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The challenge of Global Health

The challenge of Global Health

Over the years, the holistic approach to the health of the patient alongside the fight against malnutrition, which from the beginning has been part of our DNA, has led us to make available tools and skills for the many and various problems and diseases affecting the AIDS patient and more generally the African patient. In addition to considering the human and nutritional aspect we started to pay attention to the major diseases with which Africans live with: anemia, hepatitis, tuberculosis, malaria, certain types of cancer and even diseases related to the increased life expectancy of Africans and also the HIV positive patients under treatment. Cardiovascular disease, high blood pressure, metabolic diseases including diabetes mellitus.

Although the program has always considered some of the pathologies that go along with the African AIDS patient, today it aims to collect with renewed enthusiasm the challenge of global health also for Africa. The dream of DREAM is to obtain universal access for prevention, therapy and diagnostics for the main diseases. The access to treatment is still a mirage for most of the African people. Of the twenty countries with the highest maternal mortality rates in the world, nineteen are in Africa; this continent also holds the sad world record for neonatal mortality. Basic health services are still denied to many. The principle of interdependence that binds nations and continents is therefore an immense opportunity in the contemporary global world but also a challenge to be undertaken so as to cancel the growing inequality that over time can affect the lives of all peoples. Working for Africa is a crucial factor. It is even more vital if carried out through long-term programs.


Global access to antiretroviral therapy

  • TARV unavailable
  • Tarv available

Data source: WHO

The struggle against HIV / AIDS in recent years has led to great successes. Many African countries are showing successful progress in contrasting the infection, but there is still much to do to eliminate HIV / AIDS. It is necessary to increase all efforts to reach all mothers and children with the most effective drugs as well as services to prevent the transmission from mother to child, to ensure their health and well being and to give a future for their countries.

Presently, only 40% of the people infected by HIV have access to the therapy. Our goal to win the battle against AIDS is Universal Access to Treatment, i.e. to treat all AIDS patients in order to eradicate the disease in the entire population of the continent.

Likewise, we must not let our guard down but continue to lavish a big commitment to fight the stigma, which affects sick people, especially women, AIDS’s main victims, but whom at the same time lie at the heart of the African society and of the family. Nevertheless, they are often deprived of many of their basic rights and suffer gender discrimination. The solution to many of the problems of the African continent depends on their growth, both individually and as a group, especially through education to mobilize new creative energy and bring out the latent resources expressing their full potential and responding with more influence to the challenges and opportunities of life and society.

Children, who are the future, unfortunately are still the segment of the population with no access to care in Africa. In addition, they are very vulnerable to poverty, malnutrition, HIV / AIDS, tuberculosis, malaria and lack of hygiene which significantly contribute to infant mortality in the continent.


HIV/TB coinfected patients in geographical areas

  • African Region
  • South East Asian Region
  • American Region
  • West Pacific Region
  • European Region
  • East Mediterrean Region

Data source: WHO

Tuberculosis is among the five leading causes of death in women at reproductive age and the leading cause of death in people living with HIV or AIDS. An estimated 9 million people have developed tuberculosis in 2013; the rates of incidence and mortality in Africa are the highest in the world recording an average of 280 new cases per year, each 100.000 inhabitants, which is more than double the global average (126). More than one million patients worldwide are HIV positive, 80% of whom live in African countries. Tuberculosis in patients with HIV is more difficult to diagnose, because often it presents itself with extra-pulmonary and disseminated types. Often lethal, this disease generates one quarter of all deaths among HIV-positive patients.

Especially in southern Africa, more and more types of multidrug-resistant tuberculosis are spreading out which now constitute an emergency. Mortality in these patients is particularly high: nearly half inauspicious outcomes. However, tuberculosis is a treatable disease. The early diagnosis and the timely initiation of therapy have a key role. Already today DREAM produces a systematic screening of all patients for timely detection of suspect cases and provides the latest systems that make an early and accurate detection possible, and also able to detect even the drug-resistant cases. This way treatment can start early, producing huge benefits in terms of patient health and control of the disease in the population. Through specific protocols DREAM is adjoining the African health systems to cope with the disease.


