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Causes and pathogenesis of AIDS in Africa.

As of November 1996, the number of AIDS cases reported in Africa by the World Health Organization was 553,291 (Fauci et al., 1998).

Severe malnutrition has been very well known to cause immune dysfunction and other serious health effects and should be considered in the differential diagnosis in HIV infected patients with AIDS and suffering from severe malnutrition before implicating HIV as the cause of AIDS in Africa. Actually the finding of atrophy of lymphoid tissue in people suffering from malnutrition was observed as early as 1925. For example, Jackson's review on this topic in 1925 noted that many investigators had found a pronounced tendency of atrophy of lymphoid tissue in all conditions of malnutrition. Thymus weight was exquisitely sensitive to malnutrition and was earlier designated as the "barometer of nutrition" (Woodruff, 1972).

There is extensive literature describing the impact of malnutrition on the function and the structure of the immune system in people in Africa (Al-Bayati, 1999). This information clearly demonstrates that AIDS in Africa is more likely to be caused by starvation than by HIV. The functions of the immune system, especially the cellular immunity, are impaired in malnutrition cases. The severity of the impairment is dependent on the degree of malnutrition in both human and animals. In studies of 345 malnourished children and two experimental models show the impact of food deprivation on the size of the thymus and the lymphoid organs. For example, the size of the thymus of 42 malnourished children was reduced by 90% as compared with a case-match normal controls (Parent et al., 1994). In a second study involving 110 malnourished children, the thymic area was found to be 20% of the size in healthy children (Chevalier et al., 1998). The result of studies that included 493 malnourished children who showed impairment in the function of the immune system; especially the cellular immunity (Al-Bayati, 1999).

The results of autopsy of 118 malnourished children showed: 1) both thymus and peripheral lymphoid tissues are reduced in bulk in states of protein-calorie malnutrition (PCM), this reduction being disproportionately greater than the loss of body weight.; and 2) Severe thymic atrophy was presented in 70% of marasmus cases and 85% of Kwashiorkor cases. 59.3% of the children had marasmic and Kwashiorkor symptoms (Schonland, 1972). Fakhir et al., 1989 evaluated 100 severely malnourished children and found that these children had a significant reduction in the absolute lymphocytes count, T cells count, and in the skin reaction to dinitrochloro benzene. The lymphocyte function of 30 black children with PCM as assessed by the delayed hypersensitivity reaction and morphology of lymphocyte transformation was found to be impaired and serum cortisol level was elevated. The function of lymphocyte and cortisol level returned to normal after 30 days of feeding (Zeng et al., 1991).

The levels of endogenous cortisol (a natural hormone) in plasma and urine have been found to be abnormally elevated in malnourished patients. Studies that included 159 malnourished children and 148 AIDS patients who showed significant increases in cortisol levels (Membreno et al., 1987; Piedrola, et al., 1996; Aref, et al., 1982; Schonland, et al., 1972; Laditan, 1983; Zeng, et al., 1991).

Atrophy in the lymphoid organs in malnourished people is caused by increased levels of cortisol as well as by protein and vitamin deficiency. The reduction in the thymus and the lymphoid tissue size and the reduction in the function of the immune system of malnourished children and animals were reversed after proper feeding. For example, the size of the thymus increased from 20% of normal in a malnourished child to 107% of normal following 9 weeks of proper feeding. The reversal of the reduction in CD4+T cell count in HIV+ pregnant women following proper feeding was also reported by Fawzi et al., (1998). Briefly, the influence of diet on T cells counts in peripheral blood in 1,075 HIV-infected pregnant women who had poor nutritional status were studied. The CD4+ T cell counts of the women who received multivitamin increased from 424/microlitre to 596/microlitre during six months of proper feeding.

The incidence of starvation, parasitic diseases, septicemia, and low birth weight are very high in Africa and other developing countries. As shown in eleven studies that include the prevalence of malnutrition and diseases in 1,425 infants and 5,834 children surveyed in nine countries (Al-Bayati, 1999). For example, the mortality among 299 severely malnourished children in Zambia was 25.8% (Gernaat et al., 1998). Pneumonia and diarrhea were the major causes of death. In India, 49% of 183 cases of lymphadenopathy in children were found to be due to tuberculosis (Sheikh, et al., 1981).

