W. Michael Scheld, M.D.
Professor, Department of Internal Medicine
Division of Infectious Diseases, U.Va.
"No Heart of Darkness: Uganda and Response to AIDS"
April 17, 2002

So, as you see from this table, 28% of deaths occur because of AIDS.  And the other conditions, here, are well familiar to most of you in the audience--malaria, pneumonia, diarrheal diseases.  Tuberculosis is a major cause of death in African and, in fact, approximately 50% of the AIDS deaths that do occur in sub-Saharan Africa are due to Tuberculosis.  It is a very common co-infection with HIV and AIDS. 

You have seen magazines and I think that, over the last six to eight months, there have been a number of stories in The Washington Post, New York Times, and an NPR that addressed the critical issue of AIDS in Africa.  In a little while I will come back to the global fund, which I hope will be able to help us with some of our opportunities and issues that we are trying to address in Africa.

This is a picture that I took of the AIDS clinic that I took in the Malago Hospital, which I will describe to you a little later.  The Malago hospital is a major teaching hospital in Uganda.  It is considered the national hospital.  There are about 1,100 beds but there are 1,500 patients at any one given time.  So, most of the people are in the hallways and on the floor.  There is no meal service in the hospital.  None.  Their monthly budget for supplies and drugs for a hospital of 1,100 beds is 15,000 dollars a month.  This is the AIDS clinic and there are no other medicines available here other than amoxicillin and tetracycline and they are in very scant supply.  There are no antiretral virals.  We have actually moved this AIDS clinic to another area.  The hospital was operating only one half-day a week as of June of last year.  As of last month, with help from the Academic Alliance, which I will describe later, is not operating three full days a week. 

The contingent of patients that is cared for through the Malago Clinic is about fifty thousand.  And it spread all over Southern Uganda.

This shows you the projected changes in life expectancy in selected African countries that have high HIV prevalence from 1995 to 2000.  You can see the major drop.  Just take Botswana, for example.  Life expectancy back in 1955 was between 40 and 45 years.  It steadily rose to 1990 where it was between 60 and 65 years.  It had been reversed dramatically as has Zimbabwe, Zambia, Uganda and Malawi. 

This is a very sobering slide.  It shows you the lifetime risk of an AIDS death in a 15 year-old boy, assuming there is no change in the epidemic.  I will direct your attention to Botswana.  This is assuming that the current level of risk is maintained.  A 15 year-old  boy in Botswana has a 90% chance of dying from AIDS.  That is going to be there cause of death.  It is a pretty sobering statistic and it is similar for other countries like Zimbabwe.  Even if you cut the risk in half, it is still going to be around a 75% risk of death during their life from HIV and AIDS. 

This is a situation as projected for the population structure in Botswana in the year 2010.  You can see that with the elderly individuals it is not going to change very much, but not many people are going to get to be elderly because there is going to be a dramatic drop in individuals between 15 and 50 years of age due to death from AIDS, if the epidemic is not halted in some manner.

This demographic impact of AIDS in Botswana, Malawi, Mozambique, and Swaziland show that the life expectancy is now less than 40 years of age when it was 60 years of age not long ago.

In Africa, the life expectancy has declined from 62 to 47 years over all.  In Haiti, which has also been affected by this epidemic in a major way, life expectancy has dropped from 59 to 53 years.  And in the Bahamas, 60% of the deaths among children less than five years of age, are due to AIDS.  In Zimbabwe, this figure is 70%.

The economic impact is dramatic.  The annual per capita growth in half of the countries that I have described here today is falling by .5 and 1 percent.  Gross Domestic Product, by 2010, may drop by 8% overall and by 2020, it is estimated that it may drop more than 20%.  That is a very huge difference. 

In several countries, 53% of all the illnesses around workers are AIDS related.  7 million farm workers have died from AIDS and over 85% of the teacher deaths in sub-Saharan Africa have been due to AIDS. 

I will just tell you another anecdote.  Teachers are being decimated by this epidemic.  In addition, students and teachers in medical schools are not exempt from the epidemic.  In Mozambique they have one medical school which produces about 40 physicians a year for a population of 18 million people.  There are 400 doctors in the country of Mozambique, total.  25% of the medical students, upon entering medical school, are HIV positive.  The school has decided, in recent weeks, that they are going to screen incoming medical students for HIV, and if they are positive, they will not be admitted.  I am not going to get into the ethics of that, but as you can see, training would be very long and if you are not going to be around at the end of your training, they are probably not going to put their emphasis there.