Malaria deaths in 2013


malaria deaths occurred worldwide in 2013
  • Children
  • Adults

Data source: WHO

The effects of the interaction between malaria and HIV infection currently represent a pressing question for public health in sub-Saharan Africa. These are two diseases with high prevalence and mortality, with considerable overlap in the geographical distribution. As is known, in areas with high endemic malaria many individuals are carriers of a state of so-called “semi-immunity” which allows, if not to avoid the infection at all, at least to limit the severity of malarial episodes. But children and pregnant women who need to be protected from infection are excluded from this condition. As for the prophylaxis and treatment of malaria, DREAM abides by the international guidelines, but at the same time gives out continuous health education for pregnant women, accompanied by the supply of mosquito nets for them and their future offspring, for night protection.


In our experience, the diagnosis and treatment of malaria is essential, also for the severe anemia that it generates and which is cause of 50% of deaths, particularly in children. Community studies indicate that in Africa as much as 68% of children under 5 years of age are anemic. The interaction between malnutrition and infection is still the most important element at the base of infant mortality in the continent. In the DREAM centers, early diagnosis of malaria allows an effective treatment which, linked with nutritional support, allows to save many lives.

Anemia in children in Africa

  • Children with anemia
  • Children without anemia

Viral Hepatitis

Hepatitis B prevalence in the world

Africa 7.5%
East Asia 7.5%
Middle East 3.5%
Europe 1%
North America 1%

Data source: WHO

Viral hepatitis are one of the most important health problems worldwide. These infections often lead to chronic diseases that can cause serious complications, including cancers. Unfortunately, In the African continent most people with viral hepatitis often do not receive appropriate treatment.

In Africa

Viral hepatitis are one of the most important health problems worldwide. These infections often lead to chronic diseases that can cause serious complications, including cancers. Unfortunately, In the African continent most people with viral hepatitis often do not receive appropriate treatment.

Sub-Saharan Africa registers the worst situation regarding the disease, the highest prevalence of hepatitis B and a high percentage of people with chronic infection of hepatitis type C. There is a lack of awareness of the problem at institutional levels and among the general population; most people are unaware of their infection status and there is therefore a potential risk of transmission of the disease. In many African countries there is often a lack of preventive measures: e.g. the screening carried out on blood bags used for transfusions is still poor; a clear inequality regarding the possibilities of access to diagnostic services and therapeutic treatments persists amongst the population. Lastly, vaccination programs, where available, do not yet cover the segments of population groups most at risk. For example, the child immunization or that of the workers in the health field is still far from satisfactory levels of vaccination coverage. In particular, viral hepatitis type B still retains a primary importance in sub-Saharan Africa showing high rates of maternal-fetal transmission, with high mortality from cirrhosis and hepatocellular carcinoma HBV- related in adults. This course of transmission originates a large number of infected / chronic individuals, potentially able to transmit the virus.

In these areas pregnant women are not regularly screened and vaccination against hepatitis B for infants, when available, is often administered too late, from the sixth week of life, making perinatal transmission highly probable.


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DREAM has long since put in place preventive strategies to contrast new infections with HBV and HCV through an accurate screening for early diagnosis in HIV patients and through the control of the evolution of the infection. The substance of such intervention is to be found in:

– making people aware of their infection status;

– reducing transmission from mother to child;

– promoting prevention in young people and adults who have risky behaviors, especially those that were positive for HBV or HCV in the screening test;

– promoting with the Ministries of Health of several countries the introduction of vaccination for HBV in the vulnerable population in order to achieve the elimination of transmission nationwide.


