but continue to bring forth sick children (Dr. Duggan and Dr. Hanny Friesen, Kampala ; Dr. Chintu, Lusaka).
AIDS Precipitators. Caesarian section and minor procedures like salpingohistograms can turn the asymptomatic into full blown AIDS (Dr. Duggan, Kampala.) (5).
CromwellHospital, Cromwell Road, London SW5 OTLI.
Former Director Ghana Institute of Clinical Genetics, and Consultant Physician, Korle Bu Teaching Hospital, Accra.
*Published in: Annales Universitaires des Sciences de la Santé 1987; 4 (4): 541-544.
Symptomatology of Slim : 20-40 % weight loss, persistent diarrhoea, fever, lymphadenopathy, respiratory symptoms, oral candidiasis and amenorrhoea in child bearing women, with frequent previous history of sexual exposure, of blood transfusion, and/or unsupervised injections (Dr. Sezi, Serwadda & colleagues in Kampala, physicians in Dar es Salaam, and in Lusaka and Ndola, Zambia, Dr. Neequaye et al, Ghana) (6, 7, 8).
Intractable Pruritus in adults, and in infants : this could be the commonest cause of
insomnia (Dr. Chintu and Dr Subhash Hira, Lusaka.)
Generalised hyperpigmentation with crazy-pavement dermatopathy (Professor. Bodo, Nairobi). Papulo-vesicular eruption rather like chicken pox (Dr. Sezi, Kampala).
Dupuytren's Contracture (Professors Badoe, Archampong and Jaja's new book
“Surgery in the Tropics” p.210 shows this physical sign as a complication of plaque Kaposi's sarcoma) (9). Professor Anne Bayley (Lusaka) showed me two cases of aggresive atypical Kaposi’s sarcoma (AAKS) with this sign.
Elephantiasis of limbs (upper and/or lower) and genitals from AAKS (Professors Bugingo, Rwanda and Anne Bayley, Zambia).
Multidermatomal Herpes Zoster heralds full blown AIDS (Dr. Subhash Hira, Zambia and Dr. Sezi, Uganda).
Adult Kwashiorkor. I saw this syndrome in my Krobo tribe where girls with Repatriation AIDS whose diarrhoea must have included creatorhoea with consequent protein calorie malnutrition.
Accelerated orphan Kwashiorkor. 1 saw this at Dodowa, Ghana, in a baby boy whose mother had died a week after repatriation from Ivory Coast.
Tuberculous pericarditis as a common complication (Dr. Mboussa, Brazzaville and Dr Jahazi, Dares Salaam).
Non-AIDS Diseases producing HIVseropositivity. (Dr. Fleming and Rosemary Mwendapole, Ndola, Zambia) (10). Liver pathology can confuse results and Tanzanian physician Professor Aaron Massawe postulates “immunoligical turbulence” with
Anti-TB treatment to fake seropositivity.
Radiological “bat's wing” lung in AAKS (Professors Bugingo Rwanda, and Anne Bayley, Zambia) (11)
Sworl Facies: a characteristic “Strikingly worried look”, on the faces of the more discerning patients I visited on ward rounds in Uganda, Rwanda, and Zambia.
Relative Paucity of full blown AIDS. It came as a surprise to find a Zairean man and wife, and a Kenyan itinerant salesman as the only AIDS patients in the 2100-bed KenyattaNationalHospital. Even in Uganda, Rwanda, and Burundi, wards were not overflowing with patients. I entirely agree with Professor Gottlieb Monekossoo, Director of the WHO's Regional Office for Africa when he is reported by The New Scientist as saying: “For many countries in Africa AIDS does not represent the same threat that it does in Europe. In the eyes of health managers AIDS probably ranks only tenth or lower on a list of serious tropical diseases. Malaria, measles, diarrhoeal illnesses, tuberculosis, cholera, meningitis, yellow fever and various cancers account for more deaths and illnesses than AIDS does, at the moment” (12).
Patients are not dying “like flies” as world media report (13). When Uganda's Dr. Sewankambo was recently asked in London what proportion of a hundred gravely ill patients for admission would be AIDS and he replied two, or at most three at the worst times”, he was glared at with incredulity.
Seropositive twin baby lives while seronegative twin dies. Born to a pervisemo (ie persistent virus secreting mother) the infected twin lived while the seronegative twin died from AIDS, in Kigali, Rwanda.
