Infectious Diseases in Africa

Anemias that protect against malaria

- Anemia's that relate to altered forms of hemoglobin/decreased hemoglobin provide protection against malaria - genetic anemias are more prevalent in Africa because P. Falciparum has been leading cause of death for decades - if HH - normal RBC's - if hh - sickle cell anemic - if Hh - resistant to malaria

Second stage disease African SS treatment

- Melarsoprol - Elfornithine - Nifurtimox - much more difficult to treat when the CNS is involved - side effects are much more severe and mortality is possible

Treatment for Cholera

- ORS mixed with 1L of clean drinking water is recommended therapy - very severe infection requires administration of IV fluids - hypovolemic shock could result - antibiotics can be given to decrease duration of diarrhea and to limit spread (shedding less protects community) - 3 oral vaccines available: Dukoral, Sanchol and Euvichol

First stage diseases African SS treatment

- Pentamidine - used to create gambiense (chronic) species - Suramin - used to treat rhodesciense ** both cause serious side-effects, because anti-parasitics (problems with selective toxicity)

Incubation period and signs and symptoms of African Sleeping Sickness

- Rhodesiense: few weeks - Gambiense: weeks to months symptoms of infection include: - painful chancre at infection site — may or may not be present — occurs due to parasitic replication — usually occurs w/in 1 week of infection Haemolymphatic stage of infection Second Stage of infection

Risk factors for TB

- abuse of drugs and alcohol (dec health and IS function) - smoking - diabetes - immunocompromised patients - elderly, HIV positive - babies, young children - living and working in crowded areas - many people to one house - poor access to healthcare services - travel to regions that have high TB case # - close contact/prolonged contact w/ TB positive patients

Diarrheal disease can be different types:

- acute watery diarrhea: lasts hours to days - dysentery: bloody diarrhea - persistent diarrhea: lasts greater than 14 days

treatment for giardia

can be treated with metronidazole (flagyl) - only effective in ~80% of individuals - resistance is prevalent - other treatments options available w/ serious limitations and side effects

treatment for Cryptosporidium

can be treated with nitazoxanide - cannot be used in children <1 year old, high proportion that can't be treated and have the most decreased immune system function and greatest need - no effectiveness in immunocompromised hosts (most severe disease) - spotty effectiveness in immunocompetent

Cholera

caused by Vibrio cholerae bacterium - all outbreaks caused by O1 strain - ~50% of all cases occur in children <5 years old - most infections are asymptomatic - shed bacterium in stool - symptomatic infection is mainly non-severe and develops within hours to 5 days post-inoculation

Cryptosporidium and Giardia

caused by parasites - acquired through swimming, bathing, and consuming contaminated water (drinking and cooking) - also isolated from fruits, vegetables and seafood sources - self limiting in immunocompetent hosts in ~2 weeks, severe disease in immunocomp hosts - resistance exists to disinfectants like chlorinated bleach - increased population growth and climate change are expected to increase incidence

Acid fast stain

Used to identify TB - recommended for concentrated specimen, not direct specimen (not one that's been taken from biopsy) - performed on a sputum smear, best collected first thing in the morning so it is most concentrated Carbolfuschin (pink) sticks to mycolic acid Methylene blue (basic +ve charged stain) stains all cells with a negative charge on their cell wall - a stain with both colours is a positive stain

What can help to effectively eliminate cases of pneumonia?

