Limited resources, numerous experiences

A post by An Le, PD4

IDI Clinic Building on Mulago campus

After being in Uganda for a little over a week, my two classmates and I are still having a hard time believing that we get to have this learning opportunity in Kampala, Uganda. For the past few days living in a different country, every single experience has been truly rewarding, whether it’s a trip to Gaddafi National Mosque or a rotation at the Infectious Disease Institute (IDI).

The three of us rotate through several different sites including IDI, Kirrudu General Hospital, and the neurosurgery ward within Mulago Hospital. My first rotation is at the IDI, which is located on the campus of Makerere University College of Health Sciences. This institution provides care to approximately 8,000 patients living with HIV and other comorbidities. After one of the pharmacists, Eva, gave us an overview of IDI, I was amazed by how much research has been devoted to different areas to ensure patients in this particular population receive the most optimal care. In spite of the limited resources, the pharmacists and pharmacy students are extremely eager to learn about the U.S. healthcare system and explore various research areas to improve patient care. In Uganda, HIV patients receive isoniazid (a medication for tuberculosis prophylaxis) when they come to the pharmacy to pick up their HIV medications. Tuberculosis is the most common opportunistic infection in HIV patients. However, not all patients have tests done to monitor their liver functions before taking this medication. This was surprising to me because in the United States, we learned that liver function is tested prior to isoniazid treatment since this drug can lead to hepatotoxicity. In order to ensure the medication is safe, Eva and her team are planning on a project, where they are figuring out the most effective method to monitor medication safety and promote the importance of medication adherence. After sharing with the team about how this follow-up process is usually done in the United States, I’m excited to see the outcomes of their project in the next few weeks. 

IDI Education Building, where ATIC is housed

During my rotation at the IDI, Joe, Melanie and I got to visit the AIDS Treatment Information Center (ATIC), which serves as a call center for all health providers and patients in Uganda. Here, we were able to help the provider come up with the plan on how to approach a case study for a patient living with HIV and various other comorbidities. This experience allowed us to learn more how healthcare providers communicate with each other and with the patients in Uganda. One interesting piece of information that we learned while discussing the case with the provider is that there have been a few cases on hyperglycemia as a side effect associated with the use of dolutegravir.

I have now started my next rotation at Kirrudu General Hospital, where I get to round with the cryptococcal meningitis team and monitor each patient in the ward. Rounding with the cryptococcal meningitis team has been a unique experience for me, as I have gotten to see the integration of clinical research and patient care. The majority of the patients in the meningitis research trials are taking anti-retroviral therapy and some of them are also taking medications for tuberculosis prophylaxis. While reviewing these patient’s charts, I was shocked by the low CD4+ counts in these patients, which indicates that they are extremely immunosuppressed. Dr. Nicol, Joe, and I had a good discussion on different topics including drug-drug interactions between dolutegravir and rifampin and between fluconazole and rifampin. These discussions are very helpful for me, as they give me an opportunity to recall what I learned during my didactic courses and see how well I can apply it. While at Kirrudu General Hospital, one thing I noticed was how welcoming the provider was. He was very excited when our group asked if we could join and round with him. He also frequently turned to us and checked to see if we have any input for each patient and was very patient in answering our questions. Joe and I also got to see a lumbar puncture procedure done on one of the patients. A lumbar puncture is performed to collect a cerebrospinal fluid sample for a CrAg test for cryptococcal meningitis diagnosis. This procedure is also conducted on patients with cryptococcal meningitis when their intracranial pressure is too elevated. Looking back on this experience, one thing that surprises me the most is how most the time, the medications might not be adjusted to patient’s kidney/liver function. Most patients usually get the same dose regardless of the kidney/liver function. Although the healthcare providers are aware of the importance of the kidney/liver function when dosing, they don’t have a lot of resources to achieve this goal. Moreover, it’s usually cheaper for the Ugandan hospitals to purchase medications in bulk, which can be challenging for healthcare providers to adjust doses for each patient.

Besides these incredible learning opportunities, Joe, Melanie, and I also spent some time visiting different places around Kampala. At the Gaddafi National Mosque, we got to learn about the history of the mosque and the Muslim religion within Uganda. We also got to see a whole view of the city from on one of the mosque’s towers. Last night we attended a culture troupe show and learned about different traditions across Uganda.

 

Ndere Cultural Troupe Show

Climbing the tower at Gaddafi National Mosque

That’s a wrap for now. I seriously can’t wait to share with you all more about what I get to experience in the future blogs. Stay tuned!

