Neuro AIDS in
Papua New
Guinea
Dr. Goa Tau
Heduru Clinic
Port Moresby General Hospital
Papua New Guinea
Email [email protected]
Pacific Neuro Aids Meeting Sydney July 20 2007
Contents
• PNG
• Introduction
• HIVAIDS in PNG, the epidemic
• APNAC Study PNG site
• Challenges
• Opportunities
• Way forward
• Conclusions
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PNG AND AUSTRALASIA
PNG
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PNG The country
Population 6.5 mil
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Neuro Aids in Papua New
Guinea
HIV medicine in PNG
• Little is known
• HIVAIDS neuro unknown
• General observation shows that
infections affecting the nervous
has a high mortality and indeed
morbidity.
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Disease burden
• Malaria
• Pneumonia
• HIV AIDS
• Infant and maternal mortality
• Non communicable diseases
National Health Conference 2007
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The epidemic
National
Urban
Rural
7
6
General Prevalence 1.6 %
5.07
5
Prevalence
5.74
4
3
2
1.44
1.24
1
1.02
0.04 0.1
0.05
0.98
0
1993' 1994' 1995' 1996' 1997' 1998' 1999' 2000' 2001' 2002' 2003' 2004' 2005' 2006' 2007' 2008' 2009' 2010' 2011' 2012'
Years
Source, PNG, NDOH Consensus data 2007
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Morbidity 2000-2007
PMGH
Morbidity 2000-2006
Tuberculosis
Asthma
HIV/AIDS
CRF
Malaria
Cancers
Pneumonia
COPD
Snakebite
Corpulmonale
IHD
1400
1245
1200
1226
Numbers
1000
800
753
600
529
400
334
200
225
197
161
115
111
103
75
64
40
0
2000'
312
262
251
131
130
104
70
63
31
11
2003'
229
127
122
115
92
57
53
48
2006'
Years
Source: PMGH Internal Medicine Audit 2000-2006(2007) Tau
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Mortality 2000-2006
PMGH
Mortality 2000-2006
Tuberculosis
HIV/AIDS
Malaria
Pneumonia
Snakebite
Asthma
CRF
Cancers
COPD
Corpulmonale
IHD
180
161
160
140
120
Numbers
109
100
92
96
80
60
65
63
40
47
40
36
20
25
19
0
35
33
28
24
23
9
8
1
6
2
2000'
2003'
44
37
27
26
20
15
10
7
2006'
Years
Source: PMGH Internal Medicine Audit 2000-2006(2007
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HIV/AIDS IN ADULT MEDICAL
WARD PMGH 2000-2006
45
% ALL ADM
40
40
% ALL DEATHS
CFR %
38
35
35
32.8
30
PERCENT
30
24.3
25
20
15
10
5
12.3
9.3
23.5
17.6
16.1
11
23.3
14
7.3
4.8
4.4
0
2000'
2001'
2002'
2003'
2004'
2005'
2006'
YEARS
Source: PMGH Internal Medicine Audit 2000-2006(2007)
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THE APNAC
• APNAC 2003
• July 2005 and 2006
• Cross sectional study at ten sites in
eight countries over a two weeks
period
• To determine prevalence of HIV
associated NCI and SSPN
• MRAC PNG and PMGH approved
study
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Methodology
• Neuropsychological four test-battery
• A clinical peripheral neuropathy screening
tool
• The CES-D depression screening tool and
both alcohol and substance use
questionnaires.
• N = 658 HIV infected patients.
• PNG
= 33
• Neuropsychological test also administered
to N = 161 Controls,
• PNG
=
20
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Diagnostic criteria used
• Neuropsychological impaired
= moderate to severe imp if >= 2SDs below
N controls
• Definite SSN was present if
=symptoms + absent ankle reflexes+
vibration sense < 10 seconds.
• Probable SSN was present if
= symptoms + one of two remaining criteria
• Depression was highly likely on using CESD 20
= A score of > 16
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Demography of HIV Infected
patients
N = 33
Gender
Male 52.9%
Age (mean)
Mean
37.4yrs
BMI
Mean
21.99kbm2
Education
< high school
41.2%
High school
38.2 %
Some college
20.6 %
MSM
5.7%
Heterosexual
94.1%
Mode of HIV infection
95% CI [20.68, 23.30]
CD4
239.75
95% CI [172.91,306.59]
TLC
309.34
95%CI [1080.50,1538.18]
Median time since HIV inf
2 years
Prior AIDS illnesses
88.6
Prior CNS disease
2.9%
Hb
Mean 10.9
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95% Ci [9.9, 11.9]
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ART Infected patients ART
N = 33
Current HAART
yes
91.2
ART regimes
AZT. 3TC. NVP
(13)
41.9%
AZT. 3TC. EFV
(4)
12.9
D4T. 3TC. NVP
(7)
22.6
D4T. 3TC. EFV
(7)
22.6
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Demography HIV infected and
controls
HIV infected
patient
Control
33
20
18
15
17
3
0.010
Age
37..5
32.1
.067
BMI
21.99
25.8
.002
< high school
41
65
High school
38
30
Some college
20
5
Gender
male
Female
P - value
Education
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NCI 1 Results
Outpati
ent
Control
P
Grooved
pegboard sec
88.97
3 (33)
77.8
0.02
Semantic
fluency #
animals
13.1
1(33)
14.1
0.61
Times gait
seconds
12.9
0(33)
10.7
.04
Finger taps
# taps
35.5
9(33)
43.2
.002
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NCI Results 2
Grooved
pegboard
sec
Semantic
fluency #
animals
Times gait
secs
Finger taps
# taps
Outpat
STD d
Control
Std dev
88.97
18.6
77.8
13.2
4.09
14.1
3.4
4.06
10.7
.80
9.6
43.2
95% CI [82.47,
95.46]
13.1
95% CI [12.07,
14.92]
12.9
95% CI [11.27,
14.48]
35.5
95% CI[32.13,
38.86]
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Neuropsychological tests
PNG versus APNAC sites
PNG
Std dev
OTHER
SITES
Std dev
Groove
pegboard
88.9
18.6
73.48
20.43
Semantic
fluency
13.5
4.9
17.87
5.56
Times gait
12.88
4.06
12.54
3.87
Finger tap
35.5
9.6
35.30
8.23
Prevalence NCI and SSN Asia Pacific 2006 wright et al
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Neurocognitive impairment 3
Result 1
PNG
APNAC SITES
6 (33)
76 (647)
18%
12 %
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Depression
CESD -20
Mean score
19.79
CESD -20
13(33)
95% CI [17.71,
21.88]
33%
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SSN = PNG
PNG
Total
10 sites
Definitive
6(33)
26%
126(640)
20%
Probable
4(33)
12%
Total
38%
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Prevalence of neuro
illnesses inpatients
• During the same two weeks period all
patients admitted to adult medical ward
were screened for AIDS defining illnesses
• Consent was obtained
• Medical information was extracted from
the patient case notes.
