Represent Muslim women at the Olympics

Represent Muslim women at the Olympics: Muhammad Ibtihaj. First Muslim woman to Represent the USA at the Olympics.

HIV and TB in Practice for nurses: active TB case finding

Active versus passive TB case finding

Before a case of TB can be diagnosed and treated, possible TB cases have to be identified.

The easiest place to find a lot of people who may have TB is where people who are suffering from the symptoms of TB come to get care. In most places, this would be the outpatient clinic (OPC) or emergency room (ER) of a larger facility, or the waiting room at the primary healthcare clinic (PHC) or health care provider’s office. Training staff in these facilities to look for and recognise the symptoms of TB, especially cough, and promptly get possible cases into the diagnostic process is a highly cost-effective way to find TB.

Even though these TB cases could have been infectious before their diagnosis, in many industrialised countries with good DOTS programmes, this passive case finding — waiting for the TB patients to come to you — seemed to be all that was necessary for good TB control.

TB programmes in most of Africa don’t have such luck — in general, people, including those who have TB, put off coming to the clinic as long as they possibly can. Many never make it. As long as these cases remain undiagnosed and untreated, TB is probably being spread. On top of that, those rich countries with good TB control didn’t have a high burden of HIV to deal with. In many parts of sub-Saharan Africa, HIV not only made TB dramatically more common, it made the consequences of not finding TB soon enough far more deadly.

Passive case finding is not a nice name. The word passive doesn’t fairly describe the hard work and dedication required for nurses and other health care staff to find the TB cases among their patients and make sure they get diagnosed and onto care. There are many committed health care workers who are doing a good job identifying TB in their facilities. But in the resource-poor settings where most of our readership are working, it just doesn’t seem to be enough, even when clinics do their very best and identify virtually every case that walks through their door by passive case finding. The huge burden of TB in many communities tells us there is a lot of TB being transmitted there, probably coming from people who don’t get diagnosed soon enough, or who don’t get a diagnosis at all.

In these settings, something is clearly needed over and above passive case finding. These other cases must be found. So, researchers have begun investigating ‘active’ case finding approaches — going out and looking in other places where there might be many previously undiagnosed people with TB. The goal is to find, diagnose and treat TB sooner in virtually all the people with the disease. Only by doing this can we really hope to stop the transmission of the infection.

There are several broad categories of active case finding, and even within categories approaches vary. Every programme is a little different.

Different approaches to TB case finding

Household contact tracing 

Household contact tracing takes place after a TB patient is identified, to find out about his or her living situation over the period his TB could have been infectious. Who are (or were) they living with? Are there any young children (under five years of age) or people living with HIV in the home? Many programmes try to get the patient to bring these individuals in for screening, but this could be logistically difficult for the household to do. Generally, sending a trained outreach team to visit the household is the best way to identify everyone who has been living there, and provide TB screening and other services such as HIV testing. Trained nurses often lead these teams, supported by counsellors and community health workers who can make certain that anyone in need of care is connected to it.

TB screening campaigns

TB screening campaigns in communities (such as townships or informal settlements) could be an important way to better control TB in communities with a high burden of TB. In most countries, these are the poorer communities with inadequate, substandard housing, and high rates of malnutrition who have a higher burden of TB than wealthier communities. However, these campaigns can take a variety of forms, from door to door screening, mobile vans offering TB screening and other services, temporary festival-like events held over the course of a week or weekend in a different community each week. Different approaches may work better in some communities than others. Getting the approach right to identify previously unidentified cases earlier in a community may be a process of trial and error.

Active case finding in groups at high risk of TB

Active case finding in groups at high risk of TB (such as miners or prisoners) or where the consequences of TB are very grave and/or access to TB screening and diagnostic services low (such as in pregnant women).  The success of these screening programmes is dependent on accessing the group when and where they can be found. These may be workplace programmes in the case of miners, or the primary entry points of care for pregnant women and their children, such as antenatal clinics and other maternal and child health clinics.

Many people with a high risk of TB or TB/HIV belong to oppressed groups that have poor access to health services and may have multiple risk factors for TB. For instance, the risk of being exposed to TB in prison is extremely high, and many prisons in resource-limited settings are filled with members of marginalised populations already at very high risk of HIV and TB, such as people who use drugs, men who have sex with men (MSM), transgendered individuals, and commercial sex workers.

Intensified case finding

Case finding targeted to a group at high TB risk is sometimes called intensified TB case finding (ICF) but manyuse the term ICF specifically for screening for HIV-related TB. ICFin people living with HIV is perhaps the MOST active type of case finding because it must be performed routinely in people living with HIV because of their high risk of TB, and the greater risk that they could die of undiagnosed TB.

WHO policy mandates that PLHIV should be screened for TB at EVERY contact with the health services, regardless of whether:

• They have already received isoniazid preventive therapy (IPT) to reduce the risk of active TB,
• They are taking IPT now, or,
• They are taking antiretroviral therapy.

A programmatic guide on Implementing Collaborative TB-HIV Activities, recently produced by the International Union Against Tuberculosis and Lung Disease recommends that screening for TB in PLHIV “should be done in every section of the health facility where they are seen so that no referral is necessary. This includes out-patient departments, HIV care/ART clinics, in-patient wards, maternity and child health departments and client-initiated testing and counselling centres.” WHO recommends screening patients with its 4 TB symptom screen or a local adaptation, which will be described in more detail in the next edition.

A critical component of active case finding programmes, however, and an area where many programmes fail, is making sure that people who have been screened are effectively linked to diagnostic services and appropriate therapy (including IPT in PLHIV and child contacts of TB cases without symptoms of TB).

The best active case finding strategy will vary depending on the setting, but some approaches could be complementary. For instance, by identifying, finding, treating and curing TB in hot spots in the community, even an intervention targeting HIV-negative people in communities with a high burden of TB and HIV could help reduce the high risk of continued TB exposure for people living with HIV in that community.

Did you know?

It is policy to perform household contact tracing (in most countries), whenever a person is diagnosed or put onto treatment for smear-positive pulmonary TB. This means there should be an investigation to see:

• If other people living in the patient’s household also have TB, and
• Whether there are any children under 5 living in the household who have been exposed to TB, who need to be put on isoniazid preventive therapy (IPT) to reduce their chances of developing TB, which is often life-threatening in young children

Intensive household contact tracing

More recently, some information that could affect TB programmes and create new roles for nurses and lay providers was produced by the ZAMSTAR study, a very large trial that looked at whether two different case finding approaches in communities (or a combination of the two), could increase early TB diagnoses — and whether either would have a greater impact on a community’s TB burden than passive case finding. The preliminary results were reported at the 42nd Union World Conference on Lung Health held last October in Lille, France.

Over the better part of a decade it took to plan, prepare for and perform the ZAMSTAR study, it seemed like it was much more than a clinical study— it was more like a cultural phenomenon, particularly in Zambia, where the study mostly took place. It was huge, had an innovative design, and one of the intervention approaches was very novel — requiring a process of community selection, preparation, mass community mobilisation, training and participation, on a scale never seen before in sub-Saharan Africa.

Many of the most enduring lessons from ZAMSTAR may come out of this process, and the lessons learned about bringing together so many diverse people with a stake in improving TB case management, from elementary school students to expert patients, to nurses and newspaper reporters, to government ministers and brilliant researchers to the multi-billionaire visionary who paid for it all. Somehow, they pulled off a rigorous study which reached the clear conclusion that implementing one of the active TB case finding interventions in a community could, after several years, reduce its overall burden of TB.

