hiv/aids care and treatment in africa · dominican republic. mali. female. male. 2.10. ... mulago...
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HIV/AIDS Care in AfricaA Personal Journey
WF. Schlech,MD9th
Travel Health ConfWinnipeg
April 2011
UGANDA
Uganda: Demographics•
~200,000 sq km (Nova Scotia -
55K)
•
~26 million people•
50% under 15 years old, median 14.7 (Canada, 18% <15 yo, median 37.8)
•
Birth rate 46/1,000 (Canada 11/1000)•
Mortality 17/1000 (Canada 7.6/1000)
•
Infant mortality 88/1000(Canada 5/1000)•
Life expectancy –
45 (Canada –
80)
•
Life can be short and difficult in Uganda
A typical Ugandanfamily…
Uganda’s future…
Two friends
A global view of HIV infection33 million people [30–36 million] living with HIV, 2007
2.2
Figure
2008 Report on the global AIDS epidemic
Life expectancy at birth, selected regions, 1950–1955 to 2005–2010
2.11
Eastern Africa
Central Africa
Southern Africa
Western Africa
Western Europe
Asia
30
40
50
60
70
80
90
1950–1955
1955–1960
1960–1965
1965–1970
1970–1975
1975–1980
1980–1985
1985–1990
1990–1995
1995–2000
2000–2005
2005–2010
Yea
rs
Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2006 Revision, http://esa.un.org/unpp
UGANDA•
INDEPENDENCE 1962
•
THE ‘TROUBLED’
YEARS 69-86•
NATIONAL RESISTANCE MOVEMENT AND MUSEVENI’S LEADERSHIP (86-06)
•
THE CASTRO REPORT 1987 -
18 OF 60 UGANDAN OFFICERS HIV-POSITIVE
•
SUSTAINED LEADERSHIP AND PROGRAMATIC ACTIVITY TO REDUCE HIV INCIDENCE
Uganda: AIDS Demographics
•
2007 prevalence 5.4% •
Ugandans living with HIV –
940,000•
2007 AIDS deaths 77,000
•
AIDS orphans estimated: 1,000,000
Figure
2008 Report on the global AIDS epidemic
HIV prevalence (%) among 15–24 years old, by sex, selected countries, 2005–2007
0 5 10 15 20 25% HIV prevalence
SwazilandSouth Africa
ZimbabweCentral African Republic
Côte d'IvoireSierra Leone
RwandaHaiti
GuineaEthiopia
Benin
DR CongoNiger
SenegalCambodia
India
UgandaChad
Dominican Republic
Mali
FemaleMale
2.10 Source: Demographic and Health Surveys and other national population-based surveys with HIV testing.
Figure
2008 Report on the global AIDS epidemic
Disbursements for HIV per US$ 1 Million GDP, 2006
HSources: UNAIDS and Kaiser Family Foundation analysis, June 2007; Global Fund to Fight AIDS, Tuberculosis and Malaria online data query May 2007; International Monetary Fund, World Economic Outlook Database, April 2007.
Italy 4
Japan 24
Canada 50
Germany 60
France 93
United States 120
United Kingdom 328
Ireland 408
Sweden 462
Netherlands 521
0 100 200 300 400 500 600US$
Walking to work each day ..
Figure
2008 Report on the global AIDS epidemic
Percentage of HIV-positive pregnant women receiving antiretroviral prophylaxis, 2007
4.14 Source: UNAIDS, UNICEF & WHO, 2008; data provided by countries.
Figure
2008 Report on the global AIDS epidemic
Scale up of antiretroviral coverage over time select group of generalized and concentrated epidemic countries, 2004
to 2007
Source: UNGASS Country Progress Reports 2008.
100
0
20
40
60
80
Namibia
Rwanda
ThailandZambia
Swaziland
KenyaPapua
New GuineaMalawi
Ethiopia
Uganda
United Republic
of Tanzania
Côte d'Ivoire
LesothoNigeria
Viet Nam
Angola
Mozambique
Central A
frican
Republic
Perc
ent C
over
age
(%)
2004 2005 2006 2007
5.4
Orphans
Orphans in Uganda..
Mildmay Children’s Hospital
Orphans inUganda..
Grandma-headedfamilies..
Uncles raising nephews…
Some are more fortunate…
Some may not live long enough..
Teaching in Africa•
Working with the AIDS Training Program: a project of the Academic Alliance for AIDS Care and Prevention in Africa (AAACP)
•
AAACP is a joint initiative of the IDSA, HIVMA, and the Faculty of Medicine at Makarere University, Kampala, Uganda
•
Funding from Pfizer ($10 million)•
2 expert tutors provide intensive didactic and clinical teaching to 12-18 African physicians over a 1 month period for 2 sessions
Arrival at Entebbe…
Downtown Kampala…
Where I work…
Mulago Hospital
The “New”
Mulago Hospital
Prof. EdwardMbidde, formerhead of the UgandaCancer Institute…
…knows more aboutKaposi’s sarcomathan anyone inthe world!