Vaccines for whooping cough, H. Influenzae (DTaP), Streptococcus pneumoniae (pneumo shot), and measles - but there is poor vaccine distribution/coverage

How are cryptosporidium and giardia diagnosed?

diagnosis best accomplished with microscopic examination of fecal samples - detect parasite - ELISA and detection kits also available - ELISA needs material and infrastructure, also expensive

Diarrheal disease is defined as

discharge of: - more than 10 watery stools per day - severe diarrhea - more than a few but less than 10 watery stools per day - moderate diarrhea - discharge of a few water stools per day - mild diarrhea

local beliefs surrounding diarrhea in South Africa

occurrence due to natural causes in older infants - example: teething - treatment centres around treating symptoms involved w/ cause - not likely to provide ORS occurrence due to supernatural causes - something that the mother has done to anger spirits - stepping over evil tracks that were left behind by sorcerers - treatment of diarrhea is through to occur by correcting the lack of harmony between mother and spirits occurrence due to infectious agents - most likely to result in appropriate attention and treatment

Vertical Transmission

mother to child transmission is responsible for most childhood HIV infections - across the placenta - during birth - via breast feeding - all can be completely prevented if mother begins ARV as early as possible during pregnancy and a breast feeding infant receives ARV

MDR-TB

multidrug-resistant tuberculosis - resistant to rifampicin and isoniazid - treated w/ second line drugs - expensive and requires longer therapy - new drug developments cheaper (~1000 USD/patient) require 9-12 months of therapy vs 24 months)

Pneumonia Treatment

treated with antibiotics: - empirical treatment (treat w/o diagnosis) is recommended based on symptoms if pneumonia is suspected but diagnosis is not possible — amoxicillin Oral antibiotics: - can be administered by trained community workers — can also make diagnoses in places where healthcare clinics aren't readily accessible

Culture for TB diagnosis

very slow growing organism - generation time 24 hours

Treatment for EPTB

- 6 months recommended but for bone, joint and meningeal involvement the recommendation is 12 months

Which populations have high incidence of HIV in Africa?

- Africa has the highest # of HIV positive children high prevalence in sex workers, a high # of clients means that this is a serious avenue to infection spread - many reports of police destroying condoms carried by sex workers high incidence in marriage in young women - lack of rights - unable to ask for protected sex - male dominated relationships - high incidence of gender based violence both physical and sexual

Fluid and food curtailment

- administration of less fluid by caregivers to children with diarrhea - occurs due to misinformation and different beliefs - includes restriction of breastfeeding - especially common in low income countries - advise that treatment for diarrheal disease should occur in the community from HCP to protect against malpractice in home - food also often restricted - both are considered poor practice - in diarrheal disease, increased nutrient fluid intake are critical to promote survival

Why are negative implications of onchocerciasis more serious for females?

- because of disfiguring changes - psychological effects - aesthetic loss in women cause of nodules - leads to isolation, stigma loss of job etc.

How is Cholera diagnosed?

- can be diagnosed w/ PCR of culture of stool sample when there is clinical suspicion of infection - access to diagnostics and surveillance is critical

Malaria attacks

- can occur over x # of days, differing based on infecting species of Plasmodium - P. Falciparum causes attacks every two days lasts ~7 hours and includes: - cold stage characterized by shivering - hot stage characterized by high temperature and vomiting - sweating stage that leads to a return to normal

Complicated malaria

- cerebral malaria, that occurs when infected RBC stick to each other, to uninfected RBC and to small blood vessels - rosetting - blocks blood flow to the brain leading to hypoxia - organ failure due to damage to liver and kidneys - rupture of spleen - severe anemia due to rupture of infected RBC - exacerbates hypoxia - can't transport oxygen — accompanied by hemoglobinuria (leaked RBC components cause this in urine) ——black water fever

Onchocerciasis diagnosis

- diagnosed by microscopic detection of microfilariae in skin biopsy - 'skin snips' - do not invoke bleeding - non-invasive process - giemsa stain cal also be used

how is African sleeping sickness diagnosed?