That’s right— the community as a whole did better. Unlike most other studies, ZAMSTAR did not randomly assign individuals to different care or treatment arms. Instead, it randomised entire communities to one of four arms, each with a different TB case-finding intervention.

One of the arms was supposed to serve as a control — where the community received TB case finding in just the same way as they always had: through passive case finding at the clinic. Only, the researchers pointed out that this wasn’t entirely true — as part of the preparation for the study, all the communities had significant upgrades to their local health system, with additional staff and training to recognise and manage TB appropriately. This included rapid updates to current policy when new recommendations emerged, like the recommendation to perform intensified case finding in all people living with HIV). And, very importantly, they also got better laboratories to provide faster and more reliable diagnoses than before. Every community got these upgrades, but each community knew whether it was implementing one or both of the new interventions or in the case of the control arm, neither.

So after strengthening the capacity of communities to diagnose and manage TB, ZAMSTAR randomised communities in Zambia and the Western Cape province of South Africa into four arms, no intervention versus one or both of two different interventions to increase the early detection of TB cases. The investigators then evaluated whether there was less transmission of TB in the household or a lower prevalence of TB in the community.

One of the active case finding arms included an intensive form of ‘household contact tracing’ which involved sending counsellors to the homes of TB patients to perform contact tracing, screening household members for TB, and offering home-based HIV counselling and testing (HCT), with repeat visits to deliver TB results, educate the household about TB, and to make certain that anyone in the household with TB or HIV was effectively linked to treatment, care and support.

In communities where household contact tracing took place, TB prevalence was reduced by 22%.

Household contact tracing is nothing new — it has been an established and recommended TB control practice for some time — but one that has been rarely implemented in resource-limited settings. It has just been put on the stack of things that clinics and staff never got around to organising. The intervention included HIV testing, and involved repeated visits with more counselling and support than usual, but nothing really revolutionary — simply a slight update to, and consistent performance of, good TB control practice that programmes ought to have been doing all along.

The other intervention was called ‘enhanced case finding’ (ECF) which involved a number of activities to make a TB diagnosis easier to access and encourage people with symptoms to seek out diagnosis. In this case, sputum collection centres were set up within the community where people could collect or deliver their sputum specimens without having to go to the clinic.

The community was inundated with advocacy, communication and social mobilisation activities (community drama, radio) to educate children and adults about TB and the need to get a diagnosis. The improved labs were supposed to turn their results around very quickly — within 48 hours — but had trouble keeping up with the number of the specimens at some sites.

The ECF intervention with all the various community activities was of course the one that everyone got excited about, and that communities wanted to continue after the study was over. But it didn’t seem to do any better than the control arm — it even did a little bit worse.

On the other hand communities assigned to implementing the household contact tracing intervention saw a 22% reduction in the prevalence of culture-positive TB. This was statistically significant — and one of the first times a study has found a TB intervention to have an effect across the entire population of a community in the era of HIV.

The household contact tracing intervention arm also appeared to reduce TB transmission (as measured by tuberculin skin test conversions in children) by 55%, but this was not quite statistically significant (the limited number of communities made it hard to prove this but it would seem to be consistent with the strategy’s effect on TB burden).

Enhanced case finding identified up to a quarter of the TB cases in the communities randomised to the intervention, but as implemented in this study at least, did not lead to a reduced TB prevalence when compared to the communities that did not receive the intervention. Maybe it would have done better with newer, faster and more sensitive lab technology such as the Xpert MTB/RIF test now being introduced in some countries. Even improved fluorescent microscopy can be insensitive for TB especially in people living with HIV. It is possible that people who handed in their sputum at a collection centre could have interpreted a negative result as meaning that they didn’t have TB — when maybe they did. If this resulted in a delay going to the clinic, the approach might have backfired. If so, this underscores how very important it is for clinical teams and health educators to better communicate and support people with symptoms of TB in the quest for a diagnosis for smear-negative TB, until the cause of their symptoms is either determined or their symptoms resolve.

Implications of the ZAMSTAR study for nurses and community health workers

Many experts believe the findings of ZAMSTAR regarding intensive household contact tracing, combined with HCT and effective linkage to care should affect TB control policy and become routine practice in settings with a high burden of HIV and TB, especially in southern Africa

A number of other studies reported at last year’s World Conference on Lung Health in Lille seemed to support this conclusion. A meta-analysis found that household contact tracing can be a relative simple way to find a lot of undiagnosed TB cases. Another study of household contact tracing and household HIV counselling and testing in the Northwest province of South Africa, found very high rates of culture-positive, smear-negative TB in both people with and without HIV, and also led to early identification of HIV in many household members, at higher CD4 cell counts than among people diagnosed in health facilities.

According to the ZAMSTAR researchers, intensive household contact tracing can be delivered by trained lay counsellors at relatively low cost. Another study also found that task shifting, in this case, engaging Health Extension Workers in southern Ethiopia to perform household contact tracing as part of their routine activities, almost doubled TB case detection in the community, and in particularly increased TB diagnosis in women and children who previously had less access to TB diagnosis. These health extension workers did not require extensive additional training to perform these duties.

However, Ethiopia’s health extension workers have considerably more training than some of the people who provide home based care services in other settings.

In fact, another study reported that even within one South African province, KwaZulu Natal in South Africa, the various programmes run by the health department, and non-governmental and community-based organisations have produced a variety of community health worker cadres who go through very different training programmes, have somewhat different duties, and receive substantially different compensation.

The study suggested that community health workers currently engaged in home and community-based care interventions, could be trained to better deliver TB/HIV interventions in the home — but it wasn’t necessarily easy. In addition to the additional training, the community workers needed close supervision, which was supposed to be provided by one supervisor/community health facilitator, also at the community level. But the poor quality of the supervision undermined the project. Part of the problem was that some community health facilitators had too many workers to supervise well, and often didn’t have any transportation to get around the district.

While some community members can certainly be trained to be supervisors, one wonders whether this may require more experience and training. In the meantime, studies in other parts of South Africa have reported good findings when outreach teams have been led or supervised by trained nurse managers.

Consequently, South Africa is already piloting an intervention of intensive household TB contact tracing, combined with HCT, and maternal/child health interventions. Trained outreach teams are led by nurses and include a counsellor to deliver the key screening and counselling interventions, while the community health workers support the household in a variety of ways, including accompanying household members as needed to the health facility for effective linkages to care. However, the intervention may be more difficult and expensive to deliver in remote settings without good roads, or for programmes without the means to transport their contact tracing outreach teams.

The success of household contact tracing will depend on:

• Whether household members start – and stay on – the appropriate treatment for TB and HIV
• The training and quality of outreach services provided;
• The linkage to, and strength to the laboratory system to rapidly turn around reliable results; and
• The ability to monitor the effectiveness of the intervention being delivered by teams

HIV diagnosis and linkage to care is also an important part of the household contact tracing interventions (although earlier HIV diagnosis did not explain the impact of the household contact tracing intervention on TB incidence).

As for enhanced case finding, other studies described at the conference suggested enhanced case finding interventions that engage communities in TB control also hold promise.

For example, another study in an urban community in Zimbabwe, found that two enhanced case finding interventions, one involving a mobile clinic with advocacy. communication and social mobilisation, the other, house-to-house screening, together were associated with a reduction in the burden of TB. On its own however, the mobile van approach seemed to find more cases.

