A common side effect of HIV infection is cognitive impairment. There are evidence showing that HIV has a strong impact on mental health measured by mental distress; as many as five per cent develop dementia as a result of HIV. In Zambia there is an enormous gap between the need for expertise in diagnosing HIV-related cognitive impairment and actual, available resources.
It is important to understand the neuropsychological effects of HIV, which are often underestimated, in order to understand the various problems faced by HIV positive individuals.
An epidemic in decline?
“It is a myth that HIV in Africa was caused by poverty. On the contrary, it first took off amongst those with relatively good education and resources – in the 1970s and 80s – before preventive programmes were started,” professor Knut Fylkesnes says. The NUFU project he is coordinating shows that this has changed the past 10 to15 years: educated people responded quickly to preventive messages and now the spread of HIV is most frequent among the poor.
Fylkesnes is the Norwegian project coordinator for the NUFU-supported academic partnership in research and capacity building ‘Strengthening HIV-related interventions in Zambia: cooperation in research and institution capacity building’, which was started in 2002. The project aims to increase the academic capacity at UNZA in the field of community health and HIV prevention.
In 2011, new HIV infections amongst young urban women in Zambia dropped by forty per cent. This trend is the result of twenty years of hard work to change attitudes towards HIV, which has slowly brought about behavioural changes in the population.
With the influx of antiretroviral drugs, however, the emphasis in HIV intervention in Africa has turned from prevention to treatment. Moreover, the treatment approach is overstretching the capacity of African healthcare systems.
Zambia is one of the countries worst affected by HIV in Sub-Saharan Africa, with about 15 per cent of people aged 15 to49 infected. With more than 13 million inhabitants, the country is struggling with serious capacity shortages which are very much related to the limited pool of people with higher education.
Cutting edge projects
However, some changes are about to happen, and they are taking place at the University of Zambia (UNZA). UNZA is currently involved in three HIV-related projects, all supported by the NOMA and NUFU programmes.
The NUFU project is an academic partnership in research and research capacity building with the Centre for International Health, University of Bergen (UoB) as partner. The collaboration started in 2002, and the research component has generated new knowledge with various important policy implications in Zambia and the region.
As they proceeded through the project, they uncovered the need for training at Master’s level in the region of Southern Africa, and, as a consequence, a NOMA-supported Master of Science in Epidemiology was established in 2010. Well trained epidemiologists are in high demand throughout most of the region, the science also represents the corner stone in public health research.
The second NOMA project faces the challenge of building capacity in diagnostics of HIV-related cognitive impairment by establishing a Master of Science in Clinical Neuropsychology in collaboration with the Norwegian University of Science and Technology (NTNU). This is said to be the only Master’s degree in neuropsychology in all of Africa.
Pioneering through interdisciplinary collaboration
The NUFU-project has been focusing on building capacity in different disciplines. Zambians has been training at PhD level in epidemiology, mental health, demography, health promotion, medical anthropology, health economics, sexually transmitted diseases and maternal health. With this multidisciplinary capacity improvement, the University of Zambia has decided to establish a School of Public Health.
The Master’s degree in neuropsychology recruits students with a wide range of professional experience, including from the armed forces, police, nursing, biochemistry and education into a highly specialised research field such as neuropsychology; it is also the first interdisciplinary collaboration between three different schools within UNZA: the School of Medicine, School of Humanities and Social Sciences and School of Education.
The idea is that the neuropsychologists educated through the programme will disperse into each of the different professional fields they originally came from. In addition some of the students will stay and hopefully contribute to the growth of academic capacity at UNZA.
From policing to diagnosing HIV impairment
One of the second cohort neuropsychology students, Mazuba Hamweene, joined the police force as a police officer in 2004, but early on took an interest in disabled people and decided to do a Bachelor’s degree in Special Education. After he finished his studies, he went back to the police force to work with the victims support unit. Through his work at the unit he found himself counselling HIV patients when he was given the task of so-called pre HIV-test counselling. This triggered his interest in incorporating the health aspect in to his skills set, and he applied for the Master’s in neuropsychology at UNZA.
“This is a new field in the police force, and I will be the first one ever to have this qualification. I might meet some challenges, though, but I will fight and hope for the establishment of a neuropsychology unit in the police force. I have already started the preliminary work talking to the directors about what I am doing, and they have shown much interest. Immediately after I finish I will go back and work with them,” says Mazuba.
Prolonging life with new medication
With the advance of new antiretroviral drugs, science has now been able to extend the life expectancy of HIV-infected people so that many now enjoy a more or less normal life span. This is great news for all HIV sufferers. But there are rocks in the sea. Recent research has shown that as many as up to eighty per cent of all sufferers experience some degree of intellectual functionality impairment as a result of the virus. In addition, some of the drugs are neurotoxic, and for patients developing mental disturbances it is imperative to avoid this type of medication.
“We want to bridge this gap with the help of the new Master’s programme. HIV is an epidemic in Africa, especially in Zambia. If we, in one way or the other, can detect mental disturbances before they start to play havoc with a person’s life and disturbs his mental health, maybe we can intervene earlier and help the patient to live a better life,” says Dr. Ravi Paul, who is working at UNZA. He is originally from India but is now one of two psychiatrists in Zambia.