In 1983 the World Health Organization estimated that 300 million children had growth retardation secondary to malnutrition (Fauci et al., (1998). High prevalence of malnutrition and disease in Africa and other developing countries is also reported by Fauci et al., 1998 who stated that insufficient consumption of protein and energy causes loss of both body mass and adipose tissue. Protein energy malnutrition (PEM) occurs in developing nations and it may be present in endemic form. Under famine conditions, the prevalence of PEM may approach 25 percent. In children of developing nations two syndromes of PEM have been distinguished:(1) maramus, manifested by stunted growth, loss of adipose tissue, generalized wasting of protein mass; and (2) kwashiorkor, manifested by growth failure, edema, and hypoalbuminemia, fatty liver, and preservation of subcutaneous. Mixed forms are common in both children and adults (Fauci et al., 1998).

In PEM cell-mediated immunity is impaired as indicated by all standard tests (Fauci et al., 1998; Al-Bayati, 1999). Further more, all wounds and incisions heal more slowly in PEM and wound dehiscence is common. In woman with PEM, nearly every aspect of reproduction is impaired, including implantation, fetal growth, lactation, and parturition. The infants are stunted in size and may have cognitive impairment if they survive (Fauci et al., 1998).

Gastrointestinal infections frequently precipitate clinical PEM because of the associated diarrhea, associated anorexia, vomiting, increased metabolic needs, and decreased intestinal absorption. Parasitic infections play a major role in many parts of the world. Common infections and opportunistic infections can lead to increased morbidity and mortality. Pneumonia is common (Fauci et al., 1998).

The prevalence of KS and lymphoma, lymphadenitis, tuberculosis in Africa is similar to the male homosexuals AIDS patients in US and Europe and even higher (Al-Bayati, 1999). However, AIDS in Africa occurs almost equally in males and females because starvation affects both sexes equally. Sibanda and Stanczuk, (1993) reviewed all lymph node histopathology reports of lymph node biopsy submitted to the Histopathology unit in Harare, Zimbabwe in the period of January 1988 to June 1990. The commonest diseases in the 2,194 lymph node specimens were: non specific hyperplasia (33%), tuberculous lymphadenitis (27%); metastases (12%), Kaposi's sarcoma (9%); and lymphomas (7%). Kaposi's sarcoma (KS) involving the lymph nodes was reported in 176 (9%) of the lymph nodes. In children, the prevalence of KS was higher in children under 5 years than in 6-15 year bracket. Approximately two thirds (65%) of all patients with KS were aged between 20 and 40 years.

Furthermore, the large study of Fawzi et al., 1998 clearly demonstrated HIV is not implicated and the impairment of the immune system in a mother (HIV-positive) who suffers from malnutrition can be reversed by feeding the mother proper nutrition. This treatment also improved the outcome of pregnancy. In Tanzania, 1,075 HIV-infected pregnant women between 12 and 27 weeks gestation received vitamin A (n=269), multivitamins excluding vitamin A (n=269), multivitamins including vitamin A (n=270), or a placebo (n=267). In this study, malnutrition supplementation decreased the risk of low birth weight (<2500 g) by 44%, severe preterm birth (<34 weeks of gestation) by 39% and small size for gestational age at birth by 43%. During pregnancy, all T-cells subsets (CD4+, CD8+, and CD3+) increased in all groups between base-line (mean 18 week's gestation and 6 weeks postpartum). There was a significantly larger increase in the CD4+ T cell counts and percentage of CD4+ T cells among women assigned multivitamins. The mean increases between base-line and 6 weeks postpartum were 167 cells/micolitre and 112 cells/microlitre among women on multivitamins and those on no vitamins, respectively. If HIV were the cause of AIDS as the HIV-hypothesis claim, then improved nutrition alone will never reverse the decline of T cells in these HIV-positive women.

MOHAMMED ALI AL-BAYATI - Toxi-Health International