Enhanced case finding interventions may need to scale up access to HIV testing and linkages to HIV care and treatment (and consider, including ways to enhance the diagnosis of HIV-related smear negative TB, such as employing the smear -negative diagnostic algorithm).

Conclusion

There is a growing consensus that health programmes will need to go beyond the clinic and aggressively seek out TB cases in order to get the TB epidemic under control, particularly in southern Africa where there is a high burden of HIV and HIV-related TB.

More aggressive case detection will be more expensive than passive case detection, but some experts suggest it will cost more in the long run not to scale up more active case finding interventions. Increasing access to new diagnostics may improve case detection, though there are questions about reserving them for the highest yielding form of case detection — passive case detection — while access remains limited and their cost is high.

Nurses can be the leaders in charge of many of these campaigns and outreach teams. But involvement of civil society organisations, PLHIV and other affected communities in the TB response can increase the reach and quality of TB services for PLHIV and hard to reach populations. Guidance is being developed by WHO to promote a productive working relationship between TB programmes and the community.

Nurses can be leaders, in partnership with the community, in active case-finding programmes.

Different case finding approaches seem to work better in different populations. Much remains to be learned about which approaches to active TB case finding are most likely to reduce TB transmission and reduce the prevalence of TB. But it may be difficult to apply the lessons from a study in one community to another, because communities are different — some have poor road access, or the community mobilisation activities that work in one, may not work in another. It appears that one size does not fit all.

In the meantime, TB case finding projects and programmes that are ongoing should monitor case finding performance closely, looking to see whether they are finding cases that would have otherwise gone undiagnosed, or just spending a lot of money to identify the same people that passive case detection would have found just a day or two later.

The 19th International AIDS Conference (AIDS 2012) was held in Washington DC:Families and children news

We are pleased to partner with UNICEF to ensure the widest possible awareness of the latest developments in HIV treatment, prevention and care that will benefit infants, children and young people.

Families and children news from AIDS 2012

HIV treatment for children: how programmes are improving diagnosis and retention

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Does injectable hormonal contraception increase the risk of HIV infection?

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Mobile technologies playing a growing role in HIV care and treatment support

A number of studies presented at the 19th International AIDS Conference (AIDS 2012) in Washington DC highlighted potentially important roles for mobile phone technology in the delivery of

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Community-based support aids retention, adherence and treatment response

Patient retention and linkage throughout the cascade of HIV care remains very low, placing the concept of ‘test and treat’ as part of the solution to ending

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Transforming ‘PMTCT programmes into ART programmes’: UNICEF champions lifelong treatment for all HIV-positive pregnant women

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Keeping children in school shows impact on HIV risk behaviours in Kenya

Providing free school uniforms to enable children to stay in school, in addition to exposing primary school students to the national HIV/AIDS prevention curriculum, appeared to have

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Adolescent antiretroviral options expanding

A range of new antiretroviral drugs are in development for adolescents with HIV, a population which may have extensive experience of antiretroviral therapy and resistance to some

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New antiretrovirals for infants and children still needed

Promising new formulations of antiretroviral agents including tenofovir, fosamprevanir, dolutegravir, etravirine and raltegravir for treating the often neglected needs of infants, children and adolescents with HIV were presented

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Hillary Clinton pledges money for vulnerable minorities, reproductive rights, AIDS-free families

US Secretary of State Hillary Clinton received a relatively warm reception yesterday at the 19th International AIDS Conference (AIDS 2012) in Washington DC, as she supported the

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← First12

Researchers step up efforts to find an HIV cure

Prof. Francoise Barré-Sinoussi and Anthony S. Fauci, MD at the ‘

Towards an HIV cure’ 
opening session. Image ©IAS/Steve Shapiro – Commercialimage.net

Jump to

• ‘Berlin patient’ Timothy Brown has “inspired the field”
• What do scientists mean by an HIV cure?
• Path to a cure
• The long and winding road

‘Berlin patient’ Timothy Brown has “inspired the field”

Scientists launched a road map for research into an HIV cure ahead of the 19^th International AIDS Conference (AIDS 2012) in Washington DC, promising international collaboration and calling for more funding to be devoted to research that can eventually deliver a course of treatment that will, at the minimum, allow people with HIV to remain off medication for life even it can’t eradicate HIV from the body.

The Towards an HIV Cure declaration marks a substantial shift in the scientific consensus regarding the feasibility of HIV cure research. Over the past four years funding has begun to flow towards small intensive studies that will contribute towards cure research. Worldwide attention has been grabbed by the case of the ‘Berlin patient’, Timothy Brown, who was pronounced cured of HIV infection after a gruelling course of chemotherapy, immunosuppressive treatment and a bone marrow transplant from a donor with a rare genetic resistance to HIV infection. (See here for a full explanation of this case.)

“I don’t think anyone would want to go through what he went through to get that cure, but it has inspired the field,” Dr Steven Deeks of the University of California San Francisco, told a press conference launching the International AIDS Society’s cure research strategy prior to a pre-conference symposium, Towards an HIV Cure.

Support for a comprehensive effort to cure HIV infection is also driven by the mounting long-term cost of HIV treatment. By 2015, US$24 billion will be required to provide treatment for 15 million people; at least 35 million people are estimated to be infected with HIV, and eventually all will be eligible for HIV treatment. A cure which can be feasibly delivered at a large scale in countries with weak health systems, and which is affordable, will begin to look more and more attractive to major international donors as treatment costs continue to rise.

What do scientists mean by an HIV cure?

An HIV cure requires either the clearance of HIV from every cell in the body, or the establishment of a sufficiently strong immune response to keep HIV in check when medication is stopped. The difficulty of achieving eradication of the virus lies in the fact that HIV can remain latent within CD4+ T-cells and some other immune system cells for many years, and cannot be detected by the immune system. It is only when those cells are activated by an external stimulus that they begin to produce HIV. These cells form a ‘reservoir’ of latent virus that could cause viral rebound as soon as antiretroviral treatment is stopped. It would take the activation of only a few infected cells to cause viral rebound; the reservoir of latently infected cells probably comprises thousands of cells.

The case of Timothy Brown is the only example of an HIV cure that has been scientifically validated, but even this case raises questions about what a cure means. Scientists talk about two possible outcomes from cure research: eradication, where the virus is cleared from the body, and a ‘functional cure’, where tiny amounts of virus may persist, but the virus remains controlled without medication.

The HIV field had thought that the case of the Berlin patient represented the first example of HIV eradication, but recent data presented at the International Workshop on HIV & Hepatitis Virus Drug Resistance and Curative Strategies in Sitges, Spain, in June, indicated that some laboratories which had tested samples of plasma and tissue from the ‘Berlin patient’ Timothy Brown, had been able to detect very low levels of HIV DNA or RNA several years after the interventions. This suggests that HIV has not been completely eradicated from this patient’s body. Yet, not all laboratories were able to detect HIV, and the finding remains controversial.

Professor Sharon Lewin of the Alfred Hospital, Melbourne, commented: “My gut feeling is that it’s not real. My take on it is that the DNA and RNA samples were looked at by labs that are very experienced in this work, and in a sub-set of these laboratories there was some evidence of RNA and DNA, which may or may not be contamination. There may be contamination in the best-run labs. He certainly doesn’t have virus that is infectious or that has rebounded to a detectable level. If it’s real, we still have a fantastic example of a functional cure.”

