Visit my blog: Criminal HIV Transmission

about me

My photo
Berlin, Germany, and Brighton, United Kingdom
An advocate for the rights of people living with HIV, I work as a freelance writer/consultant on HIV-related issues. As a consultant, I work with: The Joint United Nations Programme on HIV/AIDS (UNAIDS); The Global Network of People living with HIV (GNP+); NAM (National AIDS Manual); and NAT (National AIDS Trust). As a journalist, I write for aidsmap.com and POZ magazine. For further information about me, and my work, please visit my website.

HIV Forensics (from Criminal HIV Transmission; NAM, 2007)

This is a short excerpt – a summary at the start of the HIV Forensics chapter – from my book, Criminal HIV Transmission, published by NAM in April 2007.

To purchase the book, please visit NAM's bookshop.

• When investigating an alleged criminal HIV transmission case, individual elements of the scientific evidence should be seen as small pieces of a much larger puzzle.
• Even the rarest HIV subtypes and recombinants have been found in more than two people in the UK (and some subtypes and recombinants have been found in hundreds, if not thousands of people in the UK).
• Sharing the same HIV subtype or recombinant does not ‘prove’ that transmission occurred between the complainant and defendant.
• Phylogenetic analysis can only estimate how closely related two samples of HIV are likely to be: it is a grey area – unable to create a definitive ‘match’.
• HIV, unlike human DNA samples or fingerprints, is never unique to an individual.
• Consequently, although two individuals may have HIV strains that appear to be closely related, this will not necessarily be unique to the two individuals but could extend to other people who are part of the same transmission network.
• Even with the appropriate comparison samples, phylogenetic analysis cannot ‘prove’ that HIV transmission occurred directly between two individuals
• If phylogenetic analysis is carried out rigorously it is reliable enough to show that the virus from the person under investigation and the complainant are not closely related to each other. In other words, it can exonerate (eliminate, in an investigators words) the suspect.
• Even if phylogenetic analysis suggests that the two viruses are highly similar, this does not provide enough information to know the direction or timing of the alleged transmission (i.e. who might have infected who; or who might have been infected first).
• Medical records can be accessed by the police and used in a court of law if they are relevant to a case, by obtaining a search warrant or court order.
• Neither the person under investigation nor the complainant may have been totally honest when relating their sexual history to a clinician, consequently medical notes may not be totally reliable in providing information about sexual risks.
• However, medical records will contain accurate information on clinical symptoms, as well as virological and immunological information.
• Establishing when both the person being investigated and the complainant were infected (rather than diagnosed) with HIV is important, but not always possible.
• Attempting to work out the timing of HIV infection via physical symptoms, immune status or by levels of HIV in the blood is extremely difficult, and should always be interpreted with great caution.

 

BETTER PRACTICE: Why GPs need to be integrated into HIV-positive care

Originally published in AIDS Treatment Update 158, July 2006.

In the 25 years since what is now known as AIDS was first described in a group of gay men in California and New York, for many people living in developed nations like the United Kingdom, an HIV diagnosis has evolved from a death sentence into a complex chronic condition.

Constantly-evolving monitoring and treatment are not the only reasons why HIV disease is complex. Since HIV is also primarily a sexually transmissable condition and is also an unfolding global event – with legal, social and political implications – it is further complicated by prejudice, stigma and discrimination.

The UK’s National Health Service (NHS) attempted to deal with some of these discrimination issues early on by placing HIV testing within the free and confidential GUM (genito-urinary medicine, or sexual health) clinic. Since HIV treatment necessarily evolved in both GUM clinics and other specialties, like Infectious Diseases, many doctors in general practice (GPs, who provide primary care) had limited exposure to patients with HIV.

In the 21st century, however, it is clear that both GUM clinics and HIV specialist services are struggling to meet demand. The government believe that the obvious place to relieve some of this pressure is in general practice, and it is now their strategy to involve primary care in sexual health and HIV services. The problem, however, is that most GPs are not adequately experienced or skilled in complementing seuxal health and HIV specialist care.