- diagnosed w/ microscopy of infected body fluid — lymph node samples (invasive) — lumbar puncture to evaluate CSF

Pneumonia diagnosis

- difficult to diagnosis pneumonia in resource poor areas - less than 2/3 of suspected cases of pneumonia seek medical attention - often defined as 'clinical pneumonia' based on suspicion on rather than confirmation - presents w/ cough and difficulty breathing - may or may not have a fever - the chest wall recoils during inhalation and breathing is rapid

Challenges of Onchocerciasis

- financial limitations - lots of drug donation needed to assist - thrive in remote locations making distribution challenging — villages near to high nutrient land - drug distribution fatigue - civil unrest - can interrupt treatment/prevention strategies - trans-border distribution of the parasite — issues w/ coordination and effective elimination - issues with use during pregnancy - potentially teratogenic - issues with toxicity in patients who are co-infected w/ Loa Loa microfilariae — test and not treat strategy to avoid potentially lethal complications

Why is onchocerciasis called river blindness?

- flies breed in rivers and streams with fast moving water - infection can manifest in the eye resulting in blindness

issues about diarrheal disease in affected areas

- fluid and food curtailment - differences in local beliefs surrounding diarrhea

Poor access to health care for those living in poverty

- government does not have financial resources to properly fund doctors, medication, training - leads to fatigued workers, inadequate training, lack of equipment and strained, poorly regulated system - results in distrust and failure to rely on public sector

Uncomplicated malaria

- headache, fever, chills, sweating, malaise, flu-like symptoms - can also include hepatomegaly accompanied by jaundice and splenomegaly

Hospital acquired pneumonia vs community acquired pnuemonia

- hospital acquired cases often involve organisms w/ a repertoire of antibiotic resistance — higher risk for ventilated patients/patients in ICU - also hospital acquired people are already sick (opportunistic), increased cortisol = increased immunocomp

Malaria incubation period and infection types

- incubation period 1 week to 1 month - infection can be asymptomatic, uncomplicated or severe

Extra pulmonary TB (EPTB)

- involves organ systems outside of respiratory tract - usually disseminated hematogenously (through blood) - renal TB, abdominal TB, skeletal TB, pericardial TB, lymph nodes, CNS etc. - can be diagnosed w/ biopsy or evaluation of extra-cellular fluid from infection site - can occur w/o pulmonary TB

Stigma towards HIV in Africa

- lots of stigma remains - a survey in Ethiopia had people admit that HIV positive children shouldn't be able to attend School/ would not be willing to purchase goods from HIV positive people - discrimination against HIV pos people and those w/ high risk behaviours within the healthcare system is prevalent - people said that they avoid seeing doctor to avoid discrimination - same sex relationships criminalized in many countries - attempt to over turn a law that criminalizes same sex marriage in 2019 was rejected

Prophylaxis

- many available for those travelling to endemic areas - Chloroquine, doxycycline, primaquine, mefloquine (Quine = anti-malarial) - each has pros/cons - choices must be made based on patient factors, which species will be encountered - have eukaryotic side effects

Infectious etiology of diarrheal diseases

- parasitic, bacterial or viral common: - bacterial causes include: Vibrio cholerae, Escherichia coli - viral causes: Rotavirus - parasitic causes: Cryptosporidium parvum and hominis and Giardia lamblia and intestinalis

how is diarrheal disease spread?

- person to person - zoonotic source to person - Contaminated water -- increased precipitation (ex: tsunami) often leads to increased incidence of diarrheal disease - faecal/oral route of spread

What increases the risk of pneumonia?

- poor air quality indoors and outdoors — heating homes/cook w/ solid fuels on open fire allows particulate matter to be inhaled — manure, plant matter, coal, wood

Risk factors for diarrheal disease

- poor home environments - poor hygiene (education and practice tie in), unsafe water, inadequate sanitation - open defecation into bushes, fields, water bodies - poor access to healthcare and clean drinking water in rural communities - undernutrition - lack of access to essential services - comorbidities (HIV, malaria) - migration/displacement - spread occurs in refugee camps w/ contaminated water supply

Barriers to preventing transmission of HIV

- poorly coordinated healthcare systems w/ overcrowded facilities - few trained HCP w/ gaps in knowledge - long wait times - difficult to access care - high transportation costs - expensive ARV therapy - side effects of ARV decrease compliance, don't understand resistance either - stigma/discrimination directed toward HIV positive individuals -- gender discrimination experienced by HIV positive women - religious interference -- beliefs like if you go to church you can't get HIV

How is undernutrition a risk factor for diarrheal diseases?