Dr Steve Deeks said that the findings, which his “gut feeling” tells him to be evidence of real virus, suggest three take-home messages. Firstly, more sensitive tests are needed for measurement in HIV eradication studies. Secondly, immune responses may be the most important indicators of the achievement of a functional cure, even where evidence of virus persists; Timothy Brown’s antibody levels continue to decline, suggesting that not enough HIV is being produced to stimulate immune responses. Finally, all the clinical signs suggest that the patient is doing well in the absence of antiretroviral therapy, again suggesting that any persisting low-level HIV infection that might exist is causing no physical harm.

Indeed, given all the sites and cell types that HIV may infect, a functional cure may be more feasible – and may be perfectly satisfactory for people with HIV, depending on how that affects their everyday lives.

“I asked patients in Asia recently what they wanted and they didn’t say a cure, they said ‘a treatment I can stop’,” Professor Francoise Barré- Sinoussi told the press conference.

Research conducted among people living with HIV in the Netherlands, on the other hand, suggests that when presented with different attributes of a potential curative course of treatment, people want a treatment that removes long-term uncertainty about health and side-effects, ends stigmatisation and ends the risk that they will infect partners. People living with HIV rate the psychosocial benefits of a cure very highly when asked to rank a range of possible health and psychosocial benefits, Fred Verdult told the Towards an HIV Cure symposium.

A cure, functional or otherwise, and an end to AIDS will also depend on reaching people who have HIV: those who know it and those who don’t. “What would a cure have to look like to access that group of people who are currently not either diagnosed or on treatment?” asked Steven Deeks.

Path to a cure

Views differ on what might be the most productive approach towards curing HIV infection, and researchers emphasise that there is still a great deal of ground to be covered. Tony Fauci, director of the US National Institute of Allergy and Infectious Diseases, described the ‘false start’ of the mid-1990s, when some researchers assumed that viral suppression on HAART, and the absence of new rounds of infection or evolving HIV DNA, meant that replication had been halted and that eradication was only a question of waiting a few years for all the HIV-infected cells to die a natural death. Robert Siliciano and others soon demonstrated that HIV was infecting cells that might persist for years, and that estimates of HIV eradication after a few years of HAART were wildly optimistic.

All researchers agree that a cure, functional or otherwise, will depend on a combination of approaches. Where they disagree is on the ingredients of the cocktail.

A cure for every patient will need to start with a prolonged period of antiretroviral therapy to reduce HIV to undetectable levels. This period of treatment itself could be important in determining the success of subsequent drug therapies. Will attempts to purge the HIV reservoir be more successful in people who began treatment very soon after infection? A French cohort has produced tantalising data suggesting that some people treated in acute infection can stop treatment and go for very long periods – an average of 72 months so far – without experiencing viral rebound. What is it about these people that prevents viral rebound? Is it the time they started treatment, their genes, or just random chance?

Scientists are also interested to learn whether any form of intensified antiretroviral drug regimen could shrink the pool of latently infected cells, making them easier to purge later. So far, studies have shown little or no impact of regimens drawing on the maximum number of drug classes on the size of the reservoir of latently infected cells, but further studies are planned, using more sensitive measurement techniques, to see whether five-drug combinations that target every possible step in the viral lifecycle have more effect.

Studies are also underway or planned to determine the extent to which the viral reservoirs can be emptied by using a range of drugs that will activate latently infected cells so that they can be identified and killed by the immune system, or self-destruct.

Sharon Lewin of the Alfred Hospital, Melbourne, described the range of studies already taking place using compounds called HDAC inhibitors, which stimulate latently infected cells to begin producing HIV.  A number of experimental studies with HDAC inhibitors are already underway, most notably with vorinostat (SAHA). This drug is already approved for the treatment of cutaneous lymphoma, and is currently undergoing phase II tests for a range of other malignancies, so its short-term toxicities are well characterised. In vitro toxicity studies suggest a potential long-term risk of malignancy, but at this point no human studies have reported an increased risk of malignancy. Sharon Lewin’s team is studying the effect of 14 days of vorinostat (SAHA) in 20  patients with fully suppressed viral load, and will measure the effect of vorinostat on cell-associated HIV RNA to determine the effect of the drug on HIV latency.

Professor David Margolis at the University of North Carolina is conducting a similar experimental study, measuring the effect of a sequence of single doses of vorinostat on virus production in up to 20 volunteers with fully suppressed viral load. Steven Deeks at the University of California San Francisco is testing the anti-alcohol agent disulfiram, which also activates latently infected cells. Preliminary data presented at CROI in 2012 showed that this agent stimulated HIV RNA production in a sub-set of chronically infected patients who received the drug.

In addition to these agents, there are six or seven known targets for therapies that could disrupt HIV latency, and in collaboration with Merck Prof. Margolis’s research group has identified 83 compounds with differing mechanisms of action that are being tested for their potential as disruptors of latency. Two other companies, Gilead and Janssen-Tibotec, are also engaged in major screening programmes to identify agents that could contribute towards cure research.

Ultimately a number of different agents may need to be used in combination, said Warner Greene of the Gladstone Institute, San Francisco, in order to target the different points in the transcription pathway that govern the integration and latency of HIV in cells.

Activating agents might also need to be used in combination with a therapeutic vaccine to stimulate the immune system to clear the activated cells, because researchers are still uncertain how long the activated cells will continue to produce virus once activated, and whether cells which are not fully activated are nevertheless capable of producing virus that will go to infect other cells. (Activation is a cycle rather than an on/off process.)

Researchers are also investigating gene therapy approaches that can gradually establish a pool of HIV-resistant CD4 cells. This approach is already being studied in people with HIV, but more work is needed to refine the technique and determine whether this approach can contribute towards an HIV cure.

The long and winding road

Questions of cost and scaleability will loom ever larger as researchers make progress towards a cure, but at this stage leading players are stressing the need for realistic expectations about how long this research will take.

“I can’t tell you how long it will take or how much it will cost, but now we are collaborating, it will take a considerably shorter time,” said Rowena Johnston of AmFAR, who is leading the organisation’s efforts to fund innovative cure research as a means of kick-starting a larger cure research effort.

How much it will cost and how long it will take to get there are matters of pure conjecture at the moment, and advocates and researchers are reluctant to commit themselves on either question. “The reason we don’t want someone saying it’s going to take X million dollars and X years is because we don’t want to over-promise what we can’t deliver. But if we put in more money we will get there sooner,“ said Johnston.

The research effort will also need to overcome the scepticism of a field that has seen several major breakthroughs fail to materialise.

Tony Fauci pointed out how many times the “you can’t do it” school have been proved wrong in HIV research, starting with antiretroviral therapy, all the way through efforts to deliver treatment in the developing world, to the recent PrEP studies. HIV research requires great feats of discovery, but it also requires the discovery of an approach to a scaleable cure to mobilise the resources, he told researchers.

AGAINST HIV/AIDS WITH CIRCUMCISE that COMBINED WITH THE NEWS OF AIDSMAP-Circumcision taking off in several African countries(The excellence ideas)

2012

Jump to

• Physicians at risk of circumcision ‘burn out’ in some settings
• Questions and misunderstandings
• References

Physicians at risk of circumcision ‘burn out’ in some settings

Voluntary medical male circumcision (VMMC) programmes are expanding in several African countries and in a couple of locations have almost reached saturation point, with most of the eligible young male population circumcised, the 19^th International AIDS Conference (AIDS 2012) in Washington DC heard yesterday.