This is sort of a grim beginning.  I would like to talk to you a little about what has happened in Uganda. There have been declines in HIV in Uganda that appear unique in Africa and likely relate to a behavioral change.  One of the other countries in Africa, Senegal, has held their HIV serial prevalence down around 2%.  They have used a similar program that the Ugandans have used as well. 

Let me just back up and say another thing.  President Museveni, whom you will see in a photograph later, came to power in Uganda, not under all-time peaceful circumstances in 1986.  Shortly thereafter, he sent a squadron of soldiers--80 in number--to Cuba, under Fidel Castro, to be trained as special forces. 

He got a little note back from Fidel saying that he had a little problem, here, because 18 of his 80 soldiers are HIV positive.  So, he woke up.  And, in fact, President Museveni created an Office of AIDS in the Office of the President in 1989, which was very foresightful in his regard.  He really does have the political will to direct his country in trying to prevent AIDS and he has put together a very substantial program--prevention as well as counseling--throughout the country. 

You see, here, the decline in the national serial prevalence in Uganda, based on 15 surveillance sites.  In 1990 and 1991, it was about 20%.  It was actually 28% in the late 1980's when these programs went into effect.  It is now about 6 to 7 percent overall in these sites.  The official figure in Uganda is 8.1% by UN AIDS criteria, so it has been a very dramatic decline.

This shows you the prevalence and incidence in urban Uganda.  There are three different sites that have been studied.  Jinga is a town about 30 miles away from Compala at the mouth of the Nile River.  You can see that the percent of adults between ages 15 and 49 peaked in about 1990 at about 25%.  It is not quite as low as the country as a whole, but it has come down close to 10%.  I must stress that this type of reversal has not been apparent in the other countries that we have described here today--Kenya, Tanzania, Botswana, Mozambique, Swaziland, etcetera. 

There have been a number of conclusions that have been reached about the bright glimmer of hope in Uganda, but basically there have been reported behavioral changes in Uganda that are consistent with the surveillance data on the prevalence and incidence of AIDS in the country. 

There have been major changes in age at first sex.  This is particularly prevalent among girls and not so much among boys.  The age at first sex has gone from around 15 years up to nearly 19 years, which is a huge change in less than a decade in a behavioral characteristic.  There has been a dramatic drop in casual and commercial sex in Uganda. 

Condom use is pretty important, obviously, but if you actually look at data on condom use in Uganda versus neighboring Kenya, the overall use of condoms is very similar and it is very low--not  as much as you would expect.  But, what is different is that, condom use in casual sex or with people you do not know, is dramatically higher in Uganda than it is in neighboring countries.  If you know your partner and you marry early--which is what is happening now with girls in Uganda--then condom use drops dramatically if they only have one single lifetime sexual partner.  This is the good news in the regard to serial prevalence.   

To fight AIDS we need both treatment and prevention.  I would like to describe some of the problems with instituting treatment and how it should be monitored in a resource-limited setting. Effective HIV therapy, we believe, requires a longstanding commitment infrastructure, which is greatly lacking in sub-Saharan Africa, high-tech resources and medical expertise.  In addition, there are very few folks in Africa and any of the countries that I mentioned to date, that have the sufficient expertise for the delivery and care of antiretral virals either in an urban or real setting.  This will not be achievable in resource-poor countries without the help from richer countries and international health agencies. 

There are multiple documented benefits of antiretral viral therapy.  For the individual, it increases survival, decreases opportunistic infections, decreases the number of hospitalizations.  There is a decrease in AIDS incidence, a decrease in perinatal transmission that has been conclusively shown that treatment of mom reduces transmission when you have antiretral viral therapy.  It restores hope and benefits both children and adults.

We believe that HIV care is very important to prevention.  It is an incentive for voluntary counseling and testing.  If you have care available, people will submit to voluntary counseling and testing at the present time.  If there is no care available in the large stigma associated with the disease, then nobody wants to be tested because if there is nothing to be offered, then why know? 

The targeted prevention message to people living with HIV can be achieved by this strategy.  You can engage your health care providers in the local environment.  If you do provide HIV care, then you do reduce transmission.  With a reduction in HIV viral RNA, about 3 to 3.5 logs is enough to reduce transmission of discordant couples, for example.  And you also have other benefits of reducing sexually transmitted diseases, etcetera.