Nevertheless, some of our healthcare needs – including general care for non-HIV related conditions and care relating to HIV that sits naturally in general practice (e.g. facilitating referral to mental health services in the community) – may be better managed at a GP's surgery rather than at an HIV clinic. And there may be new roles for HIV-educated GPs to play in the future (e.g. the routine monitoring of CD4 counts and viral load).

Why do we need a GP?
Until now, many HIV-positive people have been able to use their HIV clinic not just for HIV care, but also for general health issues. Many clinics currently provide prescriptions for things that are definitely not HIV-related (like flu vaccines, or asthma medicine) although some are beginning to limit their prescribing to anti-HIV drugs only.

Whatever the situation in your clinic (and London HIV clinics are already under pressure to save money this year due to only a 5% increase in funding despite at least a 10% increase in patients) their prescribing policies will probably have to change in 2008. That's when a new NHS funding system known as payment by results promises to radically alter how HIV-positive patients get services, and how HIV outpatient clinics get paid for providing them (for more on this see Does cost matter? in ATU 150; October 2005).

In May, NAM held a one-day clinical symposium to discuss issues around the future of HIV treatment. Part of the afternoon session focused on accessing care in the context of NHS overspends, cost-cutting and payment by results; how increasing HIV diagnoses are overburdening already stretched HIV clinics (which provide secondary care); and how GPs can be better integrated into the care of HIV-positive people.

"With payment by results we will no longer be able to act as GPs and refer our patients to another specialty, for example to get a hip replacement," noted Dr Margaret Johnson, Chair of the British HIV Association (BHIVA), at the symposium. "Therefore GPs are going to have to be involved, and that means we need to make sure all of our patients have GPs [by then]".

There is absolutely no possibility, however, that GPs will take over all HIV care – at least for the foreseeable future. "I think we're a long away from GPs routinely prescribing antiretroviral therapy," Martin Fisher, HIV consultant at Brighton and Sussex University Hospital, told the NAM symposium. "Maybe in ten years but not in the next few years."

And Judy Hague, HIV programme director of the London Specialised Commisioning Group confirmed that "the case for HIV remaining a specialised service is a strong one. People with HIV may have other health problems, and will require access to a balance of services [including GPs] but I don't personally anticipate that HIV care will move outside of specialised services [i.e. the HIV clinic]".

What can GPs do for us?
There are several reasons why registering with a GP and telling them of your HIV status may be beneficial. The GP’s surgery should be more accessible and may be open in the evening for appointments. Unlike HIV physicians, GPs can visit you at home and you can also access a doctor for emergency visits after hours via your GP. They are an alternative to the specialist clinics for sorting out and treating general problems for people who are largely asymptomatic or have only mild symptoms of HIV infection. And for people with advanced HIV disease, GPs are invaluable in helping to provide home support in association with specialist community care teams and nurses.

William Ford-Young, who describes himself as "a pragmatic 'coal-face' GP, with an interest in the GP's role in HIV management and support" is one of two GPs on the government's Independent Advisory Group on Sexual Health & HIV, and is also Chair of of the Royal College of General Practitioners (RCGP) Task Group for Sex, Drugs & HIV. He argues that all HIV-positive people can really benefit from having a GP, regardless of the kind of care they receive at their local HIV clinic.

"My feeling, as a GP, is that GPs have tremendous skill and experience and a whole team at their fingertips to provide ongoing care for people with chronic conditions," he says. "Certainly, people need a specialist for the complicated HIV issues like therapeutics, virology and immunology. But I think GPs are good at doing things that HIV specialists possibly aren’t good at; we can manage many of the things that go hand-in-hand with chronic disease: the psycho-social issues; the relationship difficulties; the mental health-related things, like depression; and the way that a chronic disease can generally affect your feeling of wellbeing. These are things that good GPs deal with all the time."