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Chronic Diseases

Historically, chronic diseases have affected rich societies, while countries with limited resources have developed health systems more focused on the treatment of acute diseases (malaria, respiratory infections, parasitic diseases, etc …). The last decade has witnessed a tremendous change in African societies.

80% of deaths from infective diseases are today in low and middle-income countries; cardiovascular diseases, diabetes and hypertension are increasing markedly. According to the World Health Organization, over the next decade in Africa alone 28 million people will die from chronic diseases, which will become the leading cause of death. Over the past decade the African continent has recorded the highest increase of hypertension, a huge rate increase if compared to other countries, which will continue in the coming years.

Expected increase in deaths from chronic diseases by 2030

Sub-Saharan Africa 64%
South Asia 41%
Middle East/North Africa 13%
Latin America/Caribbean 13%
East Asia/Pacific 12%
Europe/Central Asia 5%

Data source: WHO

Cardiovascular Diseases

Top 10 causes of death in low-income countries - 2012

Lower respiratory infections 91 (deaths per 100.000 population)
HIV/AIDS 65 (deaths per 100.000 population)
Diarrhoeal diseases 53 (deaths per 100.000 population)
Stroke 52 (deaths per 100.000 population)
Ischaemic heart disease 39 (deaths per 100.000 population)
Malaria 35 (deaths per 100.000 population)
Tuberculosis 31 (deaths per 100.000 population)

Data source: WHO

Blood pressure is measured routinely at every access to the DREAM center, which allows to correctly set both prevention and treatment of some of the most common diseases with greater impact on the health of patients: in low-income countries cerebral ictus and ischemic heart disease (for which hypertension is a major risk factor) are the fourth and fifth leading cause of death, first and second, if considering only chronic diseases. The diagnosis of hypertension allows giving the patient advice about lifestyle (contrast to sedentary lifestyle), diet (reduce calorie intake, if appropriate, and restrict the use of salt, smoking and alcohol) and thus realizing practices of secondary prevention of extremely important cardiovascular diseases. If needed, an antihypertensive therapy, possibly assessed by a cardiology consultation, is scheduled, which is often possible on site through an electrocardiogram and the telemedicine service that enables the consultation also of European experts not present in the area.

Diabetes Mellitus

Increase in diabetes population 2000-2030

  • 2000
  • 2030

Data source: WHO

The prevalence of diabetes in low and middle-income countries is also increasing. In sub-Saharan Africa it is estimated that 4.9% of the population suffers from the disease; this prevalence rate is the lowest in the world, but the focus of health care systems in Africa towards diabetes is still very low and the figure is probably underestimated. The improvement of living conditions and the aging population registered in the continent in recent years alongside the increased attention from health workers, will give way to a net increase in prevalence. The World Health Organization estimates that deaths related to diabetes will increase by 47% in Africa over the next 10 years, with a rate increase that will have no equal worldwide. In the DREAM centers glycemia is measured periodically giving doctors the information concerning the presence of diabetes mellitus, and thus to pharmacological therapy, eating habits and adequate physical activity. Moreover, nutritional education is one of the basic elements of the program and has important implications in the prevention of chronic diseases. Likewise, the routinely detection of weight and height allows, by calculating the Body Mass Index, counteracting overweight and obesity, which are among the main risk factors for many chronic degenerative diseases.


Average prevalence of lipodystrophy in different clinical studies

Lipodistrophy 51.7%
Mixed Syndrome 23.9%
Lipoatrophy 18.1%
Lipoaccumulation 8.7%

Data source: J-G Baril et al

Lipodystrophy has been diagnosed in many patients on antiretroviral treatment (up to 70-80% in some cohorts). This metabolic syndrome is a secondary event in patients facing lifetime treatment with antiretroviral drugs. Within the Program the management of these metabolic disorders is mainly based on the use of alternative drugs, less involved in this type of side effect, jointly with an appropriate nutritional education and the suggestion of an appropriate diet.

