South Africa has a dire shortage of organ donors. This means that doctors struggle to find suitable donor organs for critically ill patients who would die without receiving a transplant. Sometimes they have to make tough calls such as using a blood group incompatible organ to save a patient’s life – even if this comes with additional risk.
About a year ago we made a tough call of our own: we could save a child’s life by giving the child a liver transplant – but risked infecting the child with HIV in the process. The donor was the child’s mother, who is HIV positive and the child was HIV negative. The procedure came with a risk of transmitting HIV to the child.
South Africa’s law does not forbid the transplantation of an organ from a living HIV positive donor to an HIV negative recipient, provided that a robust informed consent process is in place. But this isn’t universally accepted as best clinical practice because of the risk of HIV transmission to the recipient.
The young recipient had been on the organ donor waiting list for 181 days. The average time on the waiting list in our transplant programme is 49 days. The child’s mother had repeatedly asked if she could donate a part of her liver, but we could not consider this because it was against the policy in our unit at the time. Without a transplant, the child would certainly have died.
After much consideration, and with permission from the Medical Ethics Committee at Johannesburg’s University of the Witwatersrand, we decided to go ahead with the transplant. With careful planning we were able to give the child antiretroviral drugs in advance, with the hope of preventing HIV infection.
The transplant, which happened at the University of the Witwatersrand’s Donald Gordon Medical Centre, was a success. The child is thriving, but at this point we are unable to determine the child’s HIV status. In the first month after the transplant we detected HIV antibodies in the child and it looked like HIV infection might have taken place. But as time went by the antibodies declined and are now almost undetectable. We have not been able to work out for certain whether the child has HIV or not. Even with ultra-sensitive, specialised testing, we have not been able to detect any HIV in the child’s blood or cells.
It will probably still be some time before we can be sure. However, the child is doing very well on antiretroviral treatment. And we know from cases where HIV was transmitted inadvertently that people who get HIV from an organ transplant do as well as those who get an HIV-negative organ.
This operation could be a game changer for South Africa. The country has a large pool of virally suppressed HIV-positive people who have previously not been considered for living liver donation. Viral suppression is when a person with HIV takes their antiretroviral medication as prescribed and their viral load – the amount of virus in their blood – is so low that it is undetectable.
Ethical and legal considerations
Organ transplant comes with many ethical and legal challenges. In this case, some unique and complex issues were carefully considered.
We took great care to consult widely before doing the transplant. This included speaking to the members of the transplant team, bioethicists, lawyers, experts in the field of HIV medicine and Wits University’s Medical Ethics Committee. The committee’s function is - among other things - to protect patients in medical research, and to make sure doctors are doing procedures for the correct reasons.
It was clear that a transplant was in the child’s best interests. The bigger ethical question was whether it was right to deny the mother the opportunity to save her child’s life. A fundamental principle of ethics is to treat people fairly. People with HIV should have the same health care options as everyone else.
We, along with the Ethics Committee, agreed that as long as the child’s parents understood that there was a risk the child could acquire HIV, it was acceptable to go ahead with the transplant.
Then, to ensure that the child’s parents were properly informed and in the best position to make a decision, we used an independent donor advocate. The advocate was not employed by the hospital and their main role was to support the parents by ensuring that they understood exactly what the risks were for the mother as a donor. The advocate also engaged with the transplant team on the parents’ behalf, if needed.
In this case, the parents were committed to go ahead with the operation, and had already come to terms with the risk of HIV transmission to their child. They were appreciative that the team were willing to carefully consider this option for them, given that there were no alternatives available and their child was critically ill. We asked both parents to consent to the procedure, as both are responsible for taking care of the child going forward.
Lessons and opportunities
This operation has shown that doctors can do this type of transplant, and that outcomes for the HIV positive donor and the recipient can be good. It has also created a unique opportunity for scientists at Wits to study HIV transmission under very controlled circumstances.
For now, doctors will not be able to tell parents whether or not their child will get HIV from this type of transplant. This is because this is a single case with many unanswered questions that will hopefully be answered through ongoing research.
Going forward, we will continue to ensure that parents are fully aware of the uncertainty in this situation. All future cases will be part of an ongoing research study that will investigate HIV transmission in children in more detail and the ways in which HIV may or may not be spread through organ transplantation.
Harriet Etheredge, Bioethicist and Health Communication Specialist, University of the Witwatersrand; Jean Botha, Head of Transplants at Donald Gordon Medical Centre, University of the Witwatersrand, and June Fabian, Research Director at Donald Gordon Medical Centre , University of the Witwatersrand
The EU plans to invest more in Africa and wants to intensify trade relations. Since the refugee crisis, Europe has been courting African governments and banking on increased cooperation.
For many years now, the EU's Africa policy has been a graveyard of big words, good intentions and unfulfilled promises. However, since the refugee crisis interest in a new strategy for cooperation with the continent has increased sharply.
The Europeans have stood by and watched as China established itself in Africa, investing billions in the continent. EU states fear they will find themselves relegated to the second league. This is why, in his speech this week on the state of the EU, Commission President Jean-Claude Juncker once again announced "a new pact with Africa."