Steven Ash, HIV consultant at Ealing Hospital, in west London, agrees that "there are some problems patients may have that are better dealt with by a GP, and patients miss out if they do not make use of a GP service."

Barriers to integration
"It comes down to the right patient seeing the right doctor for the right thing," said Martin Fisher at the NAM symposium, but he added that "there are a lot of barriers" to the integration of HIV into primary care. "Some of those barriers are with the GPs, who are scared about HIV," he said. "Then there are problems with secondary care. I think we're a bit too precious and not very good at letting go, and I think we need to. And then I think there are barriers around patients being scared of their GPs having sufficient knowledge [about HIV]. We have to get over these barriers and make sure GPs get involved."

Understandably, this is causing a lot of anxiety, not just amongst HIV-positive people and the community groups that advocate for and support them, but also amongst many GPs and HIV physicians.

So far, however, no clear policy has emerged regarding who will lead this integration of GPs into HIV-positive people's care. For example, neither the DoH, nor the NHS, nor many of the leading bodies involved in either specialist HIV care or general practice - including the RCGP, BHIVA, the British Association of Sexual Health and HIV (BASHH) and the British Medical Association (BMA) - have agreed on how best to educate GPs about HIV.


Lack of trust
We are now in the unfortunate situation where the people who have lived with HIV for the longest time have the least trust in GPs. This is likely because most of the people initially affected by HIV in the UK – gay men, injecting drug users and sex workers, all of whom were marginalised from society – often experienced prejudice, stigma and discrimination from their GPs during the Thatcherite 1980s and early 1990s.

In fact, a survey undertaken last year at a north-east London HIV outpatient clinic, and presented to the BHIVA Conference this March, found that 85 out of 1687 patients (5%) had experienced HIV-related discrimination from their GP in the past [1]; gay men were much more likely to have experienced this discrimination than African men and women.

Since December 2005, the Disability Discrimination Act has protected anyone diagnosed HIV-positive from being discriminated against in a healthcare setting, since they are providing services (one of the areas covered under the Act). It is, therefore, unlawful for GPs not to provide the same services to an HIV-positive person that they provide to HIV-negative people, or to discriminate in the standard of service or the terms on which the service is provided.
However, the law cannot change attitudes overnight, and there still does appear to be a lot of concern over another, related issue: a perceived lack of confidentiality, particularly when it comes issued around informing third paties – e.g. insurance companies – about their HIV status. This continues to be a common reason given by HIV-positive people for not involving their GPs.

For example, Ealing's Steven Ash tells ATU that "around 10% of our patients have no GP. Another 30% do not allow us to communicate with their GP, and the GP is therefore unaware of their diagnosis."

William Ford-Young says that although in the past he's heard some horror stories about issues such as a lack of respect for confidentiality, things have much improved. And where they haven't, "it's important that patients, and patients' organisations, challenge wherever they are finding bad practice."


Better communication needed
"HIV remains the only condition whereby you can go from your diagnosis to your death without your GP ever knowing about it," notes Dr Ford-Young. "In this day and age, that’s appalling."

One of the problems is that the 1974 Venereal Disease Regulations – which provide for strict confidentiality within the GUM clinic – may be preventing good and clear communication between HIV clinicans and GPs and we, as patients, are often caught in the crossfire.

At the moment, HIV physicians can only keep a patient's GP informed of medication and other important treatment information if the patient gives them permission to do so. However, the simple act of asking for permission may create unecessary anxiety, and suggests that there is something inherently wrong in the GP having this information. Like any successful relationship, good communication can remove uncertainty, mistrust and fear.

Dr Ford-Young's RCGP Task Group has been trying to improve communications between GPs and HIV physicians for several years. "I think the waters have got very muddied with secondary care providing a primary care service for a lot of HIV-positive patients," he says. "To help remedy that, we are working on processes of safe communication, safe prescribing, and sorting out who’s responsible for doing what," he says. "We’re working quite hard to make sure that HIV-positive people can have good GPs, but obviously this only works well if GPs are aware of their patient's HIV status."

