Since 2000 MSF has been working in South Africa, primarily in response to the HIV epidemic. In Khayelitsha, the largest township in the Western Cape, MSF has worked with the provincial authorities to pioneer comprehensive HIV treatment, including antiretroviral (ARV) medicines, at a primary care level. Today, these clinics support over 6,000 people on ARV therapy.
In 2003, together with the Nelson Mandela Foundation, MSF opened a similar programme in Lusikisiki, one of the most underserved areas of rural Eastern Cape. By 2005 universal ARV coverage had been achieved and in 2006 the programme was finally handed over to the provincial health authorities.
At the same time, MSF was opening a programme in Lesotho based on the model implemented in Lusikisiki. There, MSF and the health authorities started a pilot nurse-based programme to provide HIV/AIDS and TB care. In less than two years, nearly 2,000 people had been initiated on ARV treatment.
Together, these programmes have done more than simply treat patients. They have provided vital lessons about how comprehensive treatment for HIV can practically be delivered both in rural and urban settings. At the same time, MSF has been lobbying, with many other organisations, for cheaper medicines, more global funding for the HIV crisis and changes in policy towards the epidemic.
Despite the successes, many challenges remain, such as the problems of TB and HIV co-infection, drug-resistant strains of TB and the issue of long-term adherence to ARV treatment. MSF works with patients, academics, local health authorities and international experts to find innovative and practical solutions to these problems. In response to the high levels of sexual violence in Khayelitsha, MSF supports the Simelela Centre for rape survivors – a one-stop location which combines practical medical care to protect against infection and psychological support with police and forensic assistance.
Four years down the line, hundreds of Zimbabwean are still crossing the border every day for the same economical and political reasons. Although the global situation has changed in Zimbabwe, there are still many areas of insecurity that cause this survival migration.
Printer-friendly version
MSF believes that everyone has the right to basic medical care. In countries with collapsed or chronically disrupted health care systems, MSF works with the local authorities to rehabilitate hospital and clinic services. MSF also works with marginalized groups in countries with advanced economies such as street children, prisoners and illegal migrants who do not get adequate medical support. 
Armed conflicts and other tense situations often cause large population movements, as individuals flee persecution or violence. A refugee is a civilian who no longer is receiving protection from his or her own government, and crosses a national border to escape the conflict or persecution.Refugees are protected by international law. According to the 1951 Convention Relating to the Status of Refugees, a refugee is a person who "owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country."
Since 1951, this definition has been broadened-in both official and informal ways. Notably, the United Nations High Commissioner for Refugees (UNHCR) extended the definition to include people fleeing in small groups or en masse from a collective danger, such as insecurity or war, rather than treating each individual on a case-by-case basis. An IDP, or internally displaced person, is a person who has also fled his or her home because of conflict but has not crossed an international border. He or she remains under the jurisdiction of national authorities and thus is not a refugee. IDPs do not benefit from any specific protection under international law.
There are more than 33 million people living with HIV/AIDS worldwide, according to the World Health Organisation (WHO), and the majority of them in sub-Saharan Africa. In 2007, 2.5 million children under 15 years old were living with HIV/AIDS, with 1,150 becoming infected every day. Without treatment, half of all infants with HIV will die before their second birthday.
The human immunodeficiency virus (HIV) is transmitted between humans through the exchange of bodily fluids such as blood, breast milk, vaginal secretions and semen. HIV is most commonly spread by sexual contact, but can also be transmitted through childbirth, breastfeeding and sharing needles. HIV gradually weakens the immune system, usually over a three to ten year period, making it difficult to fight cancer and opportunistic infections such as candidiasis, pneumonia and tuberculosis (TB). If HIV is not treated, an infected person eventually becomes very ill and may die. The advanced stage of HIV infection is called the acquired immunodeficiency syndrome or AIDS.
TB is the infection that kills the most among people living with HIV/AIDS. Today one-third of HIV-positive people around the world are co-infected with TB (according to WHO).
A combination of drugs, known as anti-retrovirals, help combat the disease and enable people to live longer, healthier lives without their immune system rapidly declining.
MSF HIV/AIDS programmes offer HIV testing with pre- and post-test counselling, treatment and prevention of opportunistic infections, prevention of mother-to-child transmission and provision of anti-retrovirals for people in the advanced clinical stages of the disease. Our programmes also generally include education and awareness activities to help people understand how to prevent the spread of the virus.
MSF began treating people living with HIV in the 1990s and started anti-retroviral treatment programmes in Cameroon, Thailand, and South Africa in 2000. MSF now operates HIV/AIDS projects in 32 countries and provides ARV treatment to more than 100,000 HIV-positive patients, including 7,000 children.
