Social Human Implications

The Test

HIV testing is at the forefront of the discussion concerning health interventions in Sub Saharan Africa. Without robust, accurate, affordable, and precise rapid diagnostic tools, many countries in the region cannot provide effective care with limited resources available. We can’t treat what we can’t diagnose. Enter the Grffithsin lectin powered HIV rapid diagnostic test. The limitations of interventions dealing with HIV begin with a lack of data surrounding who is infected. Rapid diagnostic tests are sorely needed in that area because of a profound, “difficulty in accurately measuring HIV rates” [1]. With our thermostability project aimed at encouraging the development of a rapid diagnostic test, we tried to encourage a lateral flow assay with the specificity and precision to reliably diagnose HIV without seroconversion. The rapid diagnostic test would wholly address the need for accurate measurement of HIV rates by providing a cheaper alternative to current forms of testing that are able to diagnose people between ten and fourteen days after exposure. It would also be an exciting piece of technology to screen blood for transfusions [2]. The question now is not can the lectin Grffithsin identify HIV, but how do we get it to those who need it most. Testing and counseling is a huge issue for Sub-Saharan Africa and the diagnostic test must be designed to be conducive not only to the testing, but also the counseling. Hence traditional health practitioners must be able to use the technology.

Traditional Health Practitioners

Traditional health practitioners are the first line of care for about 70% of the population in Sub-Saharan Africa [3]. Any health intervention must go through them to be effective in that area. Traditional Health practitioners and orthodox health practitioners do not always agree, So it was extremely important to our team that the test be similarly designed to something that the traditional health practitioners are technically familiar with and culturally tolerant of. Malaria rapid diagnostic tests look like a lateral flow assay: hence we have designed our project around the creation of a thermostable Grffithsin lectin for use in a lateral flow assay type test. This integrates with traditional health practitioners that are coming around to the idea of administering orthodox medicines when it comes to HIV/AIDS. The cost (projected to be cheap enough so that NGO’s can purchase them for use in the region, at least less than $5 per unit) would also be conducive to the traditional health practitioner environment. At this cost, relatively free to the practitioner, perhaps only paying costs to travel to a warehouse or distribution center, a stock could be kept, without the need for refrigeration and ergo electricity, to test individuals who come in to the traditional health practitioner clinic.

The cycle

Health is integrated. HIV is integrated. To talk about HIV in Sub-Saharan Africa we must keep in mind culture and social practices. One method of this is to identify how a cycle or pathway of disease effects a population. One such cycle is as follows. In the region, women ages 15-24 are more at risk for HIV exposure and infection than any other group of women, and women are at higher risk than men [4]. Younger marriage is also prevalent and may be a contributing factor to HIV infection. Supposing that a young woman marries an older man what are her risks of infection? Considering that older men are more likely to have had many sexual partners including sex workers during their lifetime, early marriage is really one of the first opportunities for infection in younger women. In this situation, it follows that the husband may pass before his wife, perhaps leaving children. In some cultures in the region, widow inheritance is practiced. In the case of which a man dies and leaves a widower, that widower is then married to the former husband’s closest kin. In other cases, a sexual cleanser has sex with the woman before she can move on with life, in many cases before she can leave the home [4]. If she escaped infection in early marriage, she must now go through another round of potential exposure. During the time that this occurs, children are exposed to two differing schools of thought. Religiously abstinence is taught, while socially and traditionally, sexually risky behaviors are idolized [5]. This can help to perpetuate the cycle of infection to children and thus repeats.

How can testing help?

A rapid diagnostic test is far from a comprehensive multidimensional intervention, but it does more than one may think. With rapid diagnostic testing, we may not be able to help early marriage statistics, except to encourage safe sex if one or both of the partners are infected with HIV. That outcome is wishful thinking. However, preventing HIV transmission through widow inheritance is becoming practice in some places [5]. If traditional health practitioners had access to a cheap accurate rapid HIV diagnostic test, this kind of transmission could be mitigated. This in turn can help to lower the rate of those infected by preventing the spread of infection. It could also stabilize family dynamics by preventing couples from fighting about the “unknown” of HIV. Another exciting aspect of the diagnostic test is to prevent deaths of those already infected. Because HIV is only symptomatic in its final stages, inexpensive rapid diagnostic tests are especially necessary. By testing people, they can find care, or at least are more likely to be able to seek out care if it is available. This may help to reduce the number of “AIDS orphans” in Sub-Saharan Africa by keeping parents alive longer. It may also be effective in preventing infection from those who have concurrent sexual partners. It is not wishful to think that men would want their partners to be tested for HIV before engaging in sexual activities, thus reducing the number of those affected. Dr. Broverman detailed that wealthy, mobile men were at greater risk for spreading HIV. The key word here is wealthy, these men who use sex workers would theoretically be wealthy enough to afford the test and stop themselves from contracting the disease from concurrent partners. Another key aspect of the test is that it could be used as a crude tool of virus load detection to help people plan when they need to visit orthodox medical centers to change their drug cocktails. That kind of knowledge may also do something about the hopelessness surrounding the issue of HIV[5]. Dr. Broverman talked about people asking her if testing was even a good idea, because they felt that HIV was a death sentence and that it was better not to know. With knowledge comes power, and the rapid diagnostic test intended to be created is designed to empower people, especially women (who are more likely to get tested) to take control of their status.

Limitations

This does not fix everything, there is still a huge problem with the stigma surrounding HIV. In 1998 a woman was stoned to death in the region when it was discovered she had HIV. Less than twenty years later it is understandable why some are not willing to even entertain the idea of personal infection and thus would choose not to use the test. Hopefully the integration with traditional health practitioners which should be catalyzed by the lateral flow design and cost effectiveness thanks in part to the thermostability, will diminish the stigma in the privacy of clinics. There is also the issue of preventing transmission. The test is not a cure itself, but can lead to people seeking out resources to help themselves and their family. For example, once tested positive, a pregnant woman may seek out drugs (like the Pratt pouch) designed to prevent transmission during birth in rural areas [6]. Whatever the case may be, diagnostics are the first step toward treatment and prevention of HIV in Sub-Saharan Africa.

Sources:

[1] Ramjee, G., & Daniels, B. (2013). Women and HIV in sub-Saharan Africa. AIDS research and therapy, 10(1), 30.

[2] Ile‐Ife, E. O. O. (2004). HIV/AIDS situation in Africa. International dental journal, 54(S6), 352-360.

[3] Homsy, J., King, R., Balaba, D., & Kabatesi, D. (2004). Traditional health practitioners are key to scaling up comprehensive care for HIV/AIDS in sub-Saharan Africa. Aids, 18(12), 1723-1725.

[4] Sovran, S. (2013). Understanding culture and HIV/AIDS in sub-Saharan Africa. SAHARA: Journal of Social Aspects of HIV/AIDS Research Alliance, 10(1), 32-41.

[5] Kharsany, A. B., & Karim, Q. A. (2016). HIV infection and AIDS in Sub-Saharan Africa: current status, challenges and opportunities. The open AIDS journal, 10, 34.

[6] Choy, A., Ortiz, M., & Malkin, R. (2015). Accurate dosing of antiretrovirals at home using a foilized, polyethylene pouch to prevent the transmission of HIV from mother to child. Medicine, 94(25).