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KITOVU MOBILE

On a previous trip to Uganda I went out on a Kitovu mobile and discovered it was one of the first AIDS outreach projects in Africa, and is hugely successful at handling the complex issues brought by AIDS in rural communities. For this reason we felt we could learn a lot, not only about AIDS outreach, but also about pioneering a project like HIV outreach, in rural Uganda.

Kitovu mobile works primarily with “AIDS” patients that present to Kitovu hospital, who express a need for social intervention. It provides holistic and palliative care. This includes supplying: nutritional supplements; social support; on-going community based follow up; counselling; and pain control. Drugs are provided at a cost to the patient, (even if very small) and they are only free if it is known the patient definitely cannot afford them.

Kitovu Mobile also has Involvement in education of schools and communities to ensure that the communities Kitovu mobile visit are able to work well with the staff and the patients.

Advice given

• One key piece of advice Kitovu mobile offered us was to start small. Kitovu mobile started with one very committed nun and a driver. She started by addressing the needs of one patient, then as resource and time allowed she moved onto two, then three and so on. As she started to see more and more people with AIDS she slowly expanded the project. Now after nearly 20 years they have a huge catchment of patients, however they also have the appropriate resources to continue that same standard of care.

  Though there is great need in the Kamatuuza area we must not try to stretch our resources to finely, and trust God that we can gradually grow larger as our resources (ie. Trained HIV staff, ART supplies, transport, budget to include petrol prices and vehicle maintenance etc..) allow. AIDS is a complex disease requiring on-going, committed treatment, therefore we cannot let our ambition to reach as many as we can harm our goal to treat the disease and its surrounding issues well.

• After discussion Kitovu mobile kindly offered opportunity for Wellspring staff to shadow Kitovu mobile staff, over a short period, so that we could learn from their vast experience, in order to build an effective HIV outreach team which incorporates all aspects of HIV patients needs.
• Kitovu mobile also mentioned there may be an opportunity for Kitovu mobile to run a clinic from Wellspring. Though we should remember Kitovu mobile works specifically with AIDS patients, not every
  HIV positive patient.

Conclusions

We should remember many of our patients with HIV will not have AIDS, as many will be young and therefore not have progressed into the later stages of the infection. If we can, our aims should be preventing children progressing into AIDS by identifying HIV and starting ART early, with adequate counselling, follow up and education. However we most definitely will meet many children with AIDS, so Kitovu mobile remains a valuable source for advice, guidance and support with these children.

TASO

TASO is one of Ugandas largest HIV/AIDS agencies. They are very closely tied with the government and do huge amounts of VTC, ART therapy and counselling, as well as training many professionals to be counsellors. From the meetings we had it became clear that TASO is widely considered the gold-standard for HIV counselling and training of counsellors.

Advice given

• The clinic must keep a register of all positive patients (however this must be kept strictly confidential).
• The timing of when to start ART therapy depends both on clinical picture (ie. A patient presenting with an AIDS defining illness, or a patient who is known to be HIV positive who is frequently developing infections (such as candidiasis)) and on their CD4 count. If CD4 count is not available clinicians may need to rely on the clinic picture alone, or refer to a centre where it can be measured. However where CD4 count is available it is a very useful tool.
• Babies less than 18 months need to have the antigen PCR test. This is because the antibody tests (ie. Stat pak, Unigold and determining) are unreliable at this age as HIV antibodies passed from mother to baby, via breast milk, will give false results.
• We must ensure any staff, due to have HIV counselling training, attend approved, well recognised courses. This is because there are many courses available throughout Uganda which do not provide adequate training and feedback
• It may be ideal to have specific child counsellors.
• For all children we should try to involve guardians, but this especially applies to children less than 10 years.

Offer from TASO

• TASO are able to give us a clinician/counsellor on a weekly basis, to initiate HIV VTC at the centre, if we pay for their lunch and transport. However he stressed this would be a temporary measure, as he would much rather we trained our staff in VTC, in order to lighten the burden of TASOs current work.
• We discussed with him the possibility of our staff being trained by TASO, either by attending a TASO course or TASO counsellors training our staff at wellspring during their weekly visits. He suggested:
  • TASO training courses cost 840,000 UGS per person. They have a January and July intake, part time/full time each lasting 6 months and involve clinical attachments as well as lecture based learning. Anyone wishing to attend the courses must have a degree – Professions that can enrol on the course include teachers, nurses, midwifes, clinical officers and psychologists.
  • A clinical officer/senior nurse could come for work experience in TASO once a week for around two months. This would not be ‘formal training but would allow them to gain experience and confidence in HIV testing. If this were to happen I feel they still would require some sort of assessment of competency from TASO before they leave.
• With regards to getting a positive test we have been told we can refer children to TASO for treatment. We can refer both children who test positive for HIV but currently do not have AIDS, as well as children with AIDS / suspected AIDS.