AIDS has not changed health priorities in Africa. I cannot speak for Zaire where I was not permitted to visit, but in no country has AIDS moved into the first 6 health priorities, even in Rwanda, Burundi, Zambia, and Tanzania.
Disagreement about seriousness of the problem. Some expatriate workers in Africa
prophesy doom, but most indigenous doctors while not underestimating the gravity in some countries, consider forecasts exaggerated (Uganda, Rwanda, Burundi, Zambia). I myself have judged the gravity of AIDS in Africa at 5 clinically graded levels.
Grade I, not much of a problem; Grade II, a problem exists; Grade III, a great problem;
Grade IV, an extremely great problem, and Grade V, a catastrophe (13). I recommend this approach to health workers and urge them to have their own grading criteria. Clinicoepidemiology rather than seroepidemiology will best bring out the truth about the real state of affairs of each country (1).
The Juliana Phenomenon. AIDS in the lake region of Tanzania, bordering Zaire, is known as “Juliana” because, as one prostitute told me, “A few years ago when the Navy visited Mombasa with 9, 000 troops, some of our girls who travelled there for business were given T shirts with Juliana marked on them. Many of those who wore the Juliana shirts have since had Slim and died”.
Non-Africans with AIDS. The 6 patients seen in Mombasa with AIDS (1983-1987) by a specialist, were a Zairean, and 5 non-Africans from Europe and the USA; in South Africa all the AIDS has so far occured in non-blacks (Dec 1987), and in Zaire at least 21 Europeans and Americans were known to have had AIDS (Source : Resident Greek Businessman). HIV-2 in West Africa is not specifically African, having been seen in two homosexual men in France (14) and is now known to have Portuguese connections. (15).
Complete Cure Anecdotes were heard in Uganda, Rwanda, Congo Brazzaville (related to tuberculosis) (1), Tanzania, and herbal preparations are being tried in domiciliary management of the disease in Ghana. (16).
It is important that doctors living and working in Africa adopt their own approach to a new disease like AIDS, and not import wholemeal terminologies, diagnostic criteria, and preventive slogans from abroad. Africa in my opinion should abandon the use of “homosexual”, “heterosexual”, “bisexual” etc., and should call a spade a spade. African prostitutes are said to be “heterosexual” but I met girls of whom anal intercourse was demanded by some expatriates for extra money (4), and in Burundi I recently asked a prostitute, “Y-a-t-il quelqu’un qui vous a demande de faire l`amour dans la bouche ?”
And she replied, “Oui Monsieur, mais je leur demande une grande somme d'argent”
(17). So, one should now use “peno-vaginal sex” for so called heterosexual sex, and “anal sex”or “sodomy” for what is called “homosexual relationship”. Anal sex has been demanded sometimes for money in several countries in Africa. And in the first description of the AIDS problem to come from Africa one AIDS patient had a “high recto-vaginal fistula of recent onset” (6), while the Ugandan traders who were found to be seropositive admitted to, “both heterosexual and homosexual casual contacts”(6). It is far better perhaps to say that these traders admitted to both peno-vaginal and anal intercourse (4). As regards diagnosing AIDS without blood tests the Muhimbili Criteria show that one does not have to use criteria from abroad (18).
Finally the kind of research that will help Africans curtail AIDS does not have to be the vaccine orientated research of the developed countries. Public Health methods and clinical epidemiology are Africa's best tools (1).
I thank the clinicians who took me on ward rounds during my recent Africa tour, and the Health Administrators who readily agreed to see me.
1. KONOTEY-AHULU F I D, (1987) Clinical epidemiology, not seroepidemiology, is the answer to Africa's AIDS problem. British Medical Journal 294: 1593
2. NEEQUAYE A.R., NEEQUAYE J,., MINGLE J.A., OFORI-ADJEl D. (1986). Propondernace of females with AIDS in Ghana. Lancet ii: 978
3. NEEQUAYE A. R., ANKRA-BADU G.A., AFRAM R.A. (1987). Clinical features of human immunodeficiency virus (HIV) infection in Accra. Ghana Medical Journal 21: 3-6
4. KONOTEY-AHULU FID (1987) AIDS: origin, transmission and moral dilemmas. Journal of the Royal Society of Medicine 80: 720.