Presenter Jane Bertrand of Tulane University said that, in the Nyanza Province of Kenya, which was home to the traditionally uncircumcised Luo people, the target has almost been reached of 80% of the adolescent male population (aged 15 to 24) being circumcised. Since 2008, 312,789 procedures have taken place in a province with an uncircumcised male population in that age range of around 400,000, meaning that between 73 and 82% of initially uncircumcised young men have now been circumcised.

The pace of circumcision programmes is such that a significant proportion of staff performing the operations are experiencing burn-out, presenter Dino Rech of the Centre for HIV and AIDS Prevention Studies (CHAPS) in Johannesburg said. Burn-out was more likely if doctors continued to do the operation rather than having VMMC ‘task-shifted’ so that nurses and medical auxiliaries were trained to do it.

There were very different patterns of burn-out from the four different countries surveyed (Kenya, South Africa, Tanzania and Zimbabwe). A lot of practitioners in Kenya (71%) said they experienced burn-out and had seen it in others (88%): these practitioners were providing the most circumcisions, and there was a clear link with the number of operations performed. In Tanzania, most practitioners said they had not seen burn-out in colleagues, but a high proportion admitted to it themselves. In South Africa and Zimbabwe, moderate numbers (around 30%) admitted to burn-out, though South Africa had the highest proportion of practitioners who said it was “very common” in others.

Fully qualified doctors were more likely to report burn-out than nurse or auxiliaries. This is a second strong argument (after cost) for task-shifting, the training up of nurses and auxiliaries to perform VMMC.

Zebedee Mwandi of the Centers for Disease Control (CDC) in Kenya reported that, while in VMMC performed by doctors, the proportion of adverse events (AEs) has declined from 1.4% to zero, AEs in procedures performed by nurses and clinical officers had also declined, from 2 to 0.7% in three years. He said that VMMC programmes were now taking off in other provinces, with coverage of the eligible population in Kenya’s Western province now about 20% and Nairobi about 15%, though Nyanza had contained the vast majority of Kenya’s uncircumcised man.

The CHAPS clinic in Soweto has also almost achieved saturation coverage amongst the local young male population, and is facing the expense of having to move. This is an argument for mobile circumcision clinics, and 12% of circumcisions are now being performed by mobile clinics in Kenya.

In South Africa, Nikki Soboil runs a mobile clinic in KwaZulu Natal, on behalf of the Southern African Clothing & Textile Workers’ Union, which funds HIV prevention work. An analysis comparing the costs of running a permanent establishment like CHAPS and a mobile clinic showed that, while training and transport cost more in the mobile clinic, all other costs such as capital expenditure and wages were less, meaning that the mobile clinic could perform each circumcision for 498 Rand (US$59), while in CHAPS each procedure cost 827 Rand.

In other countries, VMMC is still not receiving funding for large rollover programmes, though a survey from Swaziland found that the proportion of men in the population who were circumcised had more than doubled since 2008. This was even before a large media campaign encouraging circumcision started and in the absence of any national rollout – which, given this country’s adult HIV prevalence of 26%, was urgently needed, presenter Jason Bailey Reed of the US CDC said.

Questions and misunderstandings

Despite the rollout of circumcision, and even though the prospective data from the randomised controlled trials of VMMC is unassailable, circumcision is still a contentious subject: there were demonstrations outside the conference centre by anti-circumcision activists today. Their cause received a boost from a cross-sectional survey from Zimbabwe this month, which found that HIV prevalence was slightly higher in circumcised than uncircumcised men (14 versus 12%). This survey was mentioned by an audience member, who asked the panellists how they would explain why different survey methods gave different figures. Jason Bailey Reed answered that the Zimbabwe survey was a snapshot of the male population, many of whom would have become HIV positive before they were circumcised; on the other hand, the RCTs convincingly show a continued reduction in HIV infections over time in heterosexual men who get circumcised.

A more troubling finding from a couple of trials is that if HIV-positive men get circumcised, HIV infections in their female partners can rise. Circumcision advocate Kawango Agot of the Kenyan research and development organisation IMPACT said that, in one study from Rakai in Uganda, the infection rate in negative partners of positive men was 9.5% in the year after circumcision, compared with 7.9% in partners of men who remained uncircumcised. This is due to the fact that, as a number of surveys of HIV-negative men show, anything from 24 to 38% of men resume sex too early, before the six-week deadline given for wound healing, and the proportion who resume sex early is even higher between spouses.

Incidence in Rakai in partners of men who resumed sex too early was 28%. Agot said that this showed that women should be involved in all aspects of VMMC too: too often it was an experience men went through entirely alone, but 74% of women said that were keen to support male partners and be involved in the VMMC process. However, they needed education and information too, as 77% were unaware of the need for abstinence after the operation.

References

All references are from the 19^th International AIDS Conference, Washington DC, July 2012. See herefor session listing with abstract: presenters’ slides will be added soon.

Bertrand J et al. Implementation of VMMC efficiency elements in four sub-Saharan countries: service delivery methods and provider attitudes. Abstract MOPDE010. View the abstract on the conference website.

Bertrand J et al (presenter Rech D). Determinants of VMMC provider burnout in four sub-Saharan countries. Abstract MOPDE0102. View the abstract on the conference website.

Mwandi Z et al. Service delivery trends in Kenya’s voluntary medical male circumcision scale-up from 2008-2011. Abstract MOPDE0104. View the abstract on the conference website.

Reed JB et al. Male circumcision in Swaziland: demographics, behaviours and HIV prevalence.Abstract MOPDE0105. View the abstract on the conference website.

Soboil N et al. A comparative analysis of two high-volume male medical circumcision (MMC) operational models with similar service delivery outcomes in different settings within Gauteng and KwaZulu-Natal provinces in South Africa: urban Centre for HIV/AIDS Prevention Study. Abstract MOPDE0106. View the abstract on the conference website.

Agot K et al.We too are shareholders: why women must be meaningfully involved in the rollout of medical male circumcision in Africa. Abstract MOPDE0107. View the abstract on the conference website.

Have you ever assumed that circumcision has an important role in a reduced risk of HIV?

Recently, as the result of the International AIDS Conference in Toronto 13-18 August 2006, circumcision has become one of some recomendations to enforce for preventing the spreading of HIV-AIDS.

Therecomendation is based o  research which organized by W>B Sateren et all, among tea plantation residents in Kericho, Kenya. HiV testing method was done by ELISA  and confirmed by western Blot assay. A strong statistical significant difference in HIV prevelence was observed between the 398 uncircumcised men and the 1,321 circumcised men. This protective effect was also observed for circumcised men compared to uncircumcised men across all strata of age groups, education, marital status, history of sexually transmitted infection, and syphilis infection status. Risk to acquired HIV-AIDS is 66 % higher to uncircumcised men than circumcised men. So lets us together campaign circumcision to stop spreading HIV-AIDS (Prima almazin:i2008)

Global Challenges | Botswana Health Officials Announce HIV-Prevention Project To Circumcise 80% of Eligible Men Over Five Years

[May 11, 2009]

Botswana’s campaign to circumcise about 500,000 men by 2012 will prevent nearly 70,000 new HIV cases by 2025, according to a report published Thursday in the Journal of the International AIDS Society, AFP/Yahoo! News reports. The government’s national campaign aims to circumcise 460,000 men over the next five years, and the country has begun airing television and radio advertisements to encourage men to be circumcised at local clinics. “Scaling up safe male circumcision has the potential to reduce the impact of HIV/AIDS in Botswana significantly,” according to the study.