TB is highly infectious and spreads mainly through the air. Coughing, sneezing, talking and spitting by an infected person can spread the bacteria and it can remain in the air for several hours before being inhaled by another person. TB is particularly common amongst young children, who have immature immune systems, and people with lowered immune systems, such as those infected with HIV.
Tools available to diagnose TB are outdated, expensive and inadequate, mainly due to lack of funding for research and development. Treatment is long and complex and if interrupted can lead to the development of drug-resistant TB, a more difficult infection to treat. Where TB is resistant to most of the routine TB drugs, second-line drugs are needed. These are very expensive, have many side effects, require a long course of treatment and often have poor outcomes. Most patients in developing countries do not have access to these drugs.
MSF has been fighting TB for over 30 years. In 2006, MSF offered treatment in 100 projects spread over 44 countries. Our teams admitted more than 24,000 new patients, and diagnosed and referred even more to local health services for treatment. MSF provides treatment for TB in many different contexts, from chronic conflict situations as in southern Sudan to vulnerable patients in stable settings, such as Uzbekistan and Chechnya. In many places where we work, supervising all TB patients during their treatment is difficult or impossible. To help patients complete their treatment, MSF has therefore introduced more flexible strategies.
MSF encountered cases of drug-resistant tuberculosis (TB) in the former Soviet Union in the 1990s. The TB mycobacterium had mutated into a form that was resistant to some of the drugs used in standard TB treatment. More and more people are contracting drug-resistant forms of TB either as a result of treatment failure or by coming directly into contact with the resistant form of the TB bacteria.
A significant number of others go undiagnosed because the diagnostic tests that exist don’t work adequately, or are difficult to use and not adapted for remote settings.
TB opens up a new, more deadly front in people living with HIV. Because of the difficulties in diagnosing drug resistant TB in remote settings, it is hard to get accurate information on just how far these resistant strains have spread. What is alarmingly clear is that rate of drug-resistant strains is rising rapidly among people living with HIV/AIDS, particulary in Southern Africa.
Defining drug-resistant TB
A patient is defined as suffering from multidrug-resistant TB (MDR-TB) when they are resistant to at least rifampicin and isoniazid, the two most powerful first-line TB drugs.
Extensively drug-resistant TB
(XDR-TB) has been recently defined as a form of TB resistant to at least the two first-line drugs rifampicin and isoniazid and additionally to a fluoroquinolone and one of the injectable drugs (kanamycin, amikacin or capreomycin) among the second-line drugs.
XDR-TB: Virtually no options
In 2006, the world received a dramatic wake-up call about the dangers of drug-resistant TB in places where HIV is present. In the KwaZulu Natal province of South Africa, a group of people were identified as having an extensively resistant strain of TB that responded to nearly none of the known TB treatments. 52 out of the 53 people infected with this more deadly strain died within a space of a couple of weeks even before their diagnosis was confirmed. In fact MSF had already been treating patients with extensively drug resistant TB (XDR) in Eastern Europe for several years. The alarming fact was the rapid spread of this drug-resistant strain to countries with high HIV prevalence which lead therefore to even higher death rates.
44 of those tested in KwaZulu Natal were HIV positive. The combination of XDR-TB and HIV infection is particularly dangerous because due to the difficulties of diagnosing TB in HIV patients, diagnosis is often delayed to a point where the patient is too sick to respond to treatment.
Up to now, XDR-TB cases have been identified in more than 40 countries.
Inadequate tools to tackle the challenge of DR-TB
Diagnosing and treating patients with drug-resistant TB presents enormous challenges - particularly in the remote settings where MSF works. The diagnostic tools available take much longer to produce results than for standard TB diagnosis because in addition to seeing whether someone is infected you have to find out which drugs work and which don’t. They’re also very complex, and so cannot be carried out in those under-resourced areas where we work: that means that for many patients with drug resistant TB, the results often come too late and the patient dies before they are correctly diagnosed.
Treatment for drug-resistant strains of TB rely on older, less-potent drugs that may trigger severely toxic side effects. In MSF projects in Eastern Europe, The Caucasus and Central Asia, most patients are hospitalised and isolated for the initial “intensive” stage of their treatment whilst they are still infectious. This period can last up to four months. Cure rates are dramatically lower than for standard TB treatment: 60% in the case of MDR. In the case of XDR-TB, the options for successful treatment are virtually non-existent.
In 2006, MSF provided treatment for more than 1.8 million people with malaria in 40 countries, including Chad, Myanmar and Sierra Leone.