We believe that we also need to provide operational research in a resource-limited setting on antiretral viral drug implementation in Africa.  These are questions that we have begun to address with some of the protocols that we are writing.  When do you start antiretral viral therapy?  What should be the CD4 count?  Should it be 200, 350?  What do you start with?  When do you switch therapy?  What do you switch to?  How do you monitor therapy?  Viral loads and CD4 counts are very expensive.  Can you use clinical parameters like weight loss, thrush or diarrhea as a failure of therapy?  Can you use a total lymphocyte count instead of a CD4 count to monitor therapy?  These are some of the questions that we and many others are trying to address. 

Who should receive therapy?  If you have 914,000 people that are HIV infected in the country of Uganda, and as you will see in a moment we hope to be able to treat 30,000 of them by the end of next year, who do you start with and who decides?  It has to be the Ugandans.  How do you promote adherence to therapy?  How do you prevent and treat opportunistic infections in a resource-limited setting?    

Those of you who are conversant with AIDS care will recognize that these questions are just as relevant in the United States as they are in Uganda, but the situation is different and solutions are undoubtedly different there.

Program monitoring and evaluation will require sentinel laboratories and a longitudinal cohort to document the impact, which is part of our goal with the Academic Alliance.  We need to appraise the program and show a response in operational research that is country specific.  We also want to look at the number of patients that have been served, the number of orphans, impact on the workforce, mortality and comorbidity. 

There are many challenges to developing an HIV therapeutic service in a resource-poor setting. Access to therapy is the most important one.  Clinician skills are, as I mentioned earlier, difficult.  There are not many people that are trained in the use of antiretral virals in Africa.  The laboratory resources are very poor and the promotion of care-seeking adherence, I think, is very important. 

One of the excuses that politicians have used for a slow response to delivering antiretral virals in Africa is that there is going to be poor compliance and therefore you will develop more drug resistance.  In fact, we think that it is going to be the opposite.  Because of the social structure in Africa and because of the possibility of directly-observed therapy, which I will describe later, we actually think that drug adherence would be better. In fact, we are moving toward once-a day therapies and therapies that could be used in a rural setting.  There is very little intravenous drug use in Africa as a cause of HIV, which, as you know, is a population in the United States which are very difficult to assure compliance.

The unmet needs are an accelerated prevention program, funds for diagnostics, AIDS drugs including antiretral virals, including the global fund, infrastructure for training and clinical care in laboratory support as well as operational research so AIDS drugs including ARV's can be delivered effectively and safely.  And obviously we need an effective, preventive therapeutic vaccine, which unfortunately is years away. 

I would like to describe for you now, in the time remaining, the Academic Alliance for AIDS care and prevention in Africa and what we hope to achieve with some of your help, I hope, because we are going to hopefully be sending medical students, residents and fellows to Africa to work on this effort.

We are building and infections diseases institute at Makerere University that is part of our program.  These are the individuals that make up the Academic Alliance.  Merle Sande is well known to some in the audience.  He was a former faculty member at the University of Virginia.  He moved to San Francisco General as the Chairman of Medicine, and then to the University of Utah as the Chairman of Medicine.  He has stepped down that his position at Utah to devote most of his time to the Academic Alliance for AIDS Care and Prevention. 

Merle and Nelson Sewankambo are co-directors of the Academic Alliance and Nelson is the Dean of the Medical School at Makir University. 

Jerry Ellner has worked on tuberculosis research in Uganda since 1999.  He is currently the acting Chair of Medicine at New Jersey Medical School. 

Allen Ronald just stepped down as the Chair of the Department of Preventive Medicine in the University of Manitoba in Winnipeg, Canada.  Fortunately for all of us he is on the ground in Uganda, 9 to 10 months of the year.  He is really responsible for working with our Ugandan colleagues and implementing the programs around the ground. 

You know me, and Tom Quinn is a professor of medicine and microbiology at Johns Hopkins University and has been active in looking at transmission in concordant couples as well as the impact of circumcision on the transmission of HIV and sexually transmitted diseases. 

Elly Katabira is a very well known Ugandan on the international scene.  He has served at the WHO developing treatment guidelines as well as opportunistic infection prophylaxis guidelines and is currently the director of the HIV AIDS clinic at the Mulago Hospital. 

Harriet Myanje is the Chairman of Medicine at Makir University.  She is the first woman to hold that position and has done a number of research projects on Cryptococcal Meningitis, which, incidentally, is rampant in Uganda--about 10% of patients that have HIV eventually develop Cryptococcal Meningitis.  It is actually the second most common form of meningitis in the country.