Technology does not solve all problems
As technology advances, the more costly it gets. But technology cannot solve all problems. MRIs, CT and PET scanners can detect the pathology of the brain and body. Yet, the technology still cannot detect any mental disability or HIV-related brain trauma that a person carries.
“We don’t have any gadget to detect what mental disabilities and HIV-related brain trauma a person carries. No one was exploiting that field, and we didn’t have any hard evidence to prove that HIV is causing trauma or dementia. Now, with the help of the coming neuropsychologists we can say: this is what happens, this is what went wrong, and this is now the disabilities they are carrying,” Dr. Paul explains.
Different professional needs
There are many reasons for conducting neuropsychological testing of HIV-infected people. One is of course to uncover special needs and to provide the necessary healthcare. Another is the requirement to check workers in certain occupations before they enter into the professional field – are they capable of handling high-stress jobs? The need for educating more neuropsychologists in the years to come is beyond any doubt. Hamwenee is going back to the police force, while another student, Lumbuka Kuanda, is staying at UNZA as a staff development fellow.
“Each of us have joined the programme with our own areas of interest. My first degree was in molecular biology and biochemistry,” says Kuanda. She has recently graduated from the MSc programme as a first cohort student of clinical neuropsychology and will now work as a trainee lecturer.
A number of the students will join the staff and teach in various departments at UNZA.
The need for African adaptation
As first cohort students in a new programme, Hamwenee and Kaunda found themselves acting as ‘guinea pigs’. Everything was new: the curriculum, the teaching and also some of the research methods had to be adapted to Zambian conditions. At first they did not have any norms for the test battery they were going to apply. A test battery is a number of different tests, especially psychometric tests, used together to assess a person’s cognitive functioning. Hence, a pilot study was carried out where the NOMA students had to make their own tests adapted to the Zambian population.
“As the first cohort, the issue for us was: You have a new test battery which is sensitive to HIV-related impairment, and your task is to come up with norms for a Zambian test battery,” Kuanda says and explains how the students recruited HIV negative participants and offered them assessment using the neuropsychological test battery. Each student checked how different areas, for instance education level, culture and language (there are about 70 different languages spoken in Zambia), literacy, socio-economic data, influenced on the test performance.
“My area was hypertension and cognitive functioning. I was trying to compare the performance between hypertensives and normotensives [high and normal blood pressure] and whether there would be any statistically significant difference in the seven ability domains, such as executive functioning, working memory and so on. Until now the focus has been on the organic part of the brain, but there has been very little knowledge of the behaviour part of it - in terms of neuropsychology. The gap will be filled as we advance in this field,” Kuanda concludes.
Academic apartheid
But bridging the gap is not necessarily easy in Zambia. Education is not free, yet the level of poverty is high, and people would rather spend their money on their basic needs. This means that a huge proportion of the population is likely to remain without any education.
“Africa is being kept out of the international knowledge society. In Norway and in most other Western countries about seventy per cent of the population has access to higher education, whereas only six percent has access in African countries south of the Sahara. This is what I would call academic apartheid,” Professor Knut Fylkesnes says.
Dr. Charles Michelo was the first PhD student in the NUFU programme to graduate in 2007. He is back at UNZA, where he is now Head of the Department of Public Health, and is coordinating the NOMA project within epidemiology.
“I was among the first people to be involved in the NUFU project, of which this project can be described as an offspring. Until 2002 I was one of three members of staff in my department; the department was heavily understaffed. The launch of the NUFU project was a first effort to get the university, the Medical School and our department in particular involved in HIV prevention activities and to combine that with capacity building in education,” Dr. Charles Michelo says, adding that academic staff capacity has gone up from three to nine people, a change that he describes as huge.
“Academic apartheid is a strong expression, but it is true,” says Michelo. “But it begins at an even lower level of education. Basic education, which goes up to grade nine, is not free either. Seventy per cent drop out at grade seven, and only thirty per cent go on to grades eight and nine. Part of the reason for that is poor access. After that, fewer go to high school, which is the entry point to university. And university education is even much, much more difficult”, he concludes.
The decline in mental functioning can manifest itself at any given time in HIV-infected people. The unmet need of mental health services is general in Zambia and is not only related to the HIV epidemic. Nevertheless, education in the broad professional field of the HIV epidemic is needed in several respects: prevention and knowledge of how to avoid the virus, knowledge of feasible intervention strategies, the HIV patients themselves need to know what is happening, and last but not least, the community needs to understand it in order to be able to support them.
Projects in Zambia:
NUFU project ‘Strengthening HIV-related interventions in Zambia: Cooperation in research and institution capacity building’ is an academic partnership in research and research capacity building with the Centre for International Health, University of Bergen (UoB) as partner. The collaboration started back in 2002. The project has published more than 30 scientific papers in highly rated international journals, 15 master thesis and have trained/or under training 9 PhDs. The PhDs are covering a wide range of disciplines including mental health.
NOMA-supported Master of Science in Epidemiology: Established in 2010 at UNZA and will be run in collaboration with Centre for International Health, UoB and College of Medicine, University of Malawi.
NOMA-supported Master of Science in Clinical Neuropsychology: Collaboration with the Norwegian University of Science and Technology (NTNU). Faces the challenge of building capacity in the diagnosing of HIV-related cognitive impairment.