In 2006, MSF treated more than two million people for malaria. Every year, malaria kills nearly two million people and infects between 400–500 million. Ninety percent of these deaths occur in sub-Saharan Africa.
Malaria mainly strikes poor and rural communities. Patients are often bedridden for days and can't carry out normal daily activities. Children who survive the disease may suffer neurological damage and educational difficulties. The result can be a loss of income and a burden on families, health systems and society as a whole. This suffering and loss of life are unnecessary because malaria is largely preventable, detectable and treatable.
Malaria is caused by four species of parasite and transmitted through the bite of infected mosquitoes. Symptoms include fever, headache, vomiting and flu-like symptoms, followed by internal bleeding, kidney and liver failure and can result in coma and death. Children account for 75 percent of malaria-related deaths.
Diagnosis
Diagnosis is done with rapid dipstick tests or by counting the parasites under a microscope and is simple and easy to do in remote areas. However, diagnosis based on symptoms is still normal in much of the developing world, meaning patients are misdiagnosed as having malaria with the real reasons for their symptoms going untreated.
The most effective treatment for malaria is artemisinin-based combination therapies (ACTs). ACTs have low toxicity, few side effects and act rapidly against the parasite and MSF actively encourages governments to use them in their national programmes.
Sleeping under insecticide-treated bed nets is the best way to prevent malaria. Nets protect from bites and also reduce the number of malaria-carrying mosquitoes in the area. MSF mass distributes nets in places with endemic malaria.
For MSF projects in areas where malaria is a problem, over half of consultations can be for malaria.
Cholera causes profuse diarrhoea and vomiting, and infected people can die of profound dehydration, sometimes within a matter of hours. It often breaks out when there is overcrowding and inadequate access to clean water, rubbish collection, and proper latrines. This situation can be especially problematic in rainy seasons when houses and latrines flood and contaminated water collects in stagnant pools.
Cholera is caused by infection with bacteria, which is excreted in faeces and vomit. The infection spreads when someone ingests the bacteria through contaminated food or water, or comes into contact with excretions from an infected person and does not wash their hands before eating or preparing food. Contamination of food or water supplies causes massive outbreaks in a short period of time.
The bacteria causes the cells lining the intestine to secrete huge amounts of fluid and this leads to profuse diarrhoea and vomiting. A patient undergoing treatment can lose over 50 litres of fluid during a bout of cholera. Untreated, an infected person will die of dehydration well before this and this can take only a couple of hours.
The most effective way to prevent the spread of infection is to interrupt the contamination cycle through the provision of safe water and soap, and educating people on washing hands, disposing of faeces, pit latrines and protecting water stocks. Because of this, MSF water and sanitation engineers and logisticians have a vital role to play.
MSF has developed cholera treatment kits to provide rapid assistance and sets up cholera treatment centres in areas where there are outbreaks. Cholera is treatable and in many situations, MSF teams are able to limit the case fatality rate to less than one percent.
 |
| MSF responds to a severe cholera outbreak in Guinea Bissau. Photo: MSF |
Measles is caused by the measles virus and is highly contagious. Infection occurs by coming into contact with fluids released when an infected person coughs or sneezes.
Early symptoms include a runny nose, cough, eye infection, followed by diarrhoea, dehydration and pneumonia. If untreated, measles can kill and children infected often become chronically malnourished as well due to the energy they spend fighting the disease.
Vaccination is the best form of protection against measles and, even after the disease has begun to spread, it can still reduce the number of cases and deaths. The difficulty is that at least 95 % of the people need to be immune to prevent new outbreaks.
MSF teams initiate immunisation campaigns when an outbreak is confirmed and usually target all children between six months and 15 years old. Children under five are particularly targeted because they are most likely to die from the disease. The key to the success of a vaccination campaign is convincing parents of the importance of vaccinating their children, thus awareness strategies are very important.
The vast majority of meningitis cases and deaths occur in Africa. During the dry season (December to June), epidemics regularly hit countries in the African meningitis belt, a region that stretches across the continent from Senegal to Ethiopia.
Without treatment, meningococcal meningitis can kill up to 80 % of infected people. However, with early diagnosis and treatment with appropriate antibiotics, the death rate can be reduced to five to 10 %. Up to one in five survivors will suffer from neurological damage, such as deafness or mental retardation.
Timely mass vaccinations are the best way of limiting the spread of meningitis epidemics.