• Blood for CD4.
• Demographic data and medical data was
obtained
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Demographics
N
20
%
Gender
Males (9)
45%
Education
< high school (12)
60%
High school 7
35%
Some college 1
5%
Years positive
Mode infection
1 year
15
75%
2 year
4
20%
4 year
1
5%
Gay
2
10%
Hetero sexual 18
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90%
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ART
N
20
%
Antiretroviral
Yes 4
20 %
No 16
80 %
ARV Regimes 4
AZT. 3TC. EFV 1
D4T. 3TC. NVP 1
D4T. 3TC. EFV 2
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Results
means
95% CI
Age
33.6
[29.48, 37.7]
BMI
17.88
[16.37,19.40]
CD4
324.5
[195.56,453.44]
Hb
7.5
[6.32,8.68]
Creatinine
124
[36.07, 211.90]
Albumin
25.3
[22.30,28.29]
Protein
77.8
[70.27, 85.50]
ALT
29.9
[23.64,36.24]
AST
39.4
[28.69,50.01]
Alkaline Phosphate
177.4
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[93.65,261.29]
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Symptoms inpatients
N = 20
Yes
Headache
20%
Poor concentration
15%
Forgetfulness
5%
Difficulty with ADL
10%
Agitation
15%
Focal neuro signs
0%
Decrease LOC
15%
Neck stiffness
20%
Hyper reflexia
10%
Action tremor
10%
Abnormal reflexes
10%
Abnormal gait
10%
Abnormal cerebellar signs
0%
APNAC Prevalence Neuro aids in PNG 2006, Wright et al
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AIDS Defining illnesses
Freq
N = 20
%
Cum %
Crypt
Meningitis
2
10
10
TB meningitis
1
5
15
PTB
7
35
60
EPTB L node
1
5
65
Esop candid
4
20
85
Cryptosporidio
s
1
5
90
Wasting synd
1
5
95
PCP
1 2006,
APNAC Prevalence Neuro aids in PNG
Wright et al 5
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Summary Prevalence
Prevalence
NCI
18 %
CES-D
33 %
SSPN
26 %
Neuro HIVAIDS
inpatients
15 %
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Findings and Challenges
• With a high prevalence of NCI at 18 %
understanding during education session
will be very limited.
• Depression rate of 33 % will lead to low
morale and self esteem.
• SSPN rate of 26 % will affect the quality of
living.
• 15 % of Neuro Illnesses will need the
improve diagnostic and treatment and
monitoring tools for PLWHA in care
facilities
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Challenges Neuro AIDS
• Inadequate diagnostic facilities
• Inadequate laboratory monitoring
• Inconsistent regular supply of laboratory
supplies, OI drugs other antibiotics and
even ART
• Lack of medical personnel ( one person
doing other duties)
• Limited TB diagnosis ability ( endemic)
• No serology Toxoplasmosis. (prev 35%)
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Opportunities
• Country scale up of HIVAIDS training including
ART prescribers.
• > 20 sites providing ART
• PNGHOD now just started with 6 ART government
sites
• Increase in VCT sites, confirmation other sites
• International assistance with finance and other
means
• International collaborations (APNAC, TREAT
ASIA)
• HIV Rapid, confirmations, PCR (TBA soon)
• CT scan, Indian ink, Cryptococcal Ag
• Clinical strengths
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Way forward
• Continue train HIVAIDS and ART
cadres
• Establish a HIV AIDS national center
of excellence
• Train PNG with research methods.
• Strengthen national and international
collaborations for capacity building.
• Encourage more clinical research.
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Conclusions
• We can only do so much with what we
have in Papua New Guinea
• We have more challenges than successes
• I suppose having a proactive attitude and
making use of the opportunities should
change some of these challenges into
successes.
• Neuro AIDS issues in PNG must be
considered together as a comprehensive
issue for better care provided to the
PLWHA.
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Acknowledgment
• Heduru clinic staff
• Internal Medicine nursing and
medical staff
• PMGH
• Edwina Wright et al APNAC group
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TANIDKIU BADA HEREA
THANK YOU VERY MUCH
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