Antiretroviral drugs give HIV/AIDS sufferers a new lease of life in Uganda
Improving People’s Lives
Uganda, which lies in the Sub-Saharan region in Africa, was one of the hardest hit countries by the HIV/AIDS scourge in the 1980s, wiping out entire villages in certain parts of the country.
In response to this epidemic, proactive campaigns were put in place which, by the end of the 1990s, more or less resulted in the decline of new infections. However, it was only in the early 2000s that HIV/AIDS sufferers witnessed a breakthrough in treatment with the introduction of life-prolonging antiretroviral (ARV) drugs. This has resulted in Uganda urgently seeking to acquire competencies in ARV pharmacokinetics.
“ARV pharmacokinetics is an area not yet developed in many African countries and the developing world at large, but is extremely important in the management of HIV/AIDS patients by checking their drug levels,” says Doctor Mohammed Lamorde of Pharmacology Research Physician Department, Infectious Diseases Institute (IDI) at the Makarere University in Uganda.
Dr Lamorde is one of many medical physicians utilising the Health InterNetwork Access to Research Initiative (HINARI) to research ground-breaking ways to treat a country populated by over 28 million people.
HIV/AIDS in Uganda
The first case of HIV/AIDS in Uganda was recorded in the region along the shores of Lake Victoria in 1982. Superstition and witchcraft characterised the initial response from communities and this was worsened by the lack of a clear government response to the problem. As a result, the epidemic quickly progressed to all parts of the country with initial concentrations in urban and semi-urban centres.
By the end of 1992, the national prevalence rate was estimated at 18.3 percent with some centres registering rates above 30 percent. This was followed by a period of steady decline in prevalence rates from the mid 1990s to 2002 to around 6 percent due to favorable prevention policies.
The 2004/05 National HIV/AIDS behaviour survey conducted by the Ministry of Health Surveillance Unit estimated about 915,400 adults and children were living with HIV/AIDS. Prevalence among adults aged 15-49 years was estimated at 6.4 percent, 0.7 percent among children less than 5 years, and 5.8 percent among those aged 50-59. The Ministry of Health estimated 132,500 new infections in 2005 alone.
The survey revealed regional, rural/urban, and gender variations in HIV prevalence. The Kampala, Central, and North-Central regions registered the highest infection rates at around 8 percent while the West Nile region was at 2.3 percent. Overall infection rates are higher in urban areas compared to rural areas, and almost twice as high amongst urban women – 13 percent compared to 7 percent amongst women in rural areas.
Sub-Saharan Africa, where Uganda lies, bears the heaviest burden of the HIV/AIDS epidemic accounting for 68 percent of those living with HIV/AIDS globally. Approximately 76 percent of the AIDS related deaths in 2007 alone occurred in this region. Uganda has a prevalence rate of 6.7 percent according to a national survey conducted in 2007. It currently administers Nevirapine, Efavirenz, Lamivudine, Zidovudine and Lopinavir for AIDS patients.
HINARI Helping the Fight Against HIV/AIDS
In early 2006, Dr Lamorde discovered HINARI and started using it for research and reference purposes for his everyday medical queries. “HINARI has effectively revolutionised the way I work and ultimately how I treat patients. Moreover, what we do locally is a reflection of the efforts made elsewhere in the country.”
The primary goal is to ensure drugs remain effective in the country across time. “The key issue is to maintain a balance and ensure drugs levels are enough to suppress the virus, but not too high to cause side effects.”
Checking drug levels in a patient has two benefits; if the drug levels are low the virus may not be suppressed and over time, resistance may occur. On the other hand, should drug levels be set too high, dangerous side-effects may impact treatment.
Most of the ARV drugs doctors work with in Uganda are generic, which, according to Dr Lamorde, imply that the science behind the drugs changes rapidly and therefore demands that doctors need to be constantly updated.
“HINARI has been an incredible source of information in our medical profession. Myself and my team need to keep abreast of all evolving ARV related science. HINARI allows us to access this information swiftly and easily,” disclosed Dr Lamorde.
Relying on textbooks is not an option; most are updated only every three to five years – which is not an acceptable delay when it comes to patient treatment. Moreover, most institutions do not have the financial means to subscribe to medical journals.
In Uganda, with the help of HINARI, doctors are able to determine the right quality and quantity of drugs to be administered to each individual patient.
“HINARI allows you to find the right information applicable to the drugs available in your specific country. Navigating through the search options confirms dosage and warns of possible side-effects for patients to consider,” Dr Lamorde explained.
