Last summer on a trip to Zambia, I could not help but notice the free condoms in every restroom offering protection against pregnancy, HIV, and other sexually-transmitted diseases. Despite the public health initiatives to prevent transmission of HIV, however, reports show that less than 20 percent of the population has ever used a condom. During my trip I spoke to many Zambian people about sexually transmitted viruses. In almost every case the conversation immediately turned to HIV.
In Africa, the main avenue of transmission of HIV is through sexual intercourse and mother-child transmission. The virus infects and destroys cells of the immune system, making a person susceptible to infections that it would normally be capable of fighting off without much issue. Malaria, tuberculosis, anemia and many other treatable infections become more difficult to treat.
Most men in sub-Saharan Africa work away from home while women tend to stay in the tribal villages and work within walking distance of home. Men work for days or weeks at a time at a mine, bush camp or other job site where they live in barracks or compounds for up to three weeks at a time, leading to risky behavior involving prostitution and homosexual interaction.
Clearly, stabilizing and reducing the spread of both HIV and the human papillomavirus (HPV) must be top priorities on the world health agenda. But how should this be tackled?
According to the American Foundation for AIDS Research (AMFAR) and the World Health Organization (WHO), 70 percent of all people living with HIV, 25 million people, including 88 percent of the world’s HIV-positive children, live in sub-Saharan Africa. Each year, there are over one million newly infected people in addition to over one million deaths, accounting for 75 percent of the world’s AIDS deaths.
In Africa, both HIV and HPV are most frequently transmitted through sexual contact. Although much attention is paid to the AIDS epidemic in Africa, HPV-related cancers, particularly in people with HIV, can be as fatal as AIDS.
In May, I will be traveling with a group of physicians to Botswana for a conference sponsored by the Ministry of Health and several other organizations in hopes to inspire discussion around cancer care in Botswana and to work toward setting up a sustainable system for regular cancer treatment. Using knowledge from the AIDS epidemic, we will formulate a plan for treating the related cancers that will include education, health care training, vaccination, screening, treatment and follow-up. If the model proves deliverable in Botswana, we hope to share it with other countries facing similar epidemics, as well.
According to an American Cancer Society report, cervical cancer has been the most frequently diagnosed cancer in Sub-Saharan Africa, and the leading cause of cancer death among women. For other cancers such as Non-Hodgkins Lymphoma, liver, and others, the incidence rates for men are much higher than in the rest of the world. Many of these cancers are caused by the HPV or Hepatitis B viruses, and are accelerated in part by the compromised immune systems of people with AIDS. They are usually not seen or felt until they are already large and causing pain and obstruction – in other words, when they’re probably too late to successfully treat.
Currently, the primary goal of the health care systems in these African countries is to offer and oversee the administration of lifelong Anti-Retroviral Treatment (ART) to maintain immune system strength for a person who has been diagnosed with HIV. This reduces the likelihood of death from aggressive malaria, TB, and many forms of HPV-related cancer that can develop more rapidly in a compromised immune system.
Countries are still having a hard time getting therapy to everyone who becomes HIV positive, or giving treatment to those who present with late stage HIV/HPV related cancers. Most people in Africa can't afford the time off work or cost of treatment, so HIV and cancers go untreated.
Most of these countries have few medical resources except in the large cities. Health workers who visit villages for routine health treatment are in short supply and are neither equipped nor trained to diagnose or treat these forms of cancer. Some of them even refuse to treat HIV patients out of fear of becoming infected with the virus.
In addition to the financial limitations and health care infrastructural roadblocks, there are also cultural barriers to seeking treatment for HIV and, increasingly, cancer. Despite the fact that over 25% of the population in relatively peaceful and economically stable Zambia and Botswana is HIV Positive, the determination that a person is HIV-positive has an enormous effect on an individual and his or her family. Having HIV carries a very negative stigma. It is considered a death sentence by many, so causes fears about disclosure to partners, a lack of support from partner or family, loss of job, etc.
Thankfully, these countries are becoming increasingly motivated to begin addressing this serious situation. Additionally, many of the HIV-accelerated HPV- related cancers can be treated effectively and in a practical manner with combinations of radiation therapy, chemotherapy, and surgery in addition to short, accelerated forms of radiation therapy that can take place over a few days and that in some cases can cure the patient.
However, careful planning must be undertaken first to develop an infrastructure capable of screening, diagnosing, treating and following patients. The country must be introduced to the idea of cancer care and cancer prevention, integrated into the health care system that already exists. Health care workers require training to screen, diagnose and present viable treatment plans while medicines, equipment and tools are desperately needed.
Together, with the team of qualified physicians, we hope to build a model that can be transferrable with other countries facing similar epidemics, to work to improve the quality of life for people across the globe, starting one country at a time.
Thompson is a radiation oncologist and patient advocate. She received a Master’s Degree in Public Health in Health Care Policy and Management from Harvard University and received her MD from Johns Hopkins University School of Medicine, specializing in surgical gynecology. As founder of BFFL Co, she develops products that improve the patient experience before, during and after hospitalization, in a way that preserves dignity and enhances recovery.