Brighton's Martin Fisher agrees communication must improve – not just between GPs and HIV physicians, but between HIV-positive people and GPs as well. "It's important to have that dialogue with GPs because if we don't involve them, and if the patient doesn't tell them, they're not going to know what medications we've prescribed and that could lead to GPs prescribing drugs that interact, or change a drug we've prescribed, like a statin [lipid-lowering drugs, many of which can interact with anti-HIV medicines], through no fault of their own," he told the NAM symposium.

Enhancing services
Happily, many individuals and organisations are begining to work together to try to find solutions to these problems.

The Medical Foundation for AIDS and Sexual Health (MedFASH) - a charity supported by the BMA - recommended that all people with HIV should have access to good quality GP care encompassing prevention, diagnosis, treatment and care as part of their 'Recommended standards for NHS HIV Services', published in October 2003 and endorsed by the Department of Health (DoH). A year later, they produced an excellent booklet, HIV in primary care, aimed at educating GPs about myriad HIV issues - from HIV tests to drug-drug interactions.

Later this month, BHIVA is hosting a one-day workshop comprising many HIV professionals, representatives from the DoH and Primary Care Trusts (PCTs), and many patient advocate organisations, including NAM. Focusing primarily on how best to improve access to HIV care throughout the UK, it will also include a discussion of how GPs can best be integrated into the care of HIV-positive people.

And in several areas of the country, GPs are being educated about HIV at locally-run workshops. In Brighton, they've been running an interactive two-day HIV education course for interested GPs and their practice nurses since 2004, resulting in at least eight GP practices in Brighton and Hove providing what is known as locally enhanced services for HIV-positive people. "We're not expecting GPs to provide HIV care," explains Martin Fisher, "we're expecting the GPs to provide the primary care for people who also happen to have HIV."

Education is the solution
Surinder Singh, a south-east London GP with a special interest in HIV, and the second GP on the government's Independent Advisory Group on Sexual Health & HIV, noted at the NAM symposium there is "great variability with where locally enhanced services are available."
These services are funded by individual PCTs, and thanks to the government's decentralised funding of NHS services funding decisions are left to the discretion of individual PCTs. "So in south east London we don't have any," continues Dr Singh, "and that doesn't seem all that equitable. The patient should come first."

Dr Ford-Young agrees, but argues that HIV-positive people don't necessarily need a locally enhanced service to get the best from their GP. "The bottom line is that if you have a good quality general practice – and that’s not just the GP, but the whole team – things work well for patients with HIV no matter who they are or how they’ve acquired their HIV infection. And those issues shouldn’t have to arise because GPs should be good for everybody.

"I know that that's an ideal, and it's important to recognise that there are gaps between the ideal and reality. But educating GPs about HIV, educating patients about GPs, and creating a much better dialogue between the specialists and general practitioners can close that gap."

References
1. Elford J et al. Discrimination experienced by people living with HIV. HIV Med 7 (supplement 1), abstract P93, 2006.

 

AGEING (DIS)GRACEFULLY

OK, so you’ve got a big gut, skinny legs and more lines on your face than Bob Hope had in his joke book. But is it the HIV drugs - or because you’re not young any more? Edwin J Bernard investigates.

HIV drugs may have saved many of our lives, but sometimes it seems like we’re not feeling - or looking - any better than in the pre-treatment era. It was probably na├»ve to think that a handful of pills was all it would take to remain young, healthy and gorgeous. And then there have been all the reports about the increased risks of heart disease, stroke, joint and bone problems, diabetes and cancers in people living with HIV. The question is though, how many of these increased risks are due to the drugs we are taking to stay alive, and how many due to simply living longer and ageing (dis)gracefully? And if it’s the latter, can you do anything about it?

Is it easier to blame the drugs?