Life in Kampala, and a Review of Tuberculosis

A post by Joe Corbino, PD4

View from Kirrudu General Hospital

After a few days I feel like I am finally getting settled into life in Uganda and my first APPE rotation. So far, I have been able to experience healthcare at the Infectious Disease Institute and Kiruddu General Hospital both of which are situated in different areas of Kampala.

The Infectious Disease Institute is situated on the campus of Makerere University College of Health Sciences. This location functions as a specialized center that cares for individuals living with HIV/AIDS who are also suffering from additional co-morbidities. It is estimated that the location is currently following around 8,000 patients. On our second day in the Uganda, the other pharmacy students and I had the opportunity to interact with a pharmacist and three other interns that were completing a four-week rotation at that site. In Uganda, a pharmacist intern designation is applied to individuals that have finished “undergraduate” pharmacy course work and are now completing a year of rotations.

The most interesting experience that I have had thus far has been following the cryptococcal meningitis team to Kiruddu General Hospital to round on their patients that are currently enrolled in research trials. This experience was very different from what I am used to in the United States as patients are grouped into wards, or giant open rooms, rather than individual rooms. One thing that I noticed right away was the amount of family present. I learned that unlike in the United States, families in Uganda will often stay with the patient during the course of their hospital stay administering oral medications, preparing small meals, and sleeping on the floor at night as hospitals are not equipped to provide many of these services. When I arrived a physician was quick to notice that I was a student and offered to allow me to shadow her for most of the morning. This included watching two lumbar punctures in patients that were enrolled in her research study surrounding TB-meningitis. After this I was taken, along with Dr. Nicol, to the microbiology lab to witness how patient samples are handled for further investigational analysis. During my remaining time at the hospital, I was able to join two additional physicians to complete their rounds.

View of Kampala from the top of the minaret at Gaddafi National Mosque 

Inside of Gaddafi National Mosque 

It will never cease to amaze me the severity of immunodeficiency that the patients I have seen are experiencing. One way that this is measured is to look at an immune cell that we refer to as CD4-positive T-lymphocytes. Individuals are considered to be at the greatest risk for opportunistic infections when their CD4 count is less than 200 cells/mL. Almost all of these patients had CD4 levels that were 2-4 cells/mL. This has allowed me to reflect on two things. First, individuals in developed areas of the world are extremely fortunate to generally have access to comprehensive medical care that affords them the latest advances in HIV therapy. Second, improving the lives of individuals suffering from HIV/AIDS in developing countries is something that I want to be invested in for the foreseeable future.

I thought I would take some time to give some brief information on the subject of TB-meningitis for my family, fellow pharmacy friends, and anyone else that may be reading this blog! Tuberculosis (TB) is a disease that is caused by the organism Mycobacterium tuberculosis. The organism is spread through the air and more commonly infects individuals with compromised immune systems, such as those suffering from HIV/AIDS. In school we are taught that the disease generally manifests itself in the lungs, but it is possible that it can disseminate or spread to other areas of the body. Individuals affected commonly present with a fever and headache. They may additionally appear confused if the disease is in a later stage. A confirmatory diagnosis is made through analysis of cerebrospinal fluid, which has high protein, low glucose and a raised number of lymphocytes (immune cells). As is seen in regular TB treatment, individuals are treated with an induction phase consisting of isoniazid, rifampicin, pyrazinamide and ethambutol for two months followed by a consolidation phase of isoniazid and rifampicin for ten more months.

An and Melanie in front of Namirembe Cathedral

Aside from the clinical experiences scheduled this APPE rotation, I have had ample opportunity to explore Kampala and see how beautiful and vibrant of a city it is! So far, I have had the opportunity to go to a craft market, the second largest mosque in Africa, and various delicious restaurants near the Minnesota house. Stay tuned for more updates in the coming week from An, Melanie, and Dr. Nicol!

As the world turns

By Melanie Nicol

The first week of Uganda APPE 2019 is already over! Granted, it was a quick week since the first two days were spent travelling and much of our time here was spent settling in and getting oriented to our housing and the different parts of Makerere and Mulago where the students will be spending their time. Despite the short week, the students have already been exposed to so much. Issues such as drug availability and antibiotic resistance have been topics of recurring discussion among our group. The students have been enjoying the weekend with some excursions in Kampala- yesterday they visited the Uganda National Mosque and this afternoon we plan to visit one of the craft markets!