Conclusions

TASO is a vital resource for Wellspring. As we start to do VTC we will fall heavily on TASO for both advice and as a referral centre. Ideally all our staff would be VTC trained by TASO (however this might not be practical).

UGANDA CARES

Aids Healthcare Foundation, an Amercian NGO, together with the Uganda Ministry of Health opened the first Uganda Cares clinic in Masaka in February 2002 and was the first organization to provide antiretroviral therapy outside the capital city of Kampala.

Advice given

All VTC must involve both pre- and post-test counselling, and patients must be counselled again before commencing ART.

Uganda Cares does have the capacity to perform Virology tests however these have to be sent to Kampala so results will take time to come back.

Uganda Cares provides ART for other hospitals and NGOs, including Kitovu mobile, often providing drugs free of charge.

Conclusion

Uganda Cares is a very well set-up ART / VTC centre. If Wellspring were to send patients from the clinic for either VTC or ART we should only be sending to one centre, for the time being. Personally I believe TASO would be a better option, partly as building a strong relationship with them may help in the future when it comes to training staff. However Uganda Cares remains a resource for support and advice. It also may provide a source for ART medications.

Additional information received

As HIV still carries a lot of stigma in Uganda, many patients are unwilling to be seen to have a test. This leads to less people getting tested and treated, which allows for greater spread of the disease. For this reason Masaka use opt-out testing. This involves pre-test counselling in the waiting room of the general medical clinic, followed by the patients being told if they do not want the test they will need to opt-out, usually by moving to a different section of the room. Dr Albert felt this may work well at Wellspring. Though importantly post-test counselling should, in all circumstances, be absolutely confidential!

It was advised by Dr Musisi, head of the Masaka Health Directorate, one of the best ways to start the HIV outreach was to ask TASO if they would start VTC outreach clinics at Wellspring, and then enter some staff into January’s TASO counselling course. (Dr Mussisi stated he could provide a percentage of funding a staff member through the course).

As we look ahead to having a maternity service we should know all midwives are already trained in VTC, and are also able to provide prophylactic ARVs to pregnant / nursing mothers to prevent vertical (mother-to-child) transmission.

Wellspring believes that a “know your status” campaign initiated by the Just Care schools and promoted in the local communities would be the best way forward towards AIDS prevention, together with the ABC prevention project initiated by the Ugandan Health Department. this may be the key to our HIV outreach project. Know your status should be the next Ugandan HIV campaign!

• Malaria is caused by four species of parasitic protozoa that infect human red blood cells. Protozoa are one-celled organisms that are as sophisticated as a human cell. Malaria parasites feed on red blood cells for a living.
• Malaria parasites have a complex life cycle. In order to live, they need to have both a human and a mosquito host. The mosquito host can’t be just “any” mosquito. It has to be a female mosquito of the genus Anopheles.
  The mosquito picks up the malaria parasites from the blood of an infected human when it feeds. The parasite reproduces itself in the gut of the Anopheles mosquito, forming a sac with thousands of new malaria parasites. The parasites need the mosquito to continue their life cycle. In order to infect an individual, the infected mosquito has to live 15 days at which point the parasites burst out of their sac and reach the salivary gland of the mosquito. Then, the mosquito passes the malaria parasites to the human through its salivary glands.
• There are four different species of malaria parasites causing types of malaria that are somewhat different from each other. These species are Plasmodium falciparum, vivax, malariae and ovale.
• The worst type is caused by Plasmodium falciparum.
• Infection with Plasmodium falciparum kills approximately 1-2% of those who come down with it.
• Falciparum malaria is a serious illness characterized by fever, headache, and weakness.
• Complications of falciparum malaria include cerebral malaria, in which the brain is infected, severe malaria, in which the parasitic infection essentially “runs out of control,” and placental malaria, in which falciparum is a grave complication of pregnancy, and coma.
• Each of these complications is very serious and often fatal.
• Falciparum malaria is the major type found in sub Saharan Africa, where 90% of the world’s malaria cases occur.
• Unfortunately, falciparum malaria is also frequently resistant to drugs and is becoming more common in high elevation areas of Africa, and in portions of Asia.
• The other species of malaria cause a debilitating illness characterized by spells of chills, fever and weakness. This illness generally lasts 10-14 days, and is self-limiting in nature. The malaria caused by these species is rarely fatal.