- poorly maintained immune system leads to more severe diarrheal disease, leads to increased undernourishment and stunting - continued breast feeding up until and past the age of 2 is recommended - <40% of children <6 months are exclusively breastfed -- this is a really good nutrient source - increased maternal health and nutrition to prevent pre-term labor

How is TB transmitted?

- small infectious droplets w/ only a few bacterial cells - most effective at spreading the bacterium as they are lighter, longer time aerosolized - more readily reach the alveoli

Onchocerciasis how infection occurs?

- the worms are spread by black flies - female worms release large # of microfilariae — adult worms live in the body for up to 15 years — females produce microfilariae for up to 9 years — microfilariae live for ~2 years Worms are most often located in the subcutaneous nodules and the lymphatic system - testing of urine, blood, sputum can show microfilariae - microfilariae can migrate to the eyes and other organs

Mycobacterium pathogenesis

- uninfected host inoculated w/ Mtb bacilli from actively infected host - bacterium reach the alveoli, are phagocytosed by alveolar macrophages - the macrophage could successfully destroy Mtb, but if they don't it replicates Intracellular eventually moving to other tissues via lymphatic system or blood - immune cells recruited to site of infection forming a granuloma - fibrotic tissue provides protective chamber - inside of granuloma, some replication of Mtb, other cells are metabolically inactive and dormant - cells that are actively replicating are destroyed by IR, if the IR becomes incapacitated, replicating cells increase in # promoting development of Active TB - infected macrophage can undergo apoptosis, leading to engulfment by another —- it can also become necrotic, break down and release Mtb and caseum

Latent TB treatment

1 medication - isoniazid taken for 9 months - likelihood for resistance low because organism isn't actively dividing, but — for isoniazid resistant strains - rifampin for 4 months 2 medications - Rifampin and isoniazid for 3 months - decreased resistance likelihood even more

HIV infection in Africa part 2

1/3 AIDS related deaths occurs due to TB infection - increased HIV/TB co-infection - highlights need for effective TB treatment and elimination -Death due to HIV-related illness leaves behind many orphaned children - slow social and economic progress because of HIV prevalence - HIV has decreased life expectancy in Africa, some countries it has dropped below 50 - Africa has the highest # of HIV positive children

Active TB treatment

4 medications taken for 2 months - isoniazid, rifampin, ethambutol, pyrazinamide - cocktail therapy so decreased resistance opportunity 2 medications for another 4 months - isoniazid and rifampin Also DOT - directly observed therapy - health care worker makes visits daily to ensure meds are taken

How many HIV positive people have access to ARV in Africa and what impacts the gender imbalance of treatment?

64% of HIV positive people have access to ARV w/ 52% displaying low viral load (unlikely to spread) -- more women than men are on therapy and compliant - gender imbalance -- gender norms make it challenging for men to seek diagnosis and deal with stigma of infection - more women than men are infected but men are more likely to die from HIV related illness

Nucleic acid test for TB diagnosis

A rapid, high sensitivity, point of care testing - development of Nucleic acid test - Xpert MTB/RIF assay - allows test results in ~2 hours - detects TB genetic material in smear negative samples — not 50% of detected TB cases are smear positive - also detects resistance to rifampicin (increased risk factor with resistant strains

What is important for prevention of TB?