James is so sick of the lipodystrophy issues that he’s faced in recent years, he’s decided to interrupt his therapy indefinitely. “It’s such a relief to get off the drugs,” he says. “Everyone seems to be sicker now on the drugs than before. I’m never going back on them.” Unfortunately, the elation James currently feels at not having to take antiretrovirals, which he associates with feeling sick, may not last long.

No one is suggesting that because there are things we can personally do to the reduce the risk, that it’s our fault if we suddenly keel over and die (that’s far too Louise Hay!). But might some of us be keener to stop taking our antiretrovirals because of the recent focus on their, admittedly scary, side effects than to take a look at the other things we do in our lives and make some changes? This would include things like stopping or cutting down on our smoking and use of recreational drugs; cutting down on alcohol intake; thinking about the kind of sex we are having and making sure we don’t get or pass on bugs that could cause future health problems; adjusting our diet so that we eat balanced and regularly, eating less saturated fat and refined sugars (and NOT doing Atkins!); and exercising in any way we enjoy more often.

Is HIV more toxic than the drugs?

Studies from both Spain and Thailand presented earlier this year at an Aids conference in Boston found that the only people who could possibly cope with a ‘drug holiday’ were people whose CD4 counts had never dropped below 200 and who were well above 350 when they stopped therapy. James had reached the scary double digits before increasing to the ‘safer point’ of 250, thanks to the HAART that reduced his viral load to undetectable and also gave him these debilitating side effects. But staying off therapy for a long time is really a danger to one’s health, and at some point, everyone in the Spanish and Thai studies needed to start therapy again. But James is not alone in his dilemma, as the realities of what it means to live longer with HIV have crept up and punched us in the face. Last year, a study in the American Journal of Medicine found that a majority of HIV positive Californians would be prepared to have their life expectancy shortened by over two years if it meant avoiding the disfigurement of lipodystrophy.

The question we have to continually ask ourselves is: are the drugs really more toxic than HIV itself? Every study looking at the impact of HAART on deaths in people with HIV has found that death rates have declined substantially due to the antiretrovirals we now take for granted in the UK. For example, the EuroSIDA study - which included over 7300 people with HIV throughout Europe - found that the death rate plummeted from 16 to three per 100 people per year between 1994 and 2001 due to the availability of HAART. The simple fact is that if we stop taking the drugs when our immune system is not in control of the virus our chances of dying sooner rather than later rise dramatically. A bitter pill to swallow, but at least we in the UK can choose what pills we take and how we live our lives.

‘If I went for a bacon sandwich, he’d slap me!’

Having the high blood lipids (fats) associated with many HIV drugs, for instance, is certainly a worrying thing to deal with. But last month, Anna Poppa suggested that the most significant thing you could do to reduce the risk of heart attacks and strokes was to stop smoking. In fact a group of experts in the US recently suggested focusing on lifestyle factors generally before demanding fat lowering medications from your doctor. Stopping smoking, changing your diet and exercise can all have a remarkable effect.

BJ was at death’s door eight years ago before taking a ritonavir-based drug regime that gave him his life back.

“But then I got a huge belly and my triglycerides and cholesterol went soaring”, he recalls. He was partial to bacon sandwiches and Sugar Puffs, but after seeing a dietician at St Mary’s in west London he changed to a low saturated fat and refined sugar diet. A test three months later showed that “all my blood fats had come down very quickly.” Having a supportive partner helped, says BJ “If I went for a bacon sandwich, he’d slap me!”

James is one of the growing number of people with HIV to be diagnosed with diabetes. A recent French study found that 10 per cent of patients on antiretrovirals had developed diabetes three years into treatment. But their age, and not their antiretrovirals, was the significant risk factor. A family history of diabetes and high blood sugar levels before starting therapy may also increase your chance of developing diabetes on HAART. Co-infection with hepatitis C may also be a risk factor.

The first step in getting blood sugar levels down to normal is to do the same as you would to avoid heart trouble: eat less refined sugar and saturated fat, and take more exercise. Experts suggest doing aerobic exercise (exercise that causes your heart rate to rise above normal levels) for at least 20 minutes each day. Examples include brisk walking, swimming, cycling, jogging or doing aerobics or other heart-healthy gym classes.