A World Wide Problem

Malaria is preventable and curable, yet at endemic levels in the worlds poorest countries.
Around 2.5 billion people (at least 40% of the worlds population) are at risk of malaria in over 90 countries. Malaria causes or contributes to 3 million deaths and up to 500 million acute clinical cases each year. In other words, almost as many deaths per annum as the AIDS death total in the last 15 years.
The majority of deaths are children. Our worlds children are dying at a rate of 4 per minute, 5,000 a day and 35,000 a week.
Other high risk groups include pregnant women, refugees, migrant workers, and non-immune travelers .
Malaria is one of leading causes of morbidity and mortality in the developing world (along with TB, acute respiratory syndrome, diarrhoea and HIV) but still not recognised in developed countries as a disaster such as AIDS.

Malaria kills more people today than three decades ago. Reasons for the spread include: increasing drug resistance, increased migration and immigration, decreased mosquito control efforts (insecticide spraying), deforestation and mining (development activities)
Over 35 years ago malaria had been eradicated or dramatically reduced in 37 countries through the WHO insecticide spraying programme, but this situation is rapidly reversing. The reversal is largely due to the cost of sustaining programmes, loss of motivation in the face of a seemingly declining threat, and the development of insecticide and drug resistance.

Malaria exacts an enormous toll in lives, medical costs and days of labour lost.
Educational systems also suffer as large numbers of children miss several weeks of school each year in endemic regions.

Malaria and Africa

Malaria is Africa’s leading cause of under-five mortality and constitutes 10% of the continent’s overall disease burden. It accounts for 40% of public health expenditure, 30-50% of inpatient admissions, and up to 50% of outpatient visits in areas with high malaria transmission.
There are several reasons why Africa bears an overwhelming proportion of the malaria burden. Most malaria infections in Africa south of the Sahara are caused by Plasmodium falciparum, the most severe and life-threatening form of the disease. This region is also home to the most efficient, and therefore deadly, species of the mosquitoes which transmit the disease. Moreover, many countries in Africa lack the infrastructures and resources necessary to mount sustainable campaigns against malaria and as a result few benefited from historical efforts to eradicate malaria.
In Africa today, malaria is understood to be both a disease of poverty and a cause of poverty. Annual economic growth in countries with high malaria transmission has historically been lower than in countries without malaria.
Malaria also has a direct impact on Africa’s human resources. Not only does malaria result in lost life and lost productivity due to illness and premature death, but malaria also hampers children’s schooling and social development through both absenteeism and permanent neurological and other damage associated with severe episodes of the disease.

One of the greatest challenges facing Africa in the fight against malaria is drug resistance. Resistance to chloroquine, the cheapest and most widely used antimalarial, is common throughout Africa. Resistance to sulfadoxine-pyrimethamine, often seen as the first and least expensive alternative to chloroquine, is also increasing in east and southern Africa. As a result of these trends, many countries are having to change their treatment policies and use drugs which are more expensive, including combinations of drugs, which it is hoped will slow the development of resistance.

Malaria and HIV/AIDS

Malaria and HIV are two of the most devastating global health problems of our time. Together they cause more than 4 million deaths a year. Both are diseases of poverty, and both are causes of poverty. To a considerable extent, both are concentrated in the same geographical regions. The resulting co-infection and interaction between the two diseases have major public health implications.
HIV-infected people must be considered particularly vulnerable to malaria.

Where both diseases occur, more attention must be given to specific diagnosis for febrile patients. In HIV-infected individuals, a malaria case definition based on fever alone can result in a febrile illness due to a wide range of ordinary, virulent and opportunistic infections being misdiagnosed and treated as malaria. This may lead to inappropriate care of HIV-infected adults with severe febrile illnesses due to causes other than malaria.

Evidence of interactions between malaria and HIV in non- pregnant adults is accumulating. In areas with stable malaria, HIV increases the risk of malaria infection and clinical malaria in adults, especially in those with advanced immunosuppression. In settings with unstable malaria, HIV-infected adults are at increased risk of complicated and severe malaria and death.