Adequate testing, distribution and availability of drugs - proper use, counselling and treatment adherence is critical - supervision also critical - drug distribution is financially and geographically important - TB therapy can be terrible financially

Second stage of infection

African SS - when the parasite crosses the BBB, meningoencephalitis occurs (inflammation of brain and meninges) — second stage of infection — symptoms include behavioural changes/personality changes, slurred speech, confusion and poor concentration, coordination disturbance, seizures, difficulty walking, talking and sleep disturbance - long periods of sleep during the day and inability to sleep at night

BCG vaccine

Bacille-Calmette-Guerin - Live strain of attenuated strain of Bovine Tuberculosis - mycobacterium derived from M.bovis - unpasteurized milk is source of exposure - given as a single dose, intra-dermally to babies - can't be given to immunocomp or pregnant people because of risk of reversion - very limited effectiveness - given only to high risk groups w/ intent to reduce development of miliary Tb/development of TB meningitis - develop IR to the mycolic acid

Pneumonia etiology

Bacterial, viral, fungal, parasitic - >50% of all cases are caused by Streptococcus pneumoniae — normal member of respiratory flora but can cause disease when it enters the lower resp tract (when immunosuppressed) - RSV and influenza also culprits - Pneumocystitis jiroveci causes 25% of all pneumonia associated w/ death in young babies (poor underlying immunity), and HIV infections - bacterial causes generally more severe than viral - fungal cases are most often hospital acquired cases - parasitic cases are rare and most often in immunocomp, HIV positive children

Who is most at risk and most affected by Pneumonia?

Burden of disease on young children and elderly - 1/2 million children die each year in sub-Saharan Africa - democratic republic of Congo and Nigeria are most affected Immunocompromised children more at risk - HIV pos children have 7x higher likelihood of dying from pneumonia - high risk for opportunistic infection

How is malaria transmitted?

By female mosquitoes of the Anopheles genus - Anopheles gambiae is most common

Onchocerciasis

Caused by Onchocerca volvulus - parasitic filiarial worm spread by black flies of the genus Simulium - humans are the only animal reservoir - disease is termed 'river blindness' - nearly 100% of all cases occur in Africa — 31/54 African countries experience all cases — punctuated cases in LAC and Asia — estimated 37 global million infections

African Sleeping Sickness

Caused by Trypanosoma brucei parasite - livestock can also be infected - constant reservoir for infection - only ~1000 cases reported in 2018 - Congo disproportionately impacted - fatal infection when left untreated - documented cases of healthy carriers - different subspecies of T.brucei are responsible for disease in different geographical regions of Africa — Gambiense subspecies causes slow progressing disease in west and central Africa — most commonly diagnosed ~98% of cases — chronic disease — Rhodesience subspecies causes rapid progressing disease in east and South Africa

Malaria

Caused by parasites of the Plasmodium genus - plasmodium falciparum causes ~100% of African cases Responsible for over 400k deaths globally in 2019, ~230 million cases - 94% of deaths occur in Africa - Children <5 years old account for greatest # of deaths - poor immunity is biggest risk factor — young children, pregnant woman, elderly and traveler's from non endemic areas — children may have Ab from mom @ birth, has a 1/2 life though

Chest X-ray and CT for Tb diagnosis

Can be used to look for evidence of infection - calcified lesions indicate evidence of past infection - lots of radiation, only do if need to

Tuberculosis

Caused by Mycobacterium tuberculosis - M. Africanum causes nearly 1/2 of all TB in West Africa — part of the M. Tuberculosis complex - estimated 10 million new infections globally per year — 1.5 million deaths per year - 25% of all new infection and 25% of all deaths occur in Africa - Nigeria and SA see highest # of new infections

Onchocerciasis treatment

Complicated because its a tissue based parasite (not a localized treatment) - previous drugs had serious toxicity issues - diethylcarbamazine (DEC) Current treatment is Ivermectin - discovered in japan, produced by a soil microbe - very broad spectrum of activity - given as single annual dose (good for MDA) - kills and inhibits the ability of female worms to produce more (static therapy) - known to inhibit chemically-gated chloride channels used by glutamate - inhibits onchocerciasis by interfering w/ immune evasion strategies - steroid can sometimes be used to decrease inflammation (turn down immune system) Helicopter delivery of insecticide can control insect vectors