Edward Mbidde is a senior statesman on the faculty at Makir University.  He actually heads the cancer program there and he runs the clinical program on Kaposi's Sarcoma. 

Moses Kamya is my counterpart--we co-direct the training programs, which we will describe for you later.  Moses is the head of graduate medical education for the school

Roy Mugerwa is the former Chief of Medicine at Makir University and has worked with Jerry Ellner on tuberculosis research for about a decade.

Phillippa Musoke is a pediatrician.  She runs the HIV clinic for children at the Mulago Hospital and is part of our group.

David Serwadde and Fred Wabwire-Mangen are co-directors for the Institute for Public Health at Makerere University and have been very instrumental in both prevention as well as outreach programs. 

Peter Mugyeni is very well known internationally.  He is the head of something called the Joint Clinical Research Center, which enjoys some funding from the Ugandan government but also from international NGO's, that is Non-Governmental Organizations, and it is the only place in Uganda at the present time where antiretral virals are available. 

The 900,000 people I told you about that have HIV in Uganda--there are about 15,000 on therapy with the antiretral virals at the present time. 

These are our goals: 

• We would like to provide enhanced HIV care including antiretral virals and prophylaxis for opportunistic infections to both adults, children and their families. 

• Establish an education and training program for African physicians and health care providers in HIV care and prevention. This is being done in concert with The Infectious Diseases Society of America.

•Implement an intensive prevention program which will be run jointly by the Institute of Public Health. 

• In Makir University and the Academic Alliance we will be conducting clinical research to identify the best algorithms for patient care, including directly observed therapy and once-a-day treatment regimens.

• Establish a clinical laboratory to monitor HIV therapy and to support diagnosis of opportunistic infections, tropical diseases and sexually transmitted diseases.

We want this to be a sustainable program.  One day the North American members of this Academic Alliance want to walk away from this project and it should be all-African run, all-African trained and we have to get there with support from multiple different sources. 

President Musevini of Uganda is very aware of our project.  We have met with him several times.  He has given us 2 very important things:  access to his office twice a year, and no duty or taxes on anything we donate, including $900,000 worth of laboratory equipment--which is a very big deal. 

The AIDS Commission is run by Dr. Apuli.  This is our contact for the Global Fund, which you have heard described earlier.  We have been working with USAID which is run by Dawn Liberi.  The CDC has a post in Uganda run by Jean Mermann.  Milago Hospital and Makir University I have already mentioned.  The Ministry of Health we meet with every time we are there and they are very behind our project.  We also meet with the American Ambassador, Ambassador Brennan, on every trip.

Just a word about the training.  We have collaborated with the Infectious Disease Society of America and the Academic Alliance to put together a training program.  The initial program is focused on the training of physicians.  There will be two trainers from the IDSA.  It is a month-long training program over 4 weeks.  It is about 50% didactic classroom and 50% clinic.  There will be around 10-12 trainees per month.  This is a regional training center, which is what I want to emphasize.  It is not just for Uganda.  In the second month of training, doctors are going to be coming from Botswana as well as Zimbabwe. 

We want the trainers to be there for at least 3 months.  They are going to be teaching in various settings.  The faculty will be selected from schools throughout the world.  A lot of the training is going to be conducted by the Ugandans themselves.  They know the current situation, they know how to treat Cryptococcal Meningitis.  The curriculum is being developed by not only the IDSA, but also by Africans so that our trainees can walk away with a syllabus this thick and the Palm Pilot has three books on it as well as algorithms for treatment care which they will be able to take back to their clinic.  There will be on-site facilities to support this training program.

This is the first continuously run HIV care educational program in Africa.  We hope to train up to 80 people a year.  The course will be 4 weeks, as I have said.  The trainees get money for travel, room and board.  The program will start later this month. 

This is a laboratory program--microbiology, biology, etc.--for the care of patients as well as for development of antiretral viral resistance and CD4 counts on computerized databases, etc. 

Finally, the prevention program is based in the Institute of Public Health.  It will be focusing on HIV positive individuals and their families.  We hope to enhance voluntary counseling and testing in the medical wards.  We have a protocol that we are doing right now for the Doris Duke Foundation to do exactly that.  Screening and treatment of sexually transmitted diseases and perinatal transmission prevention is actually very well established.

This is the last slide that I am going to show you.  It is of a bunch of happy children in Uganda I took a picture of.  We would like to keep them happy.  We would like for them to have a productive and healthy life.  I think that they are already making tremendous gains there in Uganda, but we believe that the Academic Alliance can help in this effort.  It is a small start, but it's a start.