The report puts the estimated cost of the circumcision campaign at about $47 million. A UNAIDS report estimates that the HIV prevalence among pregnant women in Botswana was 43% in 2003, the year that antiretroviral drug access was introduced in the country

Botswana’s Ministry of Health is launching a project that aims to circumcise nearly 500,000 men over the next five years in an effort to prevent the spread of HIV, the AFP/Daily Telegraph reports. Janet Mwambona, a public health specialist who is leading the project, said that officials decided to launch the program following a series of studies that showed circumcision can reduce a man’s risk of HIV. “For the public health benefits of the preventive effect of circumcision to be realized, the Ministry of Health is supposed to cover 80% of eligible males in Botswana,” Mwambona said, adding that hospitals nationwide are scheduling and performing the procedure.

According to the AFP/Telegraph, about 50 health care providers, including 27 physicians, have been trained to perform surgical circumcisions. In addition, the campaign includes television and radio advertisements that encourage men to visit clinics to undergo a safe circumcision surgery (AFP/Daily Telegraph, 5/8).

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Job stress strains a woman’s heart, but no one knows why

Cambridge, MA – A new study has found that women under a lot of stress at work were almost 40% more likely to have a cardiovascular event over a 10-year period than their counterparts who reported low job strain [1]. Dr Natalie Slopen (Harvard University, Cambridge, MA) and colleagues publish their findings online July 18, 2012 in PLoS One.

The higher likelihood of a CVD event applied to both women with high job strain—defined as a highly demanding job but with low control—and those with active job strain—defined as high demand but with high autonomy. This finding is surprising, senior author Dr Michelle A Albert (Brigham and Women’s Hospital, Boston, MA) told heartwire, since most prior research—much of which has been conducted in men—has not found an increased CVD risk in those with “active” jobs.

There‘s a large proportion of the relationship between high job strain and CVD risk that we don‘t quite understand.

“Both the high-strain and the active-strain women have an almost 40% elevated risk of total CV events. I would expect the high strain [to be associated with increased risk] based on studies involving men, but the active-strain group is not a group where a lot of studies involving men have indicated there is a relationship with cardiovascular events.”

Another major surprise was the finding that >70% of the relationship between job strain and cardiovascular events “cannot be explained by traditional risk factors for CVD or anxiety/depression,” said Albert. “There’s a large proportion of the relationship between high job strain and CVD risk that we don’t quite understand,” she noted.

Robust, combined CVD end point, validated from medical records

Slopen and colleagues say that job-related stressors are known to be associated with CVD risk, but most prior studies have been conducted in men. In women, there have been a few trials, but these have mostly employed single end points, such as coronary heart disease (CHD) or stroke, and the results have been inconsistent.

Information about the effects of job-related stressors on cardiovascular health in women is important, they note, given the dramatic increase in female participation in the work force over the past few decades and the fact that psychosocial stressors may affect women and men differently.

In the new research, they studied more than 22 000 women healthcare workers who were part of the decade-longWomen’s Health Study. They asked them about the stressors in their jobs, including the pace, amount of work, demands, required skills, and control over decision making. They also asked them about job security.

Albert says one of the strengths of the work is the combined end point of nonfatal MI, stroke, coronary revascularization, and total cardiovascular death, which she notes is “pretty comprehensive and validated from medical records.”

During 10 years of follow-up there were 170 MIs, 163 ischemic strokes, 440 coronary revascularizations, and 52 CVD deaths. In Cox proportional-hazard models adjusting for potential confounders, women with high job strain (high demand, low control) were 38% more likely to experience a CVD event than their counterparts who reported low job strain (low demand, high control; rate ratio 1.38; 95% CI 1.08-1.77). Similarly, women with active jobs (high demand, high control) were 38% more likely to experience a CVD event relative to those who reported low job strain (95% CI 1.07-1.77).

No evidence of an association between CVD events and job insecurity was seen, however.

Stress beyond normal, requires coping skills

“Our body is able to adjust to normal strains so we are talking about stress beyond normal here, related to the body’s inability to adapt to the stress,” Albert notes.

“But we can’t get rid of job stress, and we can’t get rid of our jobs, so we have to find ways to cope. We know that coping plays a very important role in minimizing health effects of stress in the mental-health literature. But we don’t know as much about it in the CV health literature, because there aren’t terrific data, certainly for women.”

We can‘t get rid of job stress, and we can‘t get rid of our jobs, so we have to find ways to cope.

She recommends that to help cope with stress, people should ensure they get plenty of exercise, carve out time for relaxation activities, “and not allow jobs to interfere with private time. Because we live in the electronic age, we spend a lot of time on our electronic devices ‘off the clock,’ and we should try to avoid this.” And a social support network is very important too, she adds.

Employers also need to take some responsibility for ensuring their employees are not overburdened, she believes: “They need to realize the productivity of their employees seriously drops if people are stressed out.” And doctors, too, should remember to ask their patients about job strain, she emphasizes.

“I’m a cardiologist, and I try to ask my patients about stressors in their life. There are multiple stressors; job strain is just one type. Depending on the stressor, I will try to give them ideas of ways of coping, or I will refer them to appropriate resources that are available in our healthcare systems to deal with them.”

The authors declare no conflicts of interest.

Mental health IN AIDS/HIV

Mental health problems can affect anybody and do affect many people at some point in their lives. But, people with HIV are more likely to experience mental health problems than the general population. This could be because the groups most affected by HIV in the UK – gay men, refugees, migrants and drug users – are already more likely to have mental health problems because of the added pressures they can live with.

Having a weak immune system and low CD4 cell count because of HIV is known to increase the risk of developing some infections which involve mental health problems. Thanks to HIV treatment, these are now very rare.

But many people with HIV report being unhappy, sad, anxious, or feeling unable to cope. Some anti-HIV drugs can also cause side-effects that affect the brain.

HIV-related mental disorders

It is estimated that before HIV treatment became widely available, 7% of people with advanced HIV infection developed dementia. Mania has also been observed in people with advanced HIV disease.

It is highly unusual for a person who is taking anti-HIV drugs to develop either of these conditions as a direct result of being HIV-positive.

Emotional distress

Particular events such as receiving an HIV diagnosis, the breakdown of a relationship, bereavement, financial or work problems, or dealing with side-effects of treatment, can result in feelings of deep unhappiness which are difficult to manage and interfere in day-to-day life.

Support from family and friends can be very helpful at these times, as can support from other people with HIV, and professional help, such as counselling and psychotherapy. Many HIV clinics have specialist mental health teams and some HIV support agencies can offer short courses of counselling. Some people also find that complementary therapies, such as acupuncture, can relieve some of the symptoms of emotional distress.

Depression

Depression is thought to be around twice as common in people with HIV as in the general population. Many people get better from a period of depression without professional help. Talking through feelings and taking good care of yourself, by making sure you get enough sleep, exercising and eating well, can make a big difference.

Sometimes it’s difficult to be sure what the cause is, but depression is characterised by having most or all of the following symptoms on a daily basis for several weeks: low mood; apathy; poor concentration; irritability; insomnia; early waking or oversleeping; inability to relax; weight gain or weight loss; loss of pleasure in usual activities; feelings of low self-worth; excessive guilt; and recurrent thoughts of death or suicide.

If you are diagnosed with depression, your doctor may recommend that you take antidepressant drugs, which relieve the symptoms of depression by altering chemicals in the brain that influence mood and behaviour. They can take several weeks to work and may have side-effects.