In 2006, MSF treated 5,337 and vaccinated 1.8 million people against meningitis. During the 2006/2007 epidemic season in Africa, MSF was active in 14 outbreak responses in five countries that experienced meningitis epidemics (Burkina Faso, Chad, Sudan, Uganda and the Democratic Republic of Congo). In total, MSF was involved in the vaccination of 2.5 million people against meningitis and treated 10,500 patients affected by the disease.
Sleeping sickness, or human African trypanosomiasis (HAT), is a fatal parasitic disease that affects 36 countries in sub-Saharan Africa: 60 million people are at risk. Nearly eliminated in the 1960s, HAT has been making a comeback of epidemic proportions due to war, population movements and the collapse of health systems over the past two decades.
Sleeping sickness is caused by two sub-species of Trypanosoma parasites, which are transmitted to humans by tsetse flies. The disease has two stages. The early stage entails bouts of fever, headaches, pains in the joints and itching. The second, known as the neurological phase, begins when the parasite crosses the blood-brain barrier and infests the central nervous system. Without treatment, the disease is fatal.
Treatment with arsenic kills up to one in ten patients
"It's a terrible drug – you don't feel proud injecting it. It is caustic, it burns them, and you don't know if you are going to save your patient or kill him" – MSF Doctor, Uganda.
Most infected people only seek treatment when the disease has already advanced to the second stage. The most common treatment at this stage in national control programmes is melarsoprol, an archaic drug introduced in 1949. Melarsoprol contains arsenic, is extremely painful when injected, and kills 3-10% of patients treated.
New hope from the 'resurrection' drug: effective but costly
In the 1990s it was found that eflornithine, a drug originally developed against cancer, was extremely effective against the disease. Its success led to it being dubbed the 'resurrection drug'. But it came with a heavy price tag. Following a strong advocacy campaign by MSF and other organisations, the pharmaceutical company Aventis (now Sanofi-Aventis) came to an agreement with WHO in 2001 (an agreement renewed in 2006) to make the drug available through a donation programme. Since then the drug has been in wide use in programmes run by non-governmental organisations.
But the uptake has been much slower by national control programmes. This is largely down to the complexity of the procedure to administer the drug: intravenous infusions need to be given at 6 hourly intervals over a 14 day period. This requires round the clock nursing care and the resources and training to administer infusions.
In 2007, WHO and MSF organised the production of medical kits containing all the necessary drugs and infusion materials, available at no cost for national control programmes.
Further challenges
Despite the success of eflornithine, there is a concern that continuing to use it as a monotherapy will lead to parasite resistance. This could have catastrophic consequences. It is crucial therefore to use this drug in combination with other drugs. A promising option today is the combination of eflornithine, administered twice a day for 7 days only, with oral nifurtimox. A clinical trial involving these drugs, initiated by MSF and now sponsored by the DNDi and WHO, is presently underway.
MSF and sleeping sickness
MSF teams first encountered an epidemic of sleeping sickness in Uganda's West Nile region in 1986 among displaced people from Sudan and Uganda. As of December 2005, MSF programmes had screened at least 2 400 000 people and treated approximately 43 000 patients. The majority of these patients were already at an advanced stage of the disease. MSF remains active with ongoing programmes running in three countries; Democratic Republic of Congo, Sudan and Central African Republic. MSF is also involved in several research studies to push forward treatment and diagnostic options.
Chagas is a parasitic disease found on the American continent, where it affects 13 million people and kills up to 50,000 every year. The disease is transmitted by an insect that lives in the walls and roofs of mud and straw houses, common among rural areas and poor urban slums in South America.
Millions of people, including those infected decades ago, go undetected and untreated. This is because symptoms can lie dormant for years and determining whether a patient is infected or not requires several blood tests. About 20-30% of those infected will go on to develop the chronic symptomatic form of the disease, which causes irreversible damage to the heart, oesophagus and colon.
Existing drugs and diagnostic tests for Chagas disease are inadequate, expensive and in short supply. The drugs used cannot eliminate the parasite in the blood during the chronic phase of the disease and they are ineffective against some strains of the parasite. There is currently no drug formulation adapted for young children and the existing drugs cannot be prescribed to pregnant women (who risk passing the disease on to their babies).
Because people who have been treated can easily be re-infected, treatment is more effective in areas with active vector control (the vector in this case is the insect that transmits the disease). Through our programmes in Latin America, we aim to show that by following patients up on a weekly basis, existing drugs can be used more widely than previously understood, with manageable side effects.
However, significant funding is needed from the international community to support national programmes in Latin America. In addition, the production and availability of the two existing drugs (nifurtimox and benznidazol) must be secured, and paediatric versions developed. MSF has also called for the development of new diagnostic tests and better treatment.