If diet and exercise aren’t enough to normalise blood sugar levels, and it’s not possible to switch drugs in your HAART regime to avoid whatever is causing the glucose elevation, then drug treatment may be necessary. But even if you start diabetes treatment, diet and exercise changes are always recommended by experts because these can still help in lowering your blood sugar.

Osteoporosis: a pain in the neck...and elsewhere

How is it that a condition previously only seen in post-menopausal women is now affecting people with HIV? Osteoporosis has been reported in three to 20 per cent of people with HIV, depending on the definition you use. BJ has been suffering from pains in his legs, knees and hips for the past six months. This could be osteoporosis - which is caused by a lack of bone calcium and protein and is commonly referred to as ‘thinning of the bones’, or another bone disorder called osteonecrosis - literally ‘bone death’ - that is caused by poor blood supply to an area of bone.

The evidence from studies so far appears to show that HAART is not strongly associated with these bone disorders, whereas length of HIV infection and nutritional status do appear to be important. As with many of the other health problems affecting people with HIV, HIV itself is just one more additional risk factor on top of the usual ones seen in people without HIV which include: a family history of bone disorders, low calcium intake, smoking, and a sedentary lifestyle (ie - yet again - not exercising enough!).

Healthy mind, healthier body

Then there’s what was always one of the most frightening manifestations of Aids in the bad old days: dementia. HAART has been shown to improve the brain function of people with dementia, especially in particular drugs that cross the blood/brain barrier like AZT. But treatment does not appear to eradicate HIV dementia, or even prevent it from developing in the first place.

Of course, mental health symptoms may not have a neurological cause like dementia. Mental health problems can affect anybody, but it seems that people with HIV are more likely to experience some of them.

Depression is one of the most common forms of illness seen in people with HIV, affecting twice as many people as in the general population, not least because the groups most affected by HIV in the UK, gay men, refugees and migrants and drug users, are already more likely to have mental health problems.

One anti-HIV drug in particular has been linked with psychological disturbance, including suicidal thoughts. Last year, researchers in San Francisco General Hospital found a greater incidence of severe psychiatric illness resulting from HIV treatment with efavirenz (Sustiva) than had previously been reported, with 12 per cent of people on efavirenz experiencing depression (and almost three per cent suicidal depression) compared with only just over one per cent on nelfinavir. If you do have a history of depression and it hasn’t improved or has got worse since starting efavirenz, you should discuss with your doctor what other drugs might be suitable.

Cancer, HAART and HIV

Between 2000 and 2002, the most common cause of death at the UK’s largest HIV clinic, London’s Kobler Centre, was cancer: non-Hodgkin’s lymphoma (NHL) and non-AIDS-defining cancers (such as lung, testicular and anal cancer).

How does HAART affect cancer? Well, response to HAART appears to be a very important factor when it comes to doing well with non-Hodgkin’s lymphoma (NHL), according to a German study published earlier this year. It added to the body of evidence that although NHL is appearing relatively more often in the post-HAART era, HAART can still positively affect outcome.

The incidence of non-Aids-defining cancers in HIV positive patients is the subject of ongoing debate right now, but several studies have suggested that HIV positive patients have an increased incidence of cancers of the lip, lung, anus, penis and of Hodgkin’s disease (the other kind of lymphoma). The irony is that whilst HAART stops people from dying of HIV itself, since people are living longer they are now starting to get - and sometimes die from - the kind of cancers seen in the general population.

Living is the biggest single cause of death!

More and more diseases traditionally attributed “simply” to ageing have recently been linked with either genetic or viral factors. These include cancers, heart disease, stroke and diabetes, to name but a few.

Perhaps it’s no coincidence that the same illnesses are also ones associated with HAART. The longer HAART helps us live, the more likely we are to get sick with the kinds of illnesses that non-HIV infected people get.

