Observations on the importance and on the empahis of the laboratory diagnostic in the DREAM program scenery
21 - Jan - 2009

DREAM has always given great importance to the advanced diagnostics infection from HIV/AIDS and on the correlated pathologies, as to the monitoring of the antiretroviral therapy.

The clinical background of an HIV affected patient is composed in fact, beyond the clinical observations carried by the doctor, also of his virological and immunological situation, very indicative of the disease progression. Often in Africa you only have a medical visit, or a simple blood test – the blood count or at the most the count of the CD4 cells- and based on this data you plan an eventual therapeutic line. Not so in the West, where the analysis requested by the laboratories investigate on the above cited aspects and particularly on monitoring the so-called viral load. And where they carefully follow the effects of the therapy in the time, for its potential toxicity concern, and to appraise its effectiveness to reduce the viral number of copies in the blood. Treating AIDS without laboratory control is not practically possible.

For this reason every DREAM centre is always connected to a molecular biology laboratory as a specific support to the diagnosis service and tratment of HIV. All of this has been, and is, a really distinctive mark of the DREAM intervention in Africa. The laboratory has always been considered the necessary condition, although not sufficient, to establish the therapy in a specific site. Beyond the difficulties, also logistical (the laboratories require a constant electricity supply, etc.), that was involved in all of this. For DREAM this has been a way of continuing, proceeding in this manner, the non negotiable choice of introducing in Africa the same diagnostic tools used in the rest of the world, putting aside every minimalist and afropessimistic logic.

Today the DREAM laboratories in Africa constitute a useful reference network not only to our centers but to the national health systems of the countries in which the program is present. This last point is of not secondary importance, not only for the obvious positive health consequences, but also because this synergy between the diagnostic activity of the DREAM laboratories with the public health system has proved to be a decisive factor for the installation of the program in some specific situations.

Just to make an example, looking at things from a historical perspective, DREAM has made a breach in Mozambique in the beginning of the years two thousand thanks to an agreement with the government on the laboratories and on their utilization. This has been – this opportunity that was offered, this opportunity that could be foreseen – the key to reach the compromise initialed with the health authority of that African country, since then convinced (prevailing at the time also between the international organisms) of health care as the only possible and effective reply to the AIDS epidemic and that the tritherapy followed in the West was not possible, at least on a large scale. And however the consciousness of being able to arrange with DREAM of advanced diagnostics laboratories centers was setting up like something of very attractive for the Mozambiquans, which undrestood their value as a factor of development. And so it passed, together with the laboratories, also the idea of the beginning of the program, of the beginning of the antiretroviral tritherapy.

For DREAM, however, the laboratory was important especially because directly connected to the therapy. It wasn’t possible to prescribe in a serious and responsible manner the therapeutic lines without contextually establishing laboratories that allowed a monitoring, a control of the possible events and so on. The effectiveness of the therapy itslef depended on it; lives of the people depended on it; and, finally, the fundamental ratio that had been at the base of the DREAM birth depended on it, that is, the idea of realizing a real equality of opportunity between the West and Africa.

There is a widespread reluctance towards laboratories in Africa, that DREAM does not share, and is strongly convinced that the laboratory and the implementation of its performances will and have to be the key to enter in a dimension than unites at the same time health care, treatment, excellence and operative research.

Excellence, for DREAM, is above all the idea of having one standard, only one. That means not having "first rate" (in the West) and "second rate" patients (elsewhere), a paradox and a danger which is not abstract, if is true that the "scissor" in the treatment between European patients and African patients goes stretching, not restricting. If it is true – and it is true – that while the most recent guidelines of some European countries provide for an entrance to detect the primary resistances between the hiv-positive patients treated in our national health system, that is to introduced the genotype test to verify if a patient suffers or not of a potential intolerance to Abacavir, in Africa we are still discussing whether to carry out or not the viral loads.

And so the battle of DREAM for the viral load is first of all a battle of equality, to have only one standard treatment for the procedures regarding AIDS fighting, and this regardless the luck or the misfortune of someone to be born anywhere in the world.

But a second point that seems important to insist on in this context is the increasing consciousness in which DREAM belives in that the laboratory can be an irreplaceable operating opportunity of research. This means – and has meant in many moments in the history of DREAM – widening of the knowledge, improvement of the therapeutic routes, a raise of the quality of the treatment, increase in the chances of survival of the patients, etc..

We can make the example of the better timing of DREAM in facing a therapeutic failure and to the necessity of passing to a second line of antiretroviral medicines. Thanks to the utilization of the laboratory, for the DREAM health operators it is possible to carry out a change of therapy at the right moment, that is when a failure of the therapy is found in virological terms, whereas in Africa you wait for the clinical failure. But it is known to everyone that, when in presence of a clinical failure, the patient has already met an important worsening of the health conditions and the virus has probably acquired not only partial resistances, but transversal resistances to whole classes of medicines.

Thanks to the laboratory, DREAM has learned – and this is a rather recent novelty – that the virological response in the first six months of therapy is an important reply. It is the most important one, where the best prognosis can be made, the most significant for the future of the patient, the one which best prefigures the success and the failure, death and whatever. We have learned – and this from quiet some time – that the antiretroviral therapy followed for nine months (the three pre-birth and the six post partum during which the mother nurses) by the pregnant women maintains the viral load low in the blood of the new mother for the three successive years from the interruption of the procedure. We have learned a lot of things and a lot we still continue to learn.

For DREAM humanitarian help is also development. Often we complain – and rightly – of how much AIDS has destroyed, impoverished, left aside, in many African realities. But contrasting an epidemic can also be translated in an overall effort of improvement of the health system of a country, above all if such effort is started up with intelligence and correctness of means and of procedures.

Let us take, once again, the case of Mozambique. When, at the end of the ninetees, a DREAM mission carried out its first exploratory survey, there wasn’t any hospital in all of the country in which the count of the red corpuscles could be made in an automatic manner. It was all made with the microscope. And then the blood banks did not give any safety guarantee, and all of the diagnostic system was confused, unreliable, without a maintenance capacity, without a logistic type infrastructure. In reality the DREAM laboratories in Mozambique were the engine of a new way to confront the clinical and epidemiological phenomena (not only for what AIDS is concerned: the biochemical type analysis allow to monitor a vital series of very important functions, and to treat less complex pathologies than HIV). Today the laboratories from mozambique are one of the clear marks of the large transformation that the country has known. Even if 8-9 years are not a lot, there is no comparison between the diagnostic capacity of the mozambique health system in ’99 and those of today. And in the meanwhile there was – and still is- an AIDS epidemic and tens of thousands of dead. But there was also an investment in a challenge – not theoreticial, but concrete, centered of on a national laboratories system where the DREAM laboratories are supporting axis – that was perceived like a development challenge.

DREAM remains convinced that, for the development of the African countries and of their health system, it is not necessary to fear technology leaps. It is rather necessary to favor the fact that those same systems could use appropriate technologies. The molecular biology technologies can be the key for many further developments, that we still cannot imagine; to study more, to understand more. Besides also DREAM has found to develop some threads that were not predictable at the beginning.

And it is in this direction that the new DREAM laboratory is moving for the study of the resistances, recently opened in Blantyre (Malawi), as another very interesting development in the mark of excellence. It seems they were five in Africa, until now, the laboratories for the monitoring of the resistances, of which only two were open to the common patients (the others do researches for authorities and pharmaceutical companies). The Blantyre one – and that of next opening, of Maputo, always DREAM – are instead available to all the patients and want to represent the pride of those countries and of their doctors, not only the pride of DREAM. This is because the search of excellence has among its many effects also that of returning pride and motivation to many.


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