Treatment for African sleeping sickness

Drug manufacturers distribute drugs to the WHO as donations - allow access in resource poor areas that are endemic First Stage disease and Second Stage are treated differently

Malaria diagnosis

Diagnosed with microscopy to visualize parasite - finger prick to obtain capillary blood - sample stained with Giemsa stain (for Eukaryotes)

Miliary TB

Form of pulmonary Tb that has lesions on the lungs, but also extra-pulmonary involvement

More than 50% of Tb patients in Africa are co-infected w/ _______

HIV - diseases advance each other - weakened immune system allows M tuberculosis to thrive - opportunistic infection that accelerates HIV disease

how does onchocerciasis cause blindness?

Immune response to the parasite - damage to the circulation in the eye which leads to glaucoma - damage to the retina - blindness - can occur many years after initial infection

Mantoux test

Injection of tuberculin (cell wall material from Mtb) underneath skin in forearm - patient returns in 48-72 hours to have results read — size of welt indicates likelihood of TB — induration must be measured, not erythema Positive Mantoux test doesn't indicate active TB — could indicate patient has received BCG vaccine — latent infection — exposure to other Mycobacterial sp - further testing needed for diagnosis - a positive result is a type 4 hypersensitivity reaction

Malaria most affects those who are

Living in poverty - poor education - lack of access/improper use of mosquito nets - poor access to health care - cultural beliefs and traditions can be incorrect failing to provide protection against malaria transmission (need to sensitively address the issues which ties into training) - low immunity as a key risk factor - displaced populations are at increased risk when migration occurs from non-endemic areas to endemic areas (no-underlying immunity

TB diagnosis

Mantoux test, chest x-ray, acid-fast staining, culture, Nucleic acid test

Malaria Transmission Cycle

Mosquito takes blood meal from infected person - male and female gametocytes from the parasite mate in the gut of mosquito - after a period of development (lasts 2 weeks) the sporozoite form of the parasite migrates to salivary gland of the mosquito - transmission to an uninfected human occurs when the mosquito takes another blood meal - anticoagulant is used to prevent clot formation enhancing blood flow - sporozoite enters liver cells, where it replicates forming a schizont - liver stage of disease can be dormant stage lasting more than a year - when schizont ruptures the parasite enters the blood and begins blood stage of infection

When testing infants for HIV infection, can Ab testing be used?

No - they have an underdeveloped IS - antibodies from HIV positive mother could provide false positives (natural passive immunity) - detect viral RNA instead

Latent TB

Non-communicable - asymptomatic and unable to spread bacterium - controlled by the IS - but can collapse - should be treated to prevent development of active TB — 10% of latent TB infection will become active TB infection

Haemolymphatic stage of infection

Parasite replicates via binary fission at bug bite site - high levels of parasite migrate into the blood via lymphatic vessels - first stage results - symptoms include headache, arthralgia, fatigue, enlarged lymph nodes and itchiness - can include fever

Blood stage of infection

Plasmodium in blood infects red blood cells - coincides with onset of symptoms - blood transmission possible via transfusion, mother to child, needle stick

Active TB

Pulmonary Tb - communicable (means can spread) some people display symptoms of infection including: - productive cough that lasts > 2 weeks (produces sputum) — thick cloudy mucus — sputum may contain blood - night sweats, weakness, fatigue, weight loss May not seek medical attention - 2/3 survive w/o treatment 1 person w/ active Tb infects ~10-15 others over 12 month period

Drug resistant TB

Resistance occurs bc drugs are used incorrectly, compliance to treatment isn't adequate, single drug therapy, etc. - MDR-TB - XDR-TB

Signs and symptoms of onchocerciasis

Signs and symptoms develop due to immune activation that occurs mainly in response to the presence of dead microfilariae - eosinophil activation - inflammation causes pruritis (itchiness) - disfiguring changes to the skin — dermatitis — loss of elasticity causes premature aging - lizard skin — leopard skin —— loss of pigmentation —— most commonly occurs on shins Nodules are plentiful but rarely painful - vary in diameter, contain adult worms - often palpable - can cause blindness - rapid destruction of microfilariae due to drug therapy can exacerbate disease

Which part of Africa has the highest # of HIV cases?