Training room
Presenting cases…
learning about labs…
Dermatology clinic
Mulago wards
Uganda Cancer Institute ward
JCRC rounds with Francis Ssali
Outside the oldIDC
…note brothercarrying patientwith CNS toxo
150-200 patients/day…
IDC staff physicians
The new IDI…
Inside the new IDI, 2006 –
200-300 per day
A new case of CM in Urgent Care –
note wasting and stiff neck. About 40% of new patients are still presenting with WHO Stage III and IV disease despite “Know your serostatus”
effort
Last patient from a long day
-over 25,000 HIV (+)patients have been registered since 2003 in this clinic, only one of many in Kampala
Graduation day
Professor-in-Residence Program
•
Established as program of Academic Alliance for AIDS Care and Prevention in Africa
•
Senior US/Canadian academics provide 2-3 months of ongoing mentoring at the IDI and Mulago for students, residents,and fellows in clinical care and research per year
•
Rounds, lectures, advice on research, editing proposals, abstracts, and manuscripts
A day’s round on 4A…
21 yo woman high fever and HIV. She has miliary TB
21yo woman and her mother. HA and L hemiparesis-will treat for toxo. CT scans are ~$75 and unaffordable for vast majority.Septrin po is drug of choice as pyrimethamine is not affordable
24yo man withwasting, fever and breathlessness.Oxygen via nasal cannula.He has PCP pneumonia.Empiric treatment would be used and a chest x-ray would be the only diagnostic test.
This 26yo HIV(+) woman has fever, cough, and weight loss x 1 month.
Her daughter is HIV(-)
She has pulmonary tuberculosis
In the next bed!
This 32 yo HIV(+) woman has been on ARVs x 14 months and now has new cough,fever, and wt loss.
Her daughter is HIV(+)
She also has TB
23 yo man with wasting and brain abscess, HIV pending (with his wife)
27yo HIV (+) man with TB meningitis
This 33 yo man is being treated for cryptococcal meningitis but the hospital is running out of drus to finish treatment
? Prescription from IDI
A 34 yo HIV(+)man with fever and neck swelling.
A Bx was performed showing TB (scrofula)
Started on EHRZ
This 35 yo inmate at Luzira prison was brought in with fever, cough and wasting illness
This 38 yo boda-boda driver was brought in with his 8th
episode of cryptococcal meningitis
His wife said he kept running out of his fluconazole.
38yo HIV(+) lady with cough,fever and wt loss x 1 month being examined by Herbert a fine young medical resident
Advanced pulmonary TB
51yo Karamajong man with 8 months of cough and fever.
Advanced pulmonary TB
65 yo HIV(+) man with TB empyema and his son.
The oldest HIV(+) patient on ward.
42yo man with HIV kidney and heart disease. He had no measurable BP and died shortly after this picture was taken.
A Mulago enigma
Unknown male picked up on Kampala Rd in coma.
No caregiver with him, a virtual death sentence for any patient with critical illness
A 53 yo tree planter HIV+, never married with 3 kids admitted with weight loss, unable to eat solids and shortness of breath.
On exam pale conj, breathless, marked cachexiaHIV changes –
dark nails and papular pruritic eruption
(PPE). Chest and abdominal exams were normal.
We think he could have TB or cancer
He has lost 20 relatives to AIDS.
SP, 53 yo male with dyspnea and dysphagia
? Note the scribbler
Calculations to see if he could afford a chest X-ray (~$6.00). His cousin was trying to get the funds together!
Misconception: medical care in the developing worldis not publicly funded or “free”
35yo father of 5 young children walked in from the village where a “traditional healer”
was unable to help him. He presents with weight loss, a few scattered purple-black nodules on the face and arms, and a mass in the mouth making it painful for him to eat for some months.
Diagnosis: Disseminated Kaposi’ssarcoma This man is “very poor”
andcan’t afford chemotherapy at theUganda Cancer Institute. ARVs wereunavailable at the time and so he wasgiven Tylenol and sent home.
A word about stigma…
15 yo HIV (+) girl with rash and new onsetheadache and fever
Papular pruritic eruption,the stigmatizing rash ofHIV in Africa. A spinal tapWas done and she hascryptococcal meningitisas well
36 yo lady we thought might be of the Muslim faithpresenting to Dermatology Clinic
But under the mask…
Disseminated histoplasmosis( a fungal infection)
…3 years later on ARVs and fluconazole
A happy ending!....
A Woman’sStory
Gud evening Dr. Walter!!!Thank you for being in the plane today ....thank God i met you cause finally i did feel free to disclose my situation to somebody it sounds funny when one feels free to disclose such a thing to a stranger !!!! how strange you might think of it!!I dont have much time to write today cause am needed to be at the restaurant but all in all i wanted at least thank you for listening to me and your time!!! am very sorry i had to bug you during your flight all i can say is that you made my day!! i had a big load on my shoulders i couldnt think i could tell someone that am sick!!!! it really kills me but at least i verealised that i have some courage and thanks for your advice for me to get tested on the cd count will do that Doc!!!!Please help me with the counseling will you??? am not sure if i can do it by myself please help me go through it please .....please :-(Ave to go i have a lot to say but time is against me!Have a nice stay in Entebbe and i wish u all the best in whatever you do!!May God richly bless youYour Sincerely Patient
Uganda: AIDS Demographics
•
2007 prevalence 5.4% •
Ugandans living with HIV –
940,000•
2007 AIDS deaths 77,000
•
AIDS orphans estimated: 1,000,000
…But the “numbers”
represent real people, husbands and wives, brothers and sisters, parents and children, ill and well, angry or resigned, sad or joyful but all living with HIV
–
so I’d like to finally introduce you to “mukwano
jjafe”
–
our
friends