HIV & AIDS Report

The following report was provided by Dr Rick Hutchinson following his visit to Kamutuuza in June 2009. He and his team held meetings with various health professionals and AIDS organisations in the Masaka area to discover the best way forward in developing a Wellspring AIDS outreach programme.

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!