More investment, more work, more training
In the next budget period the EU plans to increase funding to Africa to €40 billion ($46.5 billion). The hope is that this money will then be multiplied by private investors. As an incentive, the EU wants to provide risk guarantees to encourage the private sector to make the commitment and invest in African countries.
At the same time, Brussels is increasingly seeking cooperation with the development banks of the EU member states and with the European Investment Bank (EIB), which are integrated into the program. The EIB, for example, is already providing €6 billion to 2020 to tackle the causes of migration and flight, and it's hoped this will trigger a further investment of around €35 billion.
The emphasis here is on education and jobs. Over the next five years the Alliance for Africa wants to create 10 million jobs; 750,000 people are to receive vocational training, with a further 100,000 students benefiting from the Erasmus exchange program. The European Commission also plans big investments in transport, road infrastructure and energy.
'Next step is to be true economic partners'
When asked whether this wasn't just another reiteration of the EU's good intentions, Neven Mimica, the EU commissioner for international cooperation and development, explained that the plans currently being put forward represent a new approach.
"Until now there wasn't a coherent economic strategy," he said. Now, though, the EU wants to define — in partnership and cooperation with African countries —the best opportunities for development in each nation, and how the private sector can be incorporated into the relevant projects.
The European Commission gave an example of this tailor-made support. With the support of the Dutch development bank FMO, microcredits are being given to internally displaced people, returnees and small businesses in sub-Saharan countries. This is intended to generate several hundred thousand jobs, from an initial capital of €75 million.
"We are already strong political partners," said Federica Mogherini, the EU's chief diplomat. "The next step is to be true economic partners and deepen our trade and investment relationship."
The EU is still Africa's biggest trading partner, accounting for 36 percent of all exports, ahead of China and the US. The aim of the European Commission is to intensify this cooperation and put it on a new contractual basis. There are already partnership agreements with 52 African countries, meaning that many goods — everything except weapons — are generally exempt from customs duty.
As a next step, Europe is aiming for a comprehensive free trade agreement between the EU and Africa. But this would also mean African partners would have to dismantle the majority of their customs barriers. African countries should, however, be allowed to retain some of their import duties in order to protect their domestic agricultural industry.
Critics have pointed out that the principle of fair exchange has already met with trouble, because European products are forcing their way onto African markets at prices that are far too low. And if farmers in Europe are hurt by low prices, they at least get compensation in the form of direct payments from the EU. For small-scale farmers in Africa, their entire livelihood may be jeopardized.
NGOs have warned there cannot be the same rules for trade between rich and poor countries. As one of the most important countries in West Africa, Nigeria has until now refused to sign a partnership agreement with the EU. The balance of interests in this field is more complicated in individual cases than one might suspect, given the EU's grand announcements.
European politicians have reacted with alarm to demographic projections that see Africa's population surpassing 2 billion by 2050. Leaders like France's Emmanuel Macron and Germany's Angela Merkel have been tirelessly visiting African nations to promote economic cooperation and development, spurred on by the prospect of increasing numbers of African migrants potentially seeking a better future in Europe.
Mogherini has said "the young people in Africa are not a burden, they are an opportunity" for the continent, though she hasn't denied that rapid population growth will be a challenge. What has gone unsaid, at least officially, is that a doubling of Africa's population in the next few decades will rapidly absorb any development progress, leaving even the most colossal international investment plan scrambling to catch up.
And comments like those by Tanzanian President John Magufuli, who recently called on the women of his country to abandon contraception and produce more babies, may well have provoked even more concern among European politicians and given rise to fresh doubts about the responsibility of some African rulers.
Readmission agreements for African migrants, which play a role in all of the EU's negotiations, are also progressing slowly. The money that migrants send home to their families from Europe is currently more important than investment pledges from the north; pledges which will only pay out in the future.
Official statements from the EU have also carefully avoided topics like corruption insecurity, so as not to create political resistance. The hope is that private investors will not be put off, and instead will see the promise of Africa's economic possibilities and allow guarantees from the EU and development banks to calm their nerves.
Air Zimbabwe has been struggling with a $300 million debt, including to foreign creditors. Only three of its planes are operational.
Zimbabwe has appointed an independent administrator to run its loss-making national airline to try and revive its fortunes, according to an official notice.
Air Zimbabwe has been struggling with a $300 million debt, including to foreign creditors. Only three of its planes are operational, with another three grounded, which has forced it to abandon international routes.
Justice Minister Ziyambi Ziyambi appointed Harare-based chartered accountant Reggie Saruchera as administrator with powers to “raise money in any way without the authority of shareholders for the purposes of the reconstruction,” according to a government gazette published late on Friday.
Finance Minister Mthuli Ncube said on Friday the government was hoping to sell stakes in Air Zimbabwe and other state-owned companies under a package of reforms - though the airline has failed to attract private investors in the past.
The government said in April it had bought two Boeing 777 aircraft and an Embraer plane from Malaysia but added that the planes would be leased to a new local airline until Air Zimbabwe returned to profitability.