The Issue of Systemic Lupus in Southern Africa

The southern African region has its own challenges with lupus. The low incidence rate in whole Africa may be the result of multiple factors. In majority of cases there is delay in diagnosis, Tiffin et al has reported in 93% of cases there is complete delay or some delay in diagnosis. Lack of awareness about SLE, limited facilities in primary health care settings, limited diagnostic centre to carry out serological and histological test for SLE and availability of specialist physicians are the major factors across Africa. 

Treatment of SLE in Africa is difficult due to high cost of drugs. Tiffin et al mentioned in their review of SLE patient in Africa that the cost of MMF is about 100$ and cost of one session of dialysis is 100-150$. This high cost of treatment is also seen in developed country. But poor socioeconomic condition of patients in developing country is a major contributor of overall outcome of SLE. A review identified the paucity of prevalence data, decreased funding for rheumatology-related research and low numbers of rheumatologist as an important contributing factors. There is a low ratio of rheumatologist per population, which varies from 1:35000 to 1:1600000.

Diagnostic delay is seen if laboratory facility to do the serological test, urinalysis and facility for tissue biopsy are unavailable. Renal complication like lupus nephritis is a poor prognostic indicator of SLE and need early diagnosis.Renal biopsy is the gold standard investigation for lupus nephritis. These services are not available in many centres in Southern Africa. Delay in diagnosis leads to a more adverse outcome. The Anti- nuclear antibody test (ANA) facility is available in most country in southern Africa. 

Follow-up of SLE treatment is major concerns to avoid complication. The lack of laboratory facility at primary, secondary and tertiary hospital level have a negative impact on the outcome of a patient treated as SLE. It is important to monitor the treatment related toxicity. Tazi Mahek et al has mentioned in their review that MMF treated patient has less infection and treatment related hospital admission than CYC.

Immunosuppressive, biologic treatment needs prior screening for tuberculosis. HIV patient with low CD4 also needs treatment adjustment to avoid opportunistic infection. Limited number of rheumatologist can compromise early initiation of appropriate medication. The standard clinical guidelines are modified in developing country due to cost and availability of the drugs. There are some universal problems in the management of SLE. Such problem includes complication of medication; adherence and drug-drug interaction due to other illness are a challenge in lupus management. Patient’s poor adherence also contributes to their poor outcome. Tazi Mahek et al in their review of a study in Brazil mentioned that 51% of nonadherence among SLE patient is due to financial reason.

The understanding of complex disease like SLE is changing over the years. The treatment and diagnosis methods will be more effective in future. In southern Africa, it is important to increase public awareness and highlight the problem of SLE. To improve outcomes of SLE in these developing countries, there is a need to increase resources allocated to non-communicable diseases. Medical schools need to introduce students about the diagnosis and treatment of autoimmune disorders early, general physicians and other specialists need to have greater exposure to these conditions and primary care workers should be trained to manage these disorders early with disease modifying anti-rheumatic drug therapy.