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