By Kate Hawkins, COUNTDOWN
COUNTDOWN is happy to support and be a part of the International Scientific Workshop on Neglected Tropical Diseases (NTDs) which is currently taking place in South Africa. The theme of the meeting is how schistosomiasis, in particular Female Genital Schistosomiasis, impacts on HIV. On day one we were joined by some brilliant speakers who provided six keynote addresses to help provide context for discussions in subsequent breakout sessions for each topic.
Tsakani Furumele, Director, Communicable Disease Control, National Department of Health, South Africa gave an overview of combined control policies. She outlined how NTDs effect the poorest of the poor. But because they do not often kill people they are often marginalised in broader conversations on health. However, they impair physical and intellectual capacities perpetuating the cycle of poverty. At least 79% of endemic countries are co-endemic for at least 5 of the NTDs. Africa bears half of the global burden. She argued that,
“Stimulating financing for NTDs requires an evidence base and if we cannot provide it the chances of us getting support are very, very slim.”
There are a number of regional and global policies to guide action in this area such as the WHA Resolution 66.12 and the WHO strategic plan for NTDs in the Africa region as well as the London Declaration. Whilst in South Africa the various HIV guidance policies stress that integration is necessary and that there is no one size fits all approach there are still barriers that effect the integration of NTDs into this portfolio and would affect action on Female Genital Schistosomiasis. These barriers include that: not all stakeholders are involved in the process of policy formulation; there are financial constraints related to the potential costs of integrated programmes; logistical and organisational limitations mean that cross policy and sectoral action is extremely difficult; and demographic heterogeneity is also an issue. To overcome these barriers we need advocacy and information sharing so that all have access to the evidence and we need facilitate joint programming and partnership and this will mobilise political will for action on NTDs.
Gita Ramjee, Director, HIV prevention Research Unit, South African Medical Research Council/London School of Hygiene and Tropical Medicine presented on Women and HIV. She outlined how there are 35.3 million people living with HIV and every hour 50 young women are newly infected. There are various overlaps of a number of factors related to Female Genital Schistosomiasis and HIV for example, their impact on vaginal mucosa, that they both effect the poorest, the relation with gender inequality, and that they effect reproductive functions.
Gita suggested that there are a range of sexually transmitted infections (STIs) which effect the genitals and there are similarities between what STIs do and what Female Genital Schistosomiasis does. Several cross sectional studies reported association between Female Genital Schistosomiasis and HIV. In addition to increasing susceptibility to infection it may also increase progression of disease by raising viral load in individuals who are infected. Further research is required to determine the contributing role of Female Genital Schistosomiasis and other NTDs on HIV incidence in Sub-Saharan Africa.
Eyrun Kjetland, Research Fellow, Norwegian Centre for Imported and Tropical Diseases, Oslo University Hospital was our third speaker and presented on Female Genital Schistosomiasis. Eyrun explained that the pertinent symptoms of Female Genital Schistosomiasis are malodorous discharge, secondary infertility and spot bleeding and that even children have symptoms. Taken together these symptoms can be confusing for the child and initiate low self-esteem, especially at a sensitive period before their first sexual debut. Whilst these symptoms can resolve with treatment with praziquantel this does not affect lesions in the vagina and cervix that have already formed which stay even if the S. haematobium eggs are dead. Also people can test negative when given a urine test but still be affected by the disease. Old, calcified S. haematobium eggs in genital tissue have been found to increase the density of HIV-receptive CD4 cells. Female Genital Schistosomiasis may be a cofactor for HIV transmission in endemic areas, and the association between schistosomiasis and HIV has been corroborated by several scientific groups. However the evidence base that can be drawn on for the association between HIV and Female Genital Schistosomiasis is small and still limited to a group of key experts.
This led one audience member to comment:
“Do we need to keep proving the links beyond doubt? Or should we just say that the effects of schisto and HIV are enough to treat. The fact that there could be an association is reason enough to start and continue with the collaborative effort of evidence gathering. For me, for now, I need to have started yesterday!”
Peter Leutsher, who is based at the Department of Infectious Diseases, Aarhus University Hospital, Denmark, gave a fascinating overview of Male Genital Schistosomiasis. He explained that most of what we know is from post-mortem studies from the 1970s which were then acceptable but today are not. It appears, however, that the seminal vesicles, prostate and vans deferens are most effected by Male Genital Schistosomiasis. Male Genital Schistosomiasis causes pelvic pain, dysuria, painful erection and ejaculation and haematospermia. There has been a study that found that the quality of sperm in men with genital schistosomiasis was poorer.
The chronic inflammation and recruitment of lymphocytes and eosinophils to the male genital tract in men with genital shistosomiasis may increase the HIV viral load in semen as well as the associated inflammatory cytokines which may also influence the immunology of the mucosal surface of the receiving partner. This may increase the likelihood of transmission of HIV from the man to his female partner (but also in men who have sex with men who were alluded to but not specifically mentioned). Peter is currently involved in an exciting Randomised Control Trial with men living with HIV and schistosomiasis in Zimbabwe to study whether praziquantel effects the viral load of semen.
Lester Chitsulo, formerly from the WHO, public health consultant from Malawi led us through the challenges in reaching women of child bearing age (15-29 years) with schistosomiasis because of medicine regulations and recommendations and the way that programmes are currently implemented. In Malawi women of childbearing age make up 21% of the total population. 81% live in rural areas and 15% have never been to school. At any one time up to 30% of these women could be pregnant or breastfeeding children. There is some confusion among government agencies and clinicians about how safe it is to give praziquantel to women who are pregnant or breastfeeding. Because you can’t always determine whether women are pregnant or not they are often routinely excluded from large-scale treatment campaigns. Furthermore mass drug administration usually takes place through programmes with children of school age. There are often operational advantages to integrating different programmes for NTDs. However programmes that target lymphatic filariasis, onchocerciasis and soil transmitted helminths cannot include pregnant women.
Lester suggested that praziquantel is safe for use in pregnant and breastfeeding women and that there is a need to do better collection of epidemiological data to see who among women of childbearing age actually need treating. If women who are pregnant are left out then they should be followed up in the maternal and child health services that the women routinely attend following delivery.
Many of the open questions and loose ends were picked up in the breakout sessions which were reported back to the audience via rapporteurs. We look forward to a similarly enlightening round of presentations on the second and final day of the conference.
Photo by Albert González Farran, UNAMID, you can find more of his photos online here…