Melanie M, An, and Joe inside the Uganda National Mosque

I keep needing to remind myself that it's been 12 months since I was last in Kampala. I've been here enough times now that everything seems familiar yet it is very obvious that when I am a half a world away, things here are constantly changing. The first significant change- the expressway from Entebbe to Kampala has been completed!  Everytime I have asked about this road for the last 3 years the response was always "it will be done in 3 months". Guess the inability to predict how long road construction projects will take is a universal one. To put in perspective the impact of this, this expressway took what used to be between a 2-4 hour drive to the airport down to about 45-60 minutes, something we were very grateful for when landing at 11pm after 24 hours of traveling.

A second difference I've already observed is the effect of the rollout of dolutegravir in Uganda. When I was last here in May 2018, the country was just beginning the rollout and it was only available in a limited capacity at a few locations. Since that time, the country has had to deal with the Botswana study report which had the unexpected finding of increased neural tube defects when women were on dolutegravir at the time of conception. The low prevalence of these birth defects (0.09% of pregnancies in the HIV-negative population) makes it very difficult to determine whether the increased prevalence observed in this study (just 4 births out of 496 pregnancies) was truly a drug effect, due to some other unidentified factor, or just random.  This has been carefully followed in the months since the report but updates at CROI earlier this year seem promising as there have been no new cases reported. This is all particularly relevant in Uganda as women of child-bearing age make a significant portion of the population living with HIV and dolutegravir is really a game-changer in HIV treatment in regards to efficacy and tolerability. Despite the struggles in rollout with how to manage this uncertain risk, dolutegravir has continued to roll out and uptake is significantly higher now than when I was here last. This opens the door for many research questions. What is the frequency of adverse effects from dolutegravir in this population? Given dolutegravir's potency, will this affect the incidence of IRIS (a question the meningitis team is particularly interested in)? Will we see changes in prevalence of antiretroviral resistance since dolutegravir has a particularly high barrier to resistance?

Many changes have been going on with my research projects as well. One of my projects in Uganda has been a collaborative project with MUJHU research that I have previously posted about (Preventing HIV infection in women). This study had just wrapped on when I was last year and we've spent the last year running lots of assays and analyzing our results. We presented our findings at CROI earlier this year and I'm excited to say these results will soon by published in Clinical Infectious Disease (link to abstract/paper here) . We found some interesting and unexpected interactions between the use of DMPA injection and the vaginal microbiome and the effects on drug concentrations in cervical tissues. Overall, our findings were encouraging in that they provide reassurance that DMPA does not negatively effect drug concentrations and women should be able to use DMPA and oral PrEP safely. Here is a link to a video interview I did with Contagion Live that summarize our findings: Contagion Live Interview.

Me with  collaborator Flavia Matovu Kiweewa presenting our results at CROI in March 2019

Watch for updates in future blogs regarding some other Kampala-based projects!

The other Melanie

A post by Melanie Mahoney, PD4

Hi everyone! My name is Melanie Mahoney and I’m a fourth year pharmacy and public health student and the University of Minnesota. I was born in France but have lived most of my life now in Minnesota. My husband and I both love travelling and have been to lots of interesting places around the United States and Europe together. We also have 2 cats that we love despite how spazzy they are!

My professional interests include infectious diseases, antimicrobial stewardship, and global health. I am currently in the Department of Experimental and Clinical Pharmacology Research Emphasis and have been working in Dr. Elizabeth Hirsch’s lab, studying Escherichia coli ST131 for about a year and a half. I have also had the opportunity to expand my understanding of global health through several international trips in pharmacy school. My first and second year I traveled to Haiti and set up a temporary clinic with other students. This past fall I attended an international pharmacy conference in Glasgow, Scotland and just last month I presented a research poster at an infectious disease conference in Amsterdam, Netherlands. While I have been fortunate enough to have traveled a lot, this experience is my first in Africa!

I am very excited to spend the next 5 weeks in Uganda! I am most looking forward to learning about a culture and healthcare system that is new to me. While I was nervous at first about my clinical knowledge and being able to apply it when asked questions, those nerves have worn off already in a couple days here. In my first few days here I have already had the chance to see infections and treatment plans that are not commonly seen in the United States.

I can’t wait to see what the rest of this experience brings!

Meet An Le

A post by An Le, PD4

Melanie M, An, and Joe in front of the Minnesota House

Hello all,

My name is An Le. I’m a fourth year pharmacy student at the University of Minnesota, Twin Cities campus. I’m originally from Ho Chi Minh City, Vietnam. I have a younger sister, who’s four years younger than me. We ALSO have the same name (how crazy!). In my free time, I enjoy trying new baking recipes, going to new restaurants/coffee shops, and doing yoga.