Additional research is needed to investigate the impact of malaria on the natural history of HIV, potential therapeutic implications, and interactions at a cellular and molecular level.

Acute malaria episodes cause a temporary increase in viral replication of HIV and hence plasma viral load. However, there is no evidence that malaria has a substantial effect on clinical progression of HIV, HIV transmission or response to antiretroviral treatment in areas where malaria and HIV overlap.

Few studies have examined the interaction of malaria and HIV in children. In areas of stable malaria, HIV-infected children may be at increased risk of clinical malaria compared to children not infected with HIV. Advanced immunosuppression in HIV- infected children results in more episodes of clinical malaria and higher parasite densities compared with HIV-infected children whose immune status is less compromised. In areas of unstable malaria HIV-infected children may be at increased risk of severe disease and death.

The effects of interactions between malaria and HIV are particularly deleterious to maternal and infant health. HIV infection impairs the ability of pregnant women to control P. falciparum infection. They are more likely to develop clinical and placental malaria, more often have detectable malaria parasitaemia and have higher malaria parasite densities.

Compared to women with either malaria or HIV infection, co-infected pregnant women are at increased risk of anaemia, preterm birth and intrauterine growth retardation. As a result, a considerable proportion of children born to women with dual malaria and HIV infection have low birth weight and are more likely to die during infancy.

Children and Malaria

• Children are especially vulnerable to malaria.
• Malaria kills one child every 30 seconds in the world today.
• Children aged one to four are the most vulnerable to infection and death. Malaria is responsible for as many as half the deaths of African children under the age of five.
• The disease kills more than one million children – 2,800 per day – each year in Africa alone.
• In regions of intense transmission, 40% of toddlers may die of acute malaria.

Anaemia, low birth-weight, epilepsy, and neurological problems, all frequent consequences of malaria, compromise the health and development of millions of children throughout the tropical world. Yet much of the impact of malaria on the worlds children could be prevented with currently available interventions.
Of the more than 500,000 African children who develop cerebral malaria (a severe form of the disease that affects the brain) each year, 10-20% die and approximately 7% are left with permanent neurological damage. Children with malaria typically develop fever, vomiting, headache and flu-like symptoms. If untreated, the disease may progress rapidly (often within 24 hours) to convulsions, coma, and death.

Malaria is a major cause of anaemia in many parts of the world. Chronic anaemia may adversely affect a childs growth and intellectual development. Repeated episodes of malaria may lead to severe, life-threatening anaemia. Blood transfusions may save lives in these circumstances, but also expose the child to the risk of HIV and other blood-borne infections.

A reduction of illness and death in young children can be achieved through:

• Prevention: Children must be protected from the mosquitoes that transmit malaria. The best way to do this is to ensure that they sleep under insecticide-treated nets (ITNs). Studies in Africa have shown that ITNs can reduce deaths among under-fives by up to one-third.
• Prompt recognition and effective treatment: There is an urgent need to ensure that effective and affordable antimalarial drugs or drug combinations are widely available to all individuals living in malaria-endemic areas.
• Anaemia: Parents and healthcare workers must be trained to recognize the clinical signs of anaemia, and to seek treatment. Malaria, nutritional iron deficiency and intestinal parasites (such as hookworm) are the most common and preventable causes of anaemia in much of the developing world.
• Prevention of malaria-related low birth weight: Pregnant mothers must be encouraged to use ITNs and take advantage of Intermittent Preventive Treatment. This has been shown to increase birth weight, a major determinant of child survival.

Ugandan Children

In Uganda, malaria has historically been a very serious health problem and currently poses the most significant threat to the health of the population.

Malaria currently accounts for:

• 25% – 40% 0f all out-patient visits at health facilities.
• 20% of hospital admissions.
• 23.4% of total discounted life years lost.
• 9 – 14% of in-patient deaths.

Malaria is the main killer of Ugandan children:

• 720,000 under fives and over one million fives and over are reported to have clinical malaria.
• 43% of deaths of under fives, in Uganda, are attributed to malaria and malaria accounts for 70,000 110,000 child deaths annually.
• With acute disease a child may die within 24 hours.

Malaria kills children often in combination with other diseases, including HIV.

Malaria also causes:

• Childhood anaemia
• Reduced growth (stunting)
• Mental retardation
• An average of 6 episodes of malaria each year
• Severe malarial anaemia resulting in a case fatality rate of 8-25% among paediatric admissions
• Up to 70% of out-patient attendances and over 50% of in-patient admissions in the under 5s.