Malignant Tumors

Cancer deaths worldwide - 2013

  • Low/middle -income countries
  • High income countries

Data source: WHO

Compared to AIDS, malaria, tuberculosis and malnutrition, cancer is not a priority for African governments and has been largely overlooked until now. 70% of deaths from cancer in the world occur in Africa. More than 60% of Africans have access to prevention programs and screenings, while oncological patients have no access to the services of chemotherapy and radiotherapy. Among the various types of cancer, those related to infections are predominant, such as stomach cancer and liver and cervical carcinoma, which are among the main oncological diagnoses and are linked to infectious factors (respectively helicobacter pylori, HBV, HCV, HPV). For many years, DREAM has undertaken a program of prevention and treatment of HPV in HIV-positive women, with access to regular gynecological examinations, Pap smears, colposcopy, conization and, where necessary, surgical treatment. Such interventions dramatically reduce the mortality of HIV positive women who have, as is known, a high risk of developing cervical cancer.


Sierra Leone



Ebola deaths in west African countries (in red)

Data source: WHO

The Ebola virus, which has severely affected some regions of Africa killing nearly 12,000 people in Western Africa and infecting more than 27,000, has quickly become a global health problem not only because of the virulence of the disease, but also due to weak health systems with limited human resources, insufficient training, lack of infrastructure, limited health literacy and therefore lack of organizational models.

Ebola in Guinea Conakry and DREAM Program

In Guinea Conakry, in the three centers of the DREAM program, which treat more than 3,500 people, we had to deal with this serious emergency. It was necessary to strengthen preventive measures to protect both the personnel and the patients. A capillary action of monitoring and screening of the population under treatment was crucial, particularly in patients who have discontinued to visit the center.

Simultaneously, a major campaign of health education and awareness about ways of transmission and preventive measures against the virus began. The United Nations has included the DREAM network concerning epidemiological surveillance for Ebola in the country. Above all, this way it was possible to limit the impact of the epidemic on the health of people under treatment for HIV and their families, ensuring the care was always received and protecting staff and patients adequately; since the beginning of the epidemic none of our patients or health workers became ill with Ebola, unlike many other health centers or hospitals, deserted by patients with severe consequences due to not being able to control the different pathologies. The onset of the disease has in fact generated fear in the population. Due to the fear of being infected, sick people stopped visiting nursing facilities and preferred to go to traditional doctors or adopt self-medication. Furthermore, in some rural areas of the country, the population accused those who intervened to stem the epidemic, the health workers, of having brought it and assaulted health centers. On the social and economic levels there was a strong stigmatization of infected persons and their families. This social stigma has had a strong relational and psychological impact and, above all, has generated dangerous reluctance in many communities that have refused to recognize the presence of the disease, further aggravating the spread of infection.

The work of health education with the patients of the DREAM centers, the personal relationship with the health care operator and the trust, have all made a difference. Patients have not only continued to attend treatment centers, but have asked for and also learned how to protect against Ebola, for themselves, for their families, for their neighbors.


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The future

Ultimately, the characteristics of health care in Africa are changing considerably. The over 24 million people now living with HIV in sub-Saharan Africa have a higher life expectancy that, thanks to the dissemination of antiretroviral therapy, is higher than that of the rest of the general population. There is therefore a preventive aspect of the therapy itself, a conviction that has been nourished by DREAM since its foundation. Nowadays, the growing risk is the emergence of non-infectious diseases, which represent a trend that opens up major challenges.

Together with contrasting HIV, the purpose of DREAM is also to increase modern, highly specialized teleconsulting services, offering advice, training and excellence, thanks to a European pool of volunteer doctors that have been cooperating for several years. Moreover, telemedicine interventions cover a wide range of specialties such as infectious diseases, cardiology, dermatology, radiology, neurology, internal medicine and hepatology and are a way to ensure that, even in these fields, Africans have access to excellence of care and diagnostics, as well as to a holistic approach.


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