Although there are three classes of antidepressant drugs used (tricyclics; MAOIs; and SSRIs), it is most likely that you will be offered a drug from the SSRI (selective serotonin re-uptake inhibitors) class, which includes drugs like fluoxetine (Prozac), as these have fewest side-effects and interactions with other drugs.

You must not take the herbal antidepressant St John’s wort if you are taking certain anti-HIV drugs, as it can reduce their effectiveness. Talk to your doctor if you have been taking St John’s wort, or are planning to.

The amount of time you stay on antidepressants will vary according to your individual circumstances and although you may start to feel better soon after starting to take them, it is recommended that you remain on them for at least three months if it is the first time you’ve developed depression or longer if your depression has recurred.

Mental health problems as a treatment side-effect

It is known that the anti-HIV drug efavirenz (Sustiva, also in the combination pill Atripla) can cause psychological problems. Some people have difficulty sleeping, or vivid dreams or nightmares. Another anti-HIV drug, rilpivirine (Edurant, also in the combination pill Eviplera) may also cause depression and mood changes. Other people have reported depression without any other apparent cause. If you think you are suffering from depression now, or have done in the past, it is important to talk to your doctor about this when deciding on the best HIV treatment options for you.

Taking interferon treatment for hepatitis C infection can also cause mental health problems, particularly depression.

Doctors often prescribe antidepressants if they think that depression might be a treatment side-effect.

Anxiety

Anxiety is a feeling of panic or worry. Often, people report symptoms such as sweating, rapid heartbeat, agitation, nervousness, headaches and panic attacks. Anxiety can accompany depression or may occur by itself. It is often caused by feeling fearful, insecure, or uncertain.

Talking through your feelings of anxiety and the reasons for it with a friend or a counsellor might be helpful. Anxiety which accompanies depression may be relieved by antidepressant drugs. Some people find massage or other complementary therapies help relieve the symptoms of anxiety.

Drugs such as benzodiazepines, including Valium, are now very rarely prescribed as a treatment for long-term anxiety because they are addictive. However, they are still used in the treatment of short periods of acute anxiety without any long-term dependency problems.

Psychological treatments

Often drug therapies for mental health problems work better if used along with special kinds of psychological therapy. Examples include psychotherapy, and cognitive behavioural therapy (CBT), both of which usually involve a short course of sessions with a psychotherapist or psychologist.

Where to go for help and support

A good place to start would be your HIV clinic. Your HIV doctor should take your mental health just as seriously as your physical health. Many of the larger HIV clinics have expert HIV mental health teams. There are also many HIV support organisations – your HIV clinic will be able to tell you about local support, or you can use our online database to search for organisations. Visit www.aidsmap.com/e-atlas.

The following counselling and mental health organisations may also be useful.

• PACE (020 7700 1323) PACE provides counselling and psychotherapy for gay men and lesbians in London, for issues including HIV. There is usually a fee for these sessions. Visit their website at: www.pacehealth.org.uk
• SANELINE (Helpline 0845 767 8000) UK mental health charity. Visit their website at:www.sane.org.uk
• Mind (Mind Info Line 0300 123 3393) UK mental health charity. Visit their website at:www.mind.org.uk
• Samaritans (08457 90 90 90) Confidential emotional support 24 hours a day. Visit their website at: www.samaritans.org

Watching Television Gives Children Larger Waistline

An increasing number of parents today are using the television as an ‘electronic babysitter’, according to evidence. Some parents tell their children that watching too much TV will make their eyes go square and, although this is not true, evidence is emerging that watching too much TV as a child could mean they end up with a larger waistline.

A new study, featured in BioMed Central’s open access journal International Journal of Behavioral Nutrition and Physical Activity, has discovered that children’s muscular fitness decreases the more hours young children spend in front of the television and that their waist lines become larger as they approach their teens, which can have potential health consequences in their adulthood.

According to recommendations by the American Academy of Pediatrics, children below the age of two years old should not exceed more than two hours of television per day, yet more and more parents appear to use the TV as an ‘electronic babysitter’.

Researchers from Montreal University in Canada decided to investigate whether the number of hours spent watching TV during early childhood is linked to lower subsequent physical fitness once these children are at school. 

The team used participants from the Quebec Longitudinal Study of Child Development, and surveyed the children’s parents asking them to report the number of hours their child watched TV per week at the age of 29 and 53 months. Given that muscle strength and abdominal fat are associated with the level of fitness, the researchers examined the children in the second and fourth grade by measuring their waist circumference and using the standing long jump test.

They discovered that for each hour per week of watching TV at the age of 29 months, children scored 0.361 cm less in the Standing Long Jump, which suggests a lower muscle strength compared with those who watched less television at that age. By increasing the weekly TV exposure by just one extra hour between the age of 29 and 53 months predicted an additional 0.285 cm less in the test. Another important finding was the fact that waist circumference at fourth grade increased by 0.047 cm for every hour of television watched between the ages of 29 and 53 months, which translates to a 0.41 cm larger waistline by the age of 10, or a 0.76 cm larger waistline in those who watched over 18 hours of TV a week.

The result could predict that those children who spend an excessive amount of time in front of the TV as a child could experience negative health outcomes in their later life due to their larger waistline and lower muscle strength, as physical fitness is directly associated with future health and longevity.

Leading researcher, Dr Caroline Fitzpatrick from New York University who performed the study at Montreal University and Saint-Justine’s Hospital Research Centre, concluded:

“TV is a modifiable lifestyle factor, and people need to be aware that toddler viewing habits may contribute to subsequent physical health. Further research will help to determine whether amount of TV exposure is linked to any additional child health indicators, as well as cardiovascular health.”

Written by Petra Rattue

The Ramadan Sermon of the Prophet Muhammed [saw]

Muhammad ibn Ibrahim says that Ahmed ibn Muhammad-al- Hamadani says that Ali ibn al-Hassan ibn Fadal quotes his father quoting al-Hassan’s father Imam Ali bin Musa al-Rida (as) who in turn quotes his father Imam Musa ibn Ja’fer (as) quoting his father the master of martyrs Imam al-Husain ibn Ali ibn Abu Talib (as) saying that the Messenger of Allah (pbuh) delivered a sermon once in which he said:

O people! A month has approached you laden with blessing, mercy and forgiveness; it is a month which Allah regards as the best of all months. Its days, in the sight of Allah, are the best of days; its nights are the best of nights; its hours are the best of hours. It is a month in which you are invited to be the guests of Allah, and you are regarded during it as worthy of enjoying Allah’s Grace. Your breathing in it praises the Almighty, and your sleeping adores Him. Your voluntary acts of worship are accepted, and your pleas are answered. Ask Allah your Lord, therefore, in sincere intentions and pure hearts to enable you to fast during it and to recite His Book, for only a wretch is the one who is deprived of Allah’s forgiveness during this great month. And let your hunger and thirst during it remind you of the hunger and thirst of the Day of Resurrection. Give alms to the poor and indigent among you; surround your elderly with respect, and be kind to your youngsters. Visit your kin and safeguard your tongues, and do not look at what Allah has prohibited you from seeing, and do not listen to anything your ears are forbidden to hear. Be kind to the orphans of others so that your own orphans will equally receive kindness. Repent your sins to Allah and raise your hands to Him in supplica- tion during the times of your prayers, for they are the best times during which the Almighty looks with mercy to His servants and answers their pleas when they plead to Him. O people! Your souls are pawned by your deeds; therefore, release them by seeking Allah’s forgiveness. Your backs are over-burdened by the weight of your sins; therefore, lighten their burden by prolonging your prostration. Be informed that the Exalted and Almighty has sworn by His Dignity not to torture those who perform their prayers and prostrate to Him, and not to terrify them by the sight of the fire when people are resurrected for judgment. O people! Whoever among you provides iftar to a believer during this month will receive a reward equal to one who sets a slave free, and all his past sins will be forgiven.

