Diary Prequel Package — page 24

discussed with him the NIAID initiatives as well as my recent interactions with Secretary Thompson, the State Department, NSC, Domestic Policy Council, and the White House concerning the development and implementation of a White House and US Government policy and plan of action for treatment of HIV in Africa and AIDS care in Africa. At the meeting was Ms. Dawn Liberi, USAID Chief for Uganda and Jonathan Mermin, a CDC person assigned to the US Embassy. Excellent meeting. Extraordinary security related to the terrorist attack on the Nairobi Embassy last year. We could not even take cell phones into the ambassador's office. Next went on to the Joint Clinical Research Center (JCRC) escorted by Peter Mugenyi and Cissy Kityo. Like Nelson Sewankambo, Peter is clearly an important physician in Uganda and the JCRC does much clinical research on HIV/AIDS. It was unclear how patients get put on a protocol and are followed at JCRC versus getting admitted as a regular patient to Mulago Hospital. The JCRC is the source of many of the important clinical studies that have come out of Kampala. I was impressed by the sophisication of their operation. Many Africans and some expatriots (mostly Americans) work here and also at other facilities that I visited including the Rakai Project (see below). Most Staff (PH.Ds, MDs, MPHs and even technicians have spent some time learning techniques and theory in the USA. Next went on to make Ward Rounds in the Department of Medicine at Mulago Hospital with Roy Mugerwa and Harriet Mayanja. This was clearly one of the defining moments of the trip for me and changed the way I think about the reality and potential of AIDS care and health care in general in Uganda and Africa since Uganda is considered one of the best. The wards were packed; people were lying in hallways, in open air virandas, and some were waiting with their families to gain admission. Most looked extremely ill and cachectic. Others were reasonable fit, but obviously acutely ill. I have rounded on thousands of patients over the years, but I have never seen anything like this except maybe when I made rounds at the King Edward Hospital at the University of Natal in Durban, South Africa in July, 2000. The difference here is that virtually no one gets treated specifically for their disease because of lack of anti-retrovirals and inability to pay even for drugs for OIs, TB and malaria. The rule (with few exceptions is that if the patients cannot pay something (even a dollar or 2), then they get no specific treatment. If they can pay, but are poor, they do "cost sharing" whereby they pay for part of what is to be done (i.e. chest x-ray, medications, etc.); however, it is severely limited by the amount which they cost share. If you are relatively wealthy and can pay, you go to a different ward and anything is possible diagnostically (chest x-ray, CT, blood work) and therapeutically (ARV, OI treatment, etc.). I saw patient after patient with HIV disease (mostly diagnosed not by serology since ELISA was too expensive - $4.00) and OIs. Overwhelmingly, patients had active TB. Here again, diagnosis was made clinically without chest x-ray and frequently without sputum smear and culture. Certainly, no CTs, bronchoscopies etc. I remember specifically a 17 year girl who had HIV disease (diagnosed by wasting and oral thrush) and likely cryptococcal meningitis (dx made clinically); they were considering doing an India ink stain on CSF, but decided not to since they could not do anything for her anyway since she could not afford amphotericin or fluconazole. The plan for the patient was hydration, analgesia and