By Alexandra Calmy, Eric Goemaere and Gilles Van Cutsem, Doctors Without Borders:
This article was originally published here.
On 6 January 2015, in an Ebola treatment centre run by Doctors Without Borders, a patient was discharged from the so-called ‘triage area’ with a certificate to attest that he was ‘not a case.’ However, he did present clinical signs of advanced HIV disease. When asked about his reaction to the HIV diagnosis, he replied, ‘I am so happy it may just be AIDS.’
We have come a long way from the first days of the AIDS epidemic. Since the beginning of the latest Ebola outbreak, several comparisons have been made between Ebola and HIV. Both viruses jumped species in the West African forest and both have generated panic and discrimination. Twenty-five years ago, with an initial death sentence, HIV caused fear and stigma to an extent that is still difficult to understand, with proposals in some countries to isolate patients in dedicated centres.
Some hypotheses suggest that the first patient became infected through contact with infected bush meat, such as a fruit bat or primate, followed by person-to-person transmission. Isolation and quarantine have been part of the public health response in many countries, including in the latest epidemic. When the first health workers returned from Ebola-affected countries, they were isolated and traced, even those who were asymptomatic, despite no scientific evidence supporting isolation of asymptomatic individuals. AIDS activists and HIV researchers were at the forefront in denouncing the paranoia that led to the isolation of health workers out of fear, having learnt long ago that HIV transmission cannot be limited through health-related discrimination. Nevertheless, there are still many countries that restrict travel for individuals with HIV. Similarly, stigma is affecting also the lives of health workers in West Africa. In Freetown, Sierra Leone, national staff working in the Prince of Wales treatment centres reported in many instances not to be able to tell their families that they were working with Ebola patients. Many convalescent patients volunteering to give plasma did so while hiding from family in Conakry: instead of heroes, they were outcasts. Among several other examples, survivors were unable to find a taxi willing to take them home and extended families were unwilling to care for orphans out of fear that they would bring Ebola back home. As with other infectious diseases, notably plague epidemics in the past centuries or, more recently, drug-resistant tuberculosis, the policy of quarantining patients has the potential to increase stigma and drive the epidemic underground.
The mobilization of HIV-related actors in the fight against Ebola disease has been substantial. Many HIV researchers and clinicians have volunteered to work in treatment centres or clinical trial sites. Prominent HIV researchers have also presented on the Ebola response in several HIV conferences. Indeed, the results of the first trial assessing the efficacy of favipiravir were presented during the 2015 edition of the Annual Conference on Retroviruses and Opportunistic Infections whose main objective is to share the latest studies on HIV/AIDS and related infectious diseases. Clearly, the Ebola outbreak has resonated strongly with HIV actors because of numerous similarities and lessons that can potentially be drawn from HIV to support the Ebola response. Even the HIV prevention ABC strategy (Abstinence, Be faithful and use Condom) has been twisted to fit with the Ebola prevention messages (Avoid Body Contact) in Sierra Leone. Interestingly, before a cure for syphilis was available, this type of poster campaign was also used as a weapon in the fight against the illness.
According to the WHO, many health workers have suffered from the epidemic with more than 800 dying from Ebola disease. Although personal protective equipment can prevent accidental exposure, the exact risk assessment for some exposures (e.g. contact of an infectious material with intact skin) is unclear and post-exposure prophylaxis is unavailable for many local health workers in the three affected countries.
By contrast with HIV, Ebola patients with no clinical symptoms do not transmit the virus. The transmission window is also short and the incubation period is no longer than 21 days. Therefore, the ability to contain the spread of the disease would appear to be easier and contact tracing is part of the epidemic fight. But this raises other questions. To what extent will the fight against the epidemic alleviate the need to protect the confidentiality of affected patients and families? How do quarantine measures affect the household? Another lesson learned from HIV is the paramount importance of involving the communities in the fight against the disease. Innovative ways of involving the community and peer educators have proven very effective in the HIV field. As an example, Ebola survivors with a persistent immunity have been involved as caregivers in the care of young children in some Ebola treatment centres and have been critical in providing essential quality healthcare.