South Africa - Nigeria is second w/ 3.4% of population infected

How is African sleeping sickness spread?

Spread by the Tse Tse fly - Glossina spp. - only found in sub-Saharan Africa - rural areas - bites during the day - painful - inoculates hosts when taking a blood meal — parasite is present in saliva Possibility for spread through blood transfusion, other forms of blood contact and mother to child (placenta, during birth), sexual transmission

Malaria Treatment

Treated w/ ACTs (Artemisinin-based combination therapy) - produced by plants - damages Plasmodium proteins killing the cell - proteins are needed for cell activity - resistance is beginning to develop Goal is to eliminate the parasite entirely preventing development of complicated malaria but also prevents spread to uninfected people

Treatment of Diarrheal diseases

Treatment with: - oral rehydration salts - low osmolarity solution of clean water, electrolytes and sugar -- can be administered by parents in the home - estimated to be >90% effective at decreasing mortality - estimated that only 1:3 children receive ORS (access, education) - zinc supplements - <5% of children in SSA w/ diarrheal disease receive zinc supplements, important co-factor - required for 10-14 days

Variable surface glycoprotein

Trypanosomes vary glycoproteins expressed on the surface of the cell membrane (antigenic variation) - allows immune evasion and promotes success in the extracellular environment - ~1000 different genotypes exist for surface protein - only one is actively expressed at a particular time — organism is able to remove and insert another protein variant — avoids Ab detection - adaptive immunity fails

Paradoxical reaction

Worsening of lesions or development of new lesions in a patient who was initially responsive to anti-TB therapy - treatment failure

How many children die of diarrheal disease per day?

estimated 1600 - global number - >50% of the deaths occur in sub-Saharan Africa - Majority occur in children <2 years old

XDR-TB

extensively drug-resistant tuberculosis - resistant to first line drugs and second line drugs - requires much longer therapy w/ more costly, side-effect inducing meds

Burden of cost of Malaria

extremely high at the indivdual and government level - cost of drugs, lost income, travel for treatment (poor access to healthcare, need to travel to get it) - training of HCP, prevention plans, insecticide spraying - direct costs alone estimated 12 billion USD

HIV Infection in Africa

globally >37 million people are HIV positive - >25 million live in Africa -- >2/3 live in eastern and southern Africa - ~2/3 of all new HIV infections occur in Africa -- 1.1 million new infections in 2018 - in 2018 there were more than 470k HIV-related deaths in Africa

iCCM

integrated community case management - for diarrheal diseases - necessary to train healthcare providers on necessity to treat w/ ORS and zinc thearpy - proper administration requires adequate training, supervision and support

Voluntary Circumcision

offered to teenage boys 15 years and older and men - consent issues w/ younger boys - patients are also provided with sex education and advice to use condoms, STI's diagnosed and treated during the visit - shown to reduce risk of HIV infection by 60% already performed on >25 million males - done w/ a collar clamp device - non surgical - not offered in all countries (different priorities)- mainly countries in east and south of the continent - reduces long term costs associated with ARV therapy - decreases transmission w/ fewer infected people

HIV-2

prevalent in West Africa - contrasts w/ HIV-1 which has global prevalence similarities between 1 and 2 - both have very similar genomic arrangement - both infect CD4+ T helper cells - both have same clinical progression terminating with AIDS but - much less transmissible - does not cause aggressive or rapid progressing infection, people are termed 'elite controllers' - lower viral loads, higher CD4+ cell counts - lower immune activation, more protective immune response than HIV-1 - HIV-2 positive individuals experience disease progression at higher CD4+ counts - AIDS stage largely the same between the types