The work done in Uganda is also important for government policy making, especially with regards to procurement and administration of drugs nationally for HIV/AIDS patients. To scale up their services to various parts of the country, Dr Lamorde stated that they have established AIDS Treatment Information Centres which have become a reliable source of information on clinical care, and especially for ARV related questions in Uganda.
Optimising Treatment Through HINARI
Dr. Pauline Byakika-Kibwika is using HINARI to help her examine artemisinin combination therapy-based anti-malaria drugs and how they are impacting those with HIV/AIDS. “Drugs have to be broken down by certain enzymes in the body. Some ARVs increase the production of the enzymes and this may lead to a drop in the anti-malaria drugs concentration because of enzymes circulating”, said Kibwika.
Those that decrease the production of enzymes may give way to high levels of the drug with serious negative consequences for malaria sufferers. Malaria is a major problem in Uganda and has been increasing with the advent of HIV/AIDS. “Our goal is to optimise treatment of malaria and HIV/AIDS and improve the health of patients through the right dosages. We reduce chances of low levels that may result in resistance and drug levels concentration that may lead to toxicity”, she said.
“We use HINARI a lot as it gives evidence-based medical information and we use this to treat our patients. We also apply the information in our research and clinical facilities for treatment of malaria”, she remarked.
Kibwika, who is also a lecturer at the Makarere University’s School of Medicine, says students use HINARI a lot when writing proposals for research and when researching amongst local communities.
Identifying Drug Combinations
Dr. Ponsiano Ocama, a clinician and researcher specialising in liver diseases, says most institutions in Africa and the majority of the developing world cannot afford to subscribe to journals so it is very important to have free access to the HINARI portal.
“I quite often visit the HINARI portal for current information on liver diseases especially viral Hepatitis B which is the main liver disease in Uganda. However, we now also have an outbreak of Hepatitis E”, he stated.
“I am dealing with a number of people with liver cancer due to Hepatitis B and though there are drugs for treatment, most of them are not effective but still suppress it. I therefore use combinations that alleviate pain to the patients.”
Ocama says Hepatitis E mostly kills pregnant women, something so common in northern Uganda ravaged by civil war between the government forces and rebel Lord’s Resistant Army. It spreads through contaminated food and water and hygiene is important.
“To deal with these,” he said, “I regularly visit HINARI for the latest information on the two ailments, one of which is life limiting, regarding drugs and care. If we discover cancer of the liver in a patient early then we can easily treat it when it is still small, but most patients come for treatment too late.”
Ocama, also a teacher at Makarere University, has helped to organise outreach programmes to educate people on the diseases and what needs to be done in villages. “The key outreach is done by the Uganda Gastroenterology Society of which I am the secretary”, said Ocama. It gathers information from HINARI and transmits it to the country through radios, healthcare workers and any person who handles blood as they are most exposed to the virus.
Statistically, 10 percent of Uganda’s 27 million plus people are suffering from Hepatitis B with the northern and eastern parts of the country accounting for 25 percent of those infected. 80 percent of patients with liver cancer in Uganda are Hepatitis B infected.
Ocama and his colleagues have also been training palliative care workers to deal with life limiting diseases such as liver cancer and they have now built a palliative care team at their Palliative Care centre at the Cancer Institute. Students at the institution have also been conducting community-based care and service programmes. “They do research in these communities including on-site treatments.”
Limited Government Support
According to Ocama, there is very little support from the government and if it were not for portals such as HINARI, he does not know where they would be today. “We work under very strenuous circumstances with little support from the government. Most of us are professionally unsatisfied for lack of information, financial resources and if it were not for HINARI it would be very difficult for us here. The free online access to evidence-based health information is making a huge impact in Uganda”, he pointed out.
In Uganda, he explained, the government does not employ doctors as this has been left to districts. Therefore, HINARI is a premium source of information in the medical sector. Ocama started using HINARI three years ago and believes it has filled a huge void that previously existed. “It helps us in the writing of manuscripts as it opens your brain to new ideas and information to really get to know what you are writing about. As a researcher I have to keep abreast with new knowledge.”
“We access most journals through HINARI and I read one to two articles a day for both my knowledge and clinical practice in areas of interest.” He also uses the information gathered to write manuscripts some of which have been published in, among others, the American Journal of Medicine, Antiretroviral Therapy, JAIDS and the African Health Science.
There can be little doubt that free online access to HINARI is providing tremendous opportunities for medical professionals in Uganda to make an impact on people’s lives.