Teaching HIV Care in Uganda
MADISON – In Uganda, HIV is known as “the slip.” “It’s because of the way people waste away,” says Frank Graziano, MD, (pictured) of UW Hospital and Clinics’ HIV Care Program.
Dr. Graziano and UW Health senior clinical pharmacist Michael Madolon recently returned from an education and training mission that started in Kampala, the capital city, and spread to small villages throughout the Ugandan countryside.
They have been making the trips a few times a year since 2003, teaching Ugandan health care workers about the best ways to prevent and treat HIV and AIDS. Their work has bolstered a widespread national campaign to stem the proliferation of the diseases.
Recent Progress
AVERT, an international HIV and AIDS charity based in the United Kingdom, calls Uganda “one of the few African countries where rates of HIV infection have declined, and it is seen as a rare example of success in a continent facing a severe AIDS crisis.”
According to the organization’s Web site, HIV incidence in Uganda was estimated at 15 percent of the adult population in the mid-1990s, and an astounding 30 percent of pregnant women in larger cities like Kampala were thought to be infected. That percentage has dropped to 6.7 percent of all adults, in large part because of a massive influx of money and resources.
Uganda is one of 15 focus countries to receive relief from PEPFAR, the U.S. President’s Emergency Plan for AIDS Relief, which funneled nearly $400 million to the country from 2004-2006. Those funds went to large-scale awareness and prevention campaigns that preach the importance of abstinence, faithfulness within marriage, and condom use; built new treatment facilities and improved existing ones; and distributed antiretroviral (ARV) drugs to patients.
Nearly 100,000 Ugandans received ARVs in 2006. AVERT says that’s only 41 percent of those who need them, but is still a significant improvement.
“PEPFAR has made a significant difference,” says Dr. Graziano. “When we used to go over four years ago, all we were talking about was people dying. Now we talk about people living. PEPFAR has given them drugs that have made their patients better.”
A New Challenge
Though Uganda is headed in the right direction, the work is hardly complete. ARVs slow the advance of HIV and AIDS, allowing infected people to live longer lives. But this increased lifespan has introduced the new challenge of dealing with the physical side effects caused by the medication. It sounds cruel to say, but five years ago Ugandan HIV and AIDS patients didn’t live long enough to have such concerns. That’s no longer the case.
“The problem we have is people living with HIV, being on these drugs and seeing all these side effects,” says Dr. Graziano, mentioning diabetes, neuropathy, high lipid counts, and increased heart attacks and cancer as some of the many adverse reactions to ARV medication regimens.
And, because more and more people are receiving ARVs and living longer, it’s a problem that looms large on the immediate horizon.
“We have maybe a million patients in North America,” says Dr. Graziano. “Multiply that by 25 (for Africa). If you look ahead, they’re going to be having the same problems, but the scope will be huge.”
Ensuring Quality Care
Reducing infection rates and mitigating medication side effects will be the result of improving the overall level of HIV/AIDS care in Uganda. For Graziano and Madolon, that means communicating with providers about the best way to care for patients.
Working with the Joint Clinical Research Center (JCRC), a Kampala-based medical research complex created by the Makerere University School of Medicine and Uganda's Ministries of Health and Defense, the pair speaks to Ugandan health care workers about the latest in HIV and AIDS care – Graziano calls it “HIV 101” - and discusses patient cases to identify the most effective means of treatment.
“We give a couple of days of lectures,” says Madolon, adding that this year’s topics included adverse drug reactions and ARV side effects. “The last day or two are for case discussions. We tell them in short what we might do in certain cases. It’s all discussable.”
That the Ugandan doctors are now able to debate treatment theory and even contest his medical opinion is a sign of progress, says Dr. Graziano.
“When we started, they asked a lot of questions but they had no clue what we were talking about,” he says. “What I love is we go there now and I say something and somebody says, ‘I don’t agree with you.’ They’re forming their own opinions on what should be done.”
And those lessons filter down through the Ugandan health care system. The doctors to whom Graziano and Madolon speak communicate in turn to doctors in the smaller clinics and remote country villages, resulting in an exponential expansion of care and knowledge.
“The JCRC is the model for how to treat HIV in all of Africa,” says Graziano. “The people over there should be really proud.”
Graziano and Madolon will be returning to Uganda in March and they have their sights set on formalizing their training curriculum and establishing a certification program for all Ugandan health care workers who treat HIV and AIDS patients. As Dr. Graziano envisions it, care providers will be expected to complete a minimum number of continuing medical education credits in a two-year period and required to pass an exam to maintain certification.
“That way we’re assuring everybody is up to date,” he says.
And assuring that HIV and AIDS patients won’t slip any further in these crucial coming years.
Date Published: 12/28/2007