Our lifestyle (our diet, smoking, exercise, drinking, sex and sunbathing habits, for example), our genetics (the susceptibility to disease we inherit from our parents), and whatever chronic viruses we carry - not only nasties like HIV and hep C but also more common and often asymptomatic ones like Epstein-Barr (the glandular fever virus), CMV and human papilloma virus (HPV) - combine to dictate the likelihood of our getting ill and dying the longer we live.

We can’t control our genetics (as yet), and if we already have these viruses we can’t usually become uninfected, but there are things we can do to attempt to turn back the ageing clock and reduce our chances of getting sick.

 

HAPPY

Edwin J Bernard reviews Ronnie Burkett's latest puppet show at Gardner Arts Centre, Brighton, 22-25 May 2003.

Ronnie Burkett's Theatre of Marionettes worked another miracle with the final production of his 'Memory Dress Trilogy', Happy, which closed the Brighton Festival in May. Canadian-born Burkett is less a puppeteer, more a playwright-illusionist, able to express deeply moving emotions and radical ideas through the magic of marionettes. Individually his skills, as puppet-maker, set-designer, writer, and performer, are remarkable, but together they are unique. Last year's Street of Blood had an AIDS theme, and Happy is about death, loss and grieving. Sounds like fun, you say?

Well, in Burkett's hands (literally) it's a remarkably rich, emotionally satisfying - and yes comic - experience. Young poet Carla unexpectedly loses her hip, cool Drew. As she and her oddball, aged neighbours deal with the loss, camp Antoine Marionette, queen of the bitchy one-liner, emcees the Grey Cabaret which mirrors Carla's five stages of grief: denial, anger, bargaining, depression and acceptance.

Mind-blowing plot twists take us through every conceivable feeling. Like Street of Blood, Burkett's agenda is both satirical and cathartic; ironic that such inanimate objects can be so life-affirming.

Happy is now retired, but miss his new show, Provenance, next year at your peril. (At the Barbican, London and as part of Manchester's Queen Up North festival in the spring.)

For more details, visit Burkett's agent's website at: www.johnlambert.ca

 

FOREIGN AIDS

Edwin J Bernard reviews Pieter Dirk-Uys' one-man show at Theatre Royal, Brighton, 18 May 2003.

In his one-man, multiple-personality show, Pieter Dirk Uys wryly remarks that his most famous creation, apartheid-yearning Evita Bezuidenhout, has been called South Africa's answer to Dame Edna. "What's the question?" he wonders.

Indeed. Whereas Barry Humphries is all frothy, sexual innuendo, Dirk Uys is primarily scathing, campaigning political satire. '

Foreign AIDS' is a remarkable tour-de-force offering an insight into the complexities (and complexes) that make up South Africa's AIDS experience. (An experience that has reached horrific proportions at this point in time.) One minute Dirk Uys reveals the incompetence and hypocrisy of President Thabo Mbeki's dissident view of HIV: "My mind is made up," he exclaims as Dr Thaboo MacBeki. "Do not confuse me with the facts."

Then there's Evita's scandalous sister, an ex-stripper with HIV who inadvertently married a Nazi and comes to London for her antiretrovirals. "Racism," she muses, "is easier to catch than AIDS."

In between constructing and deconstructing his characters on a bare stage filled with boxes of empty foreign aid bound for SA, Dirk Uys tells achingly funny, and astutely sobering, stories of real-life experiences promoting HIV awareness in his home country.

At the same time he addresses the South African parliament with a condom-covered dildo and describes visits to more than 160 schools with a shocking, but necessarily frank, show about safer sex called 'For Facts' Sake'.

While some have criticised his show for making light of tragedy, Dirk Uys firmly believes that "humour is a great weapon. I aim to make people laugh at their prejudices and confront their fears." Bullseye.

Pieter Dirk Uys should return to the UK next year. For more details contact UK Arts International on 020 7381 4115 or visit: www.evita.co.za/pieter