Having said so, people said to him: “O Messenger of Allah! Not all of us can do that!” He (pbuh), thereupon, responded by saying,

Shun the fire of hell even by half a date! Shun the fire of hell even by a drink of water! O People! Whoever among you improves his conduct during this month will have a safe passage on al-Sirat al-Mustaqeem, (the straight path) when many feet will slip away, and whoever among you decreases the burdens of his slave (or anyone who works for him) will be rewarded by Allah decreasing his reckoning. Whoever among you abstains from harming others will be spared the Wrath of the Almighty when he meets Him. Whoever among you affords generosity to an orphan will be rewarded by Allah being generous to him on the Day of Judgment. Whoever among you improves the ties with his kin will be rewarded by Allah including him in His mercy, and whoever among you severs his ties with his kin, Allah will withhold His mercy from him upon meeting Him. Whoever among you offers voluntary prayers, Allah will decree a clearance for him from the torment of the fire. Whoever among you performs an obligation will receive the reward of one who has performed seventy obligations in other months. Whoever among you increases the sending of blessings unto me, Allah will make the balance of his good deeds weigh heavily when scales will be light. Whoever among you recites one verse of the Holy Qur’an will receive the blessing of one who recites the entire Holy Qur’an in another month. O people! The gates of heaven in this month are kept open; so, pray Allah your Lord not to close them against you, and the gates of the fire are kept closed; so, pray Allah your Lord not to open them for you; and the devils are kept chained; therefore, pray Allah your Lord not to unleash them against you.

Advising the great sahabi Abu Tharr al-Ghifari, may Allah be pleased vvith him, regarding the fast being a protection against the fire, he (pbuh) is quoted saying, “Shall I inform you of a deed which, if you do it, will keep Satan away from you as much as the distance between the east of the earth and the west?” People answered, “O yes, indeed, O Messenger of Allah!” He (pbuh) said, “Fast darkens his (Satan’s) face; alms break his back; the desire to please Allah and the giving of assistance to do good deeds cut his tail off, and seeking Allah’s forgiveness cuts off his aorta.” Then he added, “For everything there is a purification (zakat), and the purification of bodies is the fast.” He (pbuh) is also quoted saying, “One who fasts is considered to be adoring his Creator even while sleeping on his bed as long as he does not backbite any Muslim.” He (pbuh) has also said, ‘There are two merry occasions for anyone who performs the fast: one when he breaks his fast, and one when he meets his Lord, the Exalted, the Almighty. I swear by the One Who controls Muhammad’s life, the excess on the mouth of one who fasts is better in the sight of Allah than the sweet smell of musk.” He (pbuh) has also said that the Exalted and Almighty has said (in a Qudsi hadith) that all good deeds of a descendant of Adam are His (to reward) “except the fast, for it is mine, and I shall reward for it. All good deeds of the son of Adam are rewarded with ten to seven hundred times except perseverance, for it is mine and I reward for it.” So, the knowledge of the rewards of perseverance is with Allah, and “perseverance” means fast.

More Prophetic counsel

Regarding the interpretation of His saying (in the Holy Qur’an) “… and seek aid with perseverance,” meaning the fast, it is reported that the person who fasts enjoys the gardens of Paradise and the angels keep praying for him till he breaks his fast. If a believer stands during a portion of the night to perform additional optional prayers, then he wakes up fasting, no sin will be recorded against him. Whenever he takes one step, it will be recorded as a good deed for him, and if he dies during daytime, his soul will ascend the heights of heaven. If he lives to break his fast, the Almighty will consider him among those who often return to Him for forgiveness.

In the book titled Thawab al-A’mal, relying on the authority of Abu Abdullah who quotes his forefathers, peace be upon all of them, the author, namely Shaikh al-Qummi al-Saduq, quotes one tradition indicating that the Messenger of Allah (pbuh) has said, “The sleep of someone fasting is like adoration, and his breath praises the Almighty.”

Ramadan: A Training Ground for the Soul

Trends are what shape and guide the lives of the civilized world. Chances are that if you don’t have to worry about food, shelter, education, security or other necessities of life, then you are at leisure to contemplate luxuries.

The most popular and controversial of recent fads is that of delving into the spiritual and metaphysical. They’re nice big words to drop in any conversation and immediately make you sound open-minded and adventurous. And besides, the mystery implied never did anyone harm.

For the unaware, the 21st Century is officially considered the Age of The Aquarian – full of exploration, invention, genius and escape from the norm. As advertising is never far behind a popular concept, the next few years will probably also be the best for the Age of The Retreat.

You know, the beautifully designed, carefully constructed mini-villages set in picturesque countryside, mysteriously (there’s that word again!) hidden behind elegant, high walls or graceful hedges to keep away prying eyes. Just a few years ago, a retreat brought images of the confused celebrity or the addicted affluent being helped to re-grasp a normal, sane life. Today, retreats are the must-do for the new-age city dweller.

Unwilling to change track from heading towards the inevitable moral destruction that awaits it, the world has decided to get rid of its guilt and at least try to enjoy the ride. Enter the Retreat: a place to de-tox, leave behind the immorality of the city and be at one with pure, unadulterated humanity. Seven to ten days of this apparently leaves the human spirit refreshed and rejuvenated enough to face the harsh world for another stint of materialism and worldliness.

Which makes me sit back and smile in wonder at the treasure of knowledge that Allah (S.W.T.) has bestowed upon us in plain view. A treasure we studiously ignore every single day.

Where the world reaches out starved spiritual hands (and healthy wallets) for the revolutionary retreat, Islam brings it home to us very year, without fail. It takes no stretch of imagination to see the similarities between the concept of the retreat and Ramadhan.

In 30 days of this month, we are given the chance to change our eating habits (de-tox), our manners and character (morality) and to address our efforts solely the journey towards Allah (S.W.T.) (being at one with our selves). We also get the added benefit of being exposed to positive vibes (the doors of Mercy and Forgiveness are wide open), to communicating with the invisible energies around us (reading the Qur’an and praying) and developing better social ties (sharing iftar and good times!).

Ramadhan gives you more time and value (results are guaranteed) AND it’s for free! My only hesitation in comparing it with world retreats is that the selfishness of the human character doles out peace-of-mind in week-long chunks, forcing the thirsting soul to come again and again – and therefore pay again and again – for the cool waters of its fountain. Allah (S.W.T.), Glory and Praise be to Him, on the other hand wants us to gain permanent benefits from the month He gave to us. He doesn’t want an infrequent traveller, indulging in a spiritual workout once a year and then returning to the baseness of the world.

Perhaps it would be better then, to compare Ramadan to a Recruiting Camp – a time allocated to training the soul and carrying the benefits with you when you re-enter the rest of the year. Whatever talents and skills you gain in Ramadan are for you to take away, not to leave behind and forget till the following year.

A soldier once trained never rejoins the civilian population and in like fashion, a soul once surrendered should never be reclaimed.