An Ebola survivor has been quarantined in India after his semen tested positive for the virus. The latest patient diagnosed with Ebola in Liberia is the wife of a cured patient. There is a theoretical plausibility for sexual transmission of Ebola virus. However, further research is needed to consider if, and if yes, to what extent, sexual activity contributes to the epidemic in order to inform individuals with regards to avoiding acquisition or transmission by those recovering from Ebola virus disease.
Ebola causes a severe, often fatal disease, and timely diagnosis is critical both for individual benefit and public health concerns. For example, the early symptoms of Ebola infection are difficult to distinguish from malaria, influenza or typhoid fever. In August 2014, the US Food and Drug Administration issued an Emergency Use Authorization for an Ebola diagnostic test developed by the Department of Defense, the Ebola Zaire Target 1 (EZ1) real-time reverse transcription PCR (TaqMan) assay. The use of rapid tests should improve the detection of cases and help control the Ebola epidemic in the same way that large-scale HIV testing helps to curb the HIV epidemic by promoting rapid access to prevention and treatment.
Access to antiretroviral drugs has been a 15-year battle and 12 million individuals are now on anti-HIV drugs worldwide. The availability of an effective treatment was a critical factor in increasing the uptake of testing and enhanced health behaviour as evidenced by low test uptake when access to antiretroviral therapy was scarce. Early phase of favipiravir and blood-based therapy (’convalescent’ plasma) trials started recently in Guinea. The admission rate suddenly increased in these sites, possibly because of the changing paradigm of the treatment centres (from isolation to treatment). How is it possible to speed up the access to antiviral drugs in the Ebola setting?
In the case of Ebola disease, the determinant of access to quality care appears to differ from HIV. First, nearly all patients treated in high-income countries had accessed experimental drugs. Despite the WHO declaration stating that it would be ethical to offer unproven interventions as potential treatment or prevention in the current context (11 August 2014), none of these drugs were used in African treatment centres until late 2014. The design of such a clinical trial for an innovative intervention, such as immune blood transfusion or ZMapp (Mapp Biopharmaceutical Inc., San Diego, California, USA) led to debate about whether a placebo-controlled trial in the context of a disease with at best a 50% case fatality rate was ethical. Although the first anti-HIV drugs had been compared with placebo in initial trials, the time taken to approve them was contested by treatment activists who were successful in ensuring fast track approval. Almost all clinical trials since then have tested one drug against another. However, the major difference between the two diseases is the fact that no cure is in sight short term for HIV, but Ebola is a curable disease and several drugs may affect the disease outcome; the reconciliation of scientific fast tracks and ethical concerns is urgent.
The controversy related to the methodology used for evaluating the efficacy of new drugs can be extended to the evaluation of vaccine efficacy. As the epidemic declines, is it a good use of resources or even ethical to expose volunteers to an experimental vaccine through a large phase III trial as the chance of being exposed to Ebola – and thus determining vaccine efficacy – will become almost zero? On the contrary, is it justifiable to mass vaccinate in a future epidemic based on the sole basis of a phase II trial? Vaccine trials just started now in all three countries will potentially lead to a new Ebola vaccine commercialization, which is still not the case in the HIV setting, despite more than two decades of research.
Point-of-care diagnostics, early antiviral treatment and vaccines will radically change the community approach to Ebola. Ebola has had an impact on both the use of healthcare facilities and specific HIV care. Recent studies have shown that the Ebola epidemic resulted in a major drop in attendance of general outpatient services, in new HIV-positive diagnosis and in new HIV-infected patients entering care. In most affected countries, access to basic care was dramatically impaired by the fear of accepting an Ebola patient in a healthcare facility. Both diseases affect all sectors of society and reach far beyond the healthcare system, ranging from economy to education, but also with an impact on cultural practices, such as circumcision for HIV and burials for Ebola. The fight against HIV has led to a massive increase in resources which have benefited health systems in resource-limited settings beyond vertical programmes. The mobilization of the international community around Ebola has the potential to similarly benefit health systems in West Africa, a region long abandoned after years of civil war. Let us not fail in the opportunity to succeed in post-Ebola recovery.
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Featured image source: Reuters/Baz Ratner