My dream career goal is to work in an area where I’m able to combine both clinical and research aspects. I decided to participate in the Uganda Advanced Pharmacy Practice Experience (APPE) rotation because the projects/activities of this rotation will give me a better understanding of how pharmacists can utilize both aspects in their jobs, which will prepare me well for my future career. After hearing more about this rotation from Dr. Nicol and other previously fourth year students, I knew this would be a great learning opportunities for me to utilize the knowledge acquired from classes and observe the pharmacists’ roles in Uganda.

My first international travel was during my junior year of high school when I decided to come to the United States to complete my high school degree and undergraduate degree. Although this is not the first time I’m traveling to another country for study abroad, I’ve had mixed feelings when I think about this trip to Kampala, Uganda. I’m most looking forward to working alongside with Ugandan students and other healthcare providers to expand my clinical knowledge and learn more about different sectors that may help narrow down the health disparities in developed countries. I’m also very excited to visit different places to absorb more Ugandan cultures during these next 5 weeks. On there other hand, I’m more nervous about being to recall and apply appropriately the knowledge in these real-life situations. However, these 5 weeks will definitely help me grow and become more prepared for the next few rotations in the United States.

Overall, I believe that these next 5 weeks in Kampala will be busy and I’m very happy that I have a chance to step out of my comfort zone to see other parts of the world. And I can’t wait to tell you all more about what I get to see and learn.

Meet Joe Corbino

Post by Joe Corbino, PD4

Hello everyone! My name is Joe Corbino and I am currently a PD4 on the Twin Cities campus. I grew up in the western suburbs of Chicago, but many of my friends like to joke that I am from Iowa due to my family now residing there. I had a fairly unconventional path to pharmacy, graduating with a bachelor’s in music from the University of Iowa. A career as a pharmacist was attractive due to being able to combine my interest in biology and infectious diseases along with the opportunity to have an impact on individuals’ lives. A few of my hobbies include traveling, listening/playing music (big surprise!!), and learning about languages and different cultures.

I’ve had several opportunities throughout my time in pharmacy school to travel abroad, which has helped to expand my understanding of the profession to a more global perspective. In fall 2017, I traveled to Seoul, South Korea with a fellow classmate to attend an international pharmacy conference. In August 2018, I traveled around central and northern Italy with my mom before hooking up with one of my close pharmacy friends to visit an international pharmacy student in Croatia that we had hosted in Minnesota the previous summer. Before heading to Kampala for my first APPE I was able to spend several days in Amsterdam exploring the city with a family friend.

Since the beginning of 2017 I have had the opportunity to be a part of Dr. Melanie Nicol’s research lab. Since hearing about this elective experience in Uganda as a first year I have wanted to be a part of it. The greater medical community in the Minneapolis/St. Paul has provided me with incredible opportunities to become more informed and involved in the area of HIV/AIDS. It was through this educational exposure that I began to become interested in care around the world, especially resource limited settings. I soon began to realize during my second and third year of pharmacy school that this experience I had merely been interested in due to the international travel aspect would also be extremely beneficial in my professional growth as a future pharmacist. I believe that it is invaluable to gain firsthand experience to how individuals are compassionately and comprehensively cared for around the world, especially in resource limited settings.

My excitement and nerves for this rotation are closely linked with one another. It will be a life changing experience to be in Uganda and experience healthcare and another culture firsthand. I want to ensure that this experience is approached as seriously as possible to ensure that the impact that the impact on patients during this 5-week experience is as beneficial for them as it is for me. After all, I am the stranger that has come to their home in order to further my abilities as a practitioner.

I look forward to writing more posts during my stay here and updating everyone on everything that I have been able to experience both in clinic and during leisure time!

The Return of the Blog

Uganda APPE 2019 has officially begun! All of us (and thankfully all our luggage) made it to Entebbe late last evening and got into our house in the early morning hours.The "Minnesota House" has moved a few plots down the street from where I have stayed previously so we all got a quick tour and tried to catch some sleep before our first full day. Unfortunately, some Ugandan dogs had other ideas- apparently they had a lot to talk about with each other between 4-7am.

For the first time in my 8 (?) visits to Uganda, I had to complete this health form, which is clearly an "Ebola Screening" form, before entering the country. Speaks to the ongoing epidemic that is not too far away in the Democratic Republic of Congo and I'm sure the Ugandan government and health officials are very aware and mindful of.

It has been 11 months since I was last in Uganda, the longest time away since my fist trip in October 2015. It means there is a LOT on my plate while I'm here. A long list of people to touch base with and projects to move forward

Over the next few days, each of the APPE students will introduce themselves. I am particularly excited about this year's cohorts as all three are students in my Department's Experimental and Clinical Pharmacology Research Emphasis program