In pregnancy, malaria may cause:

• Maternal anaemia (particularly in prime gravidae)
• Intra-uterine growth retardation
• Premature births
• Low-weight babies which is the principal contributor to infant mortality
• Still births
• Abortions/miscarriages – malaria is responsible for nearly 60% of miscarriages
• Pregnant women are 4 times as likely to suffer malaria attacks during pregnancy than when not.

Malaria does not only cause ill health and death but also has a great impact on the economic and social development of the family and the individual child.

• Expenditure on treatment and prevention. A poor malaria-stricken family may spend up to 25% of its income on malaria treatment and prevention.
• Malaria affects families most during the rainy season when families least afford to be sick, malaria interferes with their farm activities thus causing poverty in families.
• Loss of household incomes through absenteeism from work.
• Malaria causes absenteeism from school, thus affecting school performance. It is estimated that in endemic areas like Uganda, malaria may impair as much as 60% of the school childrens learning ability.
• Frequent illness or deaths of children due to malaria can lead to misunderstandings within families and between families. Those with sickly or dying children often are likely to accuse others whose children do not fall sick or die of bewitching their children which leads to hatred within and between families.

Wellspring Childrens Medical Centre

Malaria is a leading cause of ill health, poverty and death in Uganda with the children being the most vulnerable to this disease and its consequences.
It is inevitable that a great proportion of the children attending the Wellspring Medical Centre will be suffering from either acute attacks of malaria or the consequences of the disease. To be able to deal adequately and efficiently with such a work load Just Care plans to provide a specialised day care facility for malaria victims alone. This is addition, to malaria care provided in the general health clinics and outreach work. With the prospect of AIDS and other serious diseases causing problems with a definitive diagnosis of malaria, it is important that staff are trained to use laboratory equipment efficiently to ensure an accurate and prompt diagnosis of the disease. Advice regarding appropriate treatment regimes is to be sought from Kitovu Hospital. Any child who is at increased risk due to, for example, age, signs of cerebral malaria, anaemia etc, will be immediately referred to a more specialised unit.

One of the aims of the Wellspring Medical Centre is to reduce the mortality and morbidity rates for those children in the villages suffering from an acute malaria attack by ensuring prompt treatment and urgent referral to a paediatric unit when necessary. In addition, as part of the health education programme, advice will be given with regard to prevention of the disease with the use of mosquito nets, insect repellents and clearance of any areas of stagnant water etc.. Practical provision of mosquito nets will be given to those at greatest risk and with low incomes. Essential follow clinics will also be available for those children diagnosed with acute or chronic malaria.

Just Care is aware that the opening of an acute malaria unit will require dedication and expertise of the part of the staff and a huge financial undertaking with regard to medication, laboratory equipment and staffing, and referral costs. However, with so many children at risk of sickness and death as a result of this killer disease we cannot ignore the problem and will continue to appeal for assistance with regard to expert advice and funding to enable this unit to eventually open and develop.

One mosquito net can be purchased at the cost of £4!

£10 will provide 100 children with anti malarial medication!

Every child in the world is priceless.

No task is too vast, no price is too high to save the life of a child.

Just Care believes that God wants the very best for the neglected children of Uganda but He relies on those with much to provide for those who have nothing.

Sadly, over 12,000 women die in child birth annually and an estimated 45,000 babies die within their first 4 weeks of life each year, in rural Uganda. Just Care, with the help of the Operation Uganda project, aims to reduce these risks and improve neonatal and maternal care in the region of Masaka, Uganda.

The NHS produces an average of 250,000 tonnes of waste a year at a cost of some £40+ million. A large proportion of this goes for disposal by alternative technologies or incineration, and a significant amount to landfill. A large proportion of this waste is simply slightly out of date but perfectly functional, equipment which is desperately needed in the third world, including Uganda. Much of the medical equipment and resources urgently required in Uganda are unaffordable or simply unobtainable but just seen as disposable waste” in the UK. We cannot afford to waste the worlds resources in this way.

An appeal has gone out to NHS trusts, private health facilities, GP surgeries and medical suppliers for donations of surplus medical equipment which can be used in the Wellspring, Masaka and Kitovu maternity units. What we discard as out of date in the UK is invaluable to the people of Uganda.

Shipment of all donated goods will take place in March 2010 with distribution in May 2010.