5 KONOTEY-AHULU FID (1987). Surgery and risk of AIDS in HIV positive patients. Lancet ii: 1146
6. SERWADDA D., MUGERWA R.D., SEWANKAMBO N.K, LWEGABA A.,
CARSWELL J. W, KIRYA G.B., BAYLEY A.C., DOWNING R.G., TEDDER R.S., CLAYDEN S.A., WEISS R.A., DALGLEISH A.G. (1985). Slim disease: a new disease in Uganda and its association with HTLV-111 infection. Lancet ii: 849
7. SEWANKAMBO N., MUGERWA R.D., GOODGANER R.,CARSWELL JW, MOODY A., LLOYD G., LUCAS S.(1987). Enteropathic AIDS in Uganda.
An endoscopic, histological and microbiological study. AIDS 1:9
8. SEWANKAMBO N., CARSWELL J. W,. MUGERWA R.D., LLOYD G., KATAAHA P.,
DOWNING R.G., LUCAS S.(1987) HIV Infection through normal heterosexual contact in Uganda. AIDS 1 :113
9. BADOE E.A., ARCHAMPONG E.Q., JAJA M., Eds, Principles and Practice of Surgery in the Tropics. Accra: Ghana Publishing Co; 1986
10. FLEMING A.F., KAZI A.R., SCHEINEDER J., GUILLOT F., MWENDAPOLE R., WENDLER I., HUNTSMANN G. (1986). Comparison of HTLV-111 in some Zambian patients. AIDS Forschung (AIFO) 8: 434.
11. BAYLEY C A. (1983). Aggressive Kaposi’s sarcoma in Zambia. Lancet i: 1318-1320
12. MONEKOSO G. In Second International Conference on AIDS in Africa. Naples October 1987. Interview with Sharon Kingman. New Scientist, 15th October 1987, p 26.
13.KONOTEY-AHULU F I D. (1987). AIDS in Africa: Misinformation and Disinformation. Lancet, ii: 206-207.
14. BRUCKER G, BRUN-VEZINET F, ROSENHEIM M, REY M A, KATLAMA C, GENTILINI M. (1987). HIV-2 in two homosexual men in France. Lancet, i: 223
15. KINGMAN SHARON. (1987). The Portuguese connection. New Scientist, 15th October, p 27
16. QUARTEY J K M, MATE-KOLE M O, OKAI GLORIA, BENTSI CECILIA, DJABANOR F F T, KONOTEY-AHULU F I D. (1988). Domicilliary management and prognosis of AIDS in the Krobo region of South east Ghana. The First International Conference on the Global Impact of AIDS. Barbicon Centre, London, 8 – 10 March.
17. KONOTEY-AHULU F I D. Extensive palatal echymosis from felllatio – a note of caution with AIDS at large. (1987). British Journal of Sexual Medicine, 14: 286-287
18. PALLANGYO K J, MBAGA I M, MUGUSI F, MBENA E, MHALU F S, BREDBERG U, BIBERFIELD G. (1987). Clinical case definition of AIDS in African adults. Lancet, ii: 972.
First published in Annales Universitaires des Sciences de la Santé 1987; 4: 541-544
Postscript January 2008: What has happened in Africa in the past 20 years since this article was published defies logic. Countries (like South Africa, Namibia, and Malawi) that have moved from my 1987 classification of Grade I (not much of a problem) to Grade IV, tottering on V (Catastrophe) in just two decades require more high quality epidemiological research like Guisselquist and colleagues’ [Reference i] and of Didier Fassin and Helen Schneider [Ref ii] to work out very clearly the way the epidemic is being propagated. It is impossible for sex alone to account for the Financial Times (London) statement that 85% of the inhabitants of Zevenfontein in South Africa are HIV-Positive [Ref iii]. We need a paradigm shift in our approach to the management of this epidemic in Africa [Ref iv].
(i) Guisselquist D, Rothenberg R, Potterat J, Drucker E. HIV infections in sub-Saharan Africa not explained by sexual or vertical transmission. Internatrional Journal of HIV & AIDS Oct 2002: Vol 13: pages 657-666.
(ii) Fassin D, Schneider H. The politics of AIDS in South Africa: beyond the controversies. British Medical Journal 2003; Vol 326: pages 495-497 (1 March)
(iii) Financial Times. AIDS in South Africa. Friday, 20 September 2002, page 14.
(iv) Konotey-Ahulu FID. AIDS in South Africa: wake up call and need for paradigm shift. http://bmjjournals.com/cgi/eletters/326/7387/495#30917 April 3 2003.