Differences in practice of pharmacy in Uganda vs U.S.

A post by An Le, PD4

It’s frightening to think how three weeks has gone by so fast already!!

Although I grew up in Vietnam, where is known for its notorious traffic, I have to say that Ugandan traffic IS even more terrifying. This past week, we had to say goodbye to Dr. Nicol, as she returned to the United States. For the rest of our time in Uganda, Prosperity Eneh, who just recently completed the Global Pharmacy Engagement, Education, and Research fellowship at the University of Minnesota, will be with us for rest of our time. As Prosperity has been to Uganda before, we are very excited to learn more about Ugandan health system and explore the Kampala city with her. Between my previous post and this post, Joe, Melanie, and I had so many more incredible experiences that allowed us to further submerge in the Ugandan culture and healthcare system.

Before Dr. Nicol went back to the US., the four of us got to spend a 3-day weekend at the Murchison Falls National Park, where we were all amazed by the beauty of the Ugandan wildlife. Spending the whole day driving through the safari to be close to the wild animals was completely worthwhile. This might sound dramatic, but I don’t think words can’t describe my excitement when we were 10-20 feet away from a group of giraffes and elephants. I’m not sure if I should say it here, but Joe and I were looking forward to seeing some chasing between the animals. The 3-day weekend zipped through! When we got back to Kampala city, we found out we got another day off because of Eid al-Fitr celebration, marking the end of Ramadan. In order to decide which day marks the end of Ramadan, the Muslim advisers had to watch the moon. Therefore, a lot of institutions, meetings, and other pre-scheduled activities had to adapt to the celebration.

I also just finished my rotation at Kirrudu General hospital. As I briefly mentioned in my previous blog post, Kirrudu General Hospital has one specific ward that houses patients living with HIV, who also concurrently have cryptococcal meningitis. From my understanding, there are three on-going studies being conducted on this floor: AMBITION, ASTRO, and RIFT. I spent the majority of my time with the meningitis team to assess patients for the AMBITON-CM or ASTRO study. AMBITION-CM study is conducted to evaluate the efficacy and safety profile of a single high-dose liposomal amphotericin compared to the conventional 7-day deoxycholate amphotericin. Being with the clinical team the past week has allowed me to have a closer exposure to the entirety of clinical research process from screening patients for eligibility, obtaining patients’ consent, to randomizing patients into different treatment arms in the study. It was extremely interesting to see the whole process occurs in real life. In contrast to the United States, all patients have to share one common large room on the ward. Their family members take turn to be with the patients, so they can help the nurses remove the catheter or set up the feeding tube. During my time with the rounding team, I was blown away by how motivated the patients are to improve their health in spite of the limited resources.

Ironically, the topic for my journal club was on a phase 2 study assessing the efficacy and safety of 3 alternative schedules of intermittent high-dose liposomal amphotericin B (single-dose, 2-dose, 3-dose regimen) compared to the conventional dose of 3mg/kg/day liposomal amphotericin B for 14 days. The outcomes of this phase 2 study demonstrated a non-inferiority between a single-dose and conventional therapy of liposomal amphotericin B. This journal club was really helpful for me, as my goal is to get better at analyzing the study design and outcomes to review the validity of the study. We also had a very good discussion on different ethical issues within the study, which helped me a chance to look at the study from the different perspective.

This past week, Joe, Melanie, and I also had an opportunity to learn more about the “Pharmacy antiretroviral therapy refill” program. This initiative is implemented at 6 different private pharmacies by the Infectious Disease Institute and Kampala Capital City Authority. Kampala Capital City Authority organizes numbers of outreach programs that collaborate with other institutions on national, regional, district, and community level. This program started in November 2016 with the goal to improve retention and adherence to treatment, direct more care towards critically-ill patients living with HIV, and provide a more flexible medications refill for virologically suppressed patients. In order to be qualified for the program, patients have to show good adherence, be on standard 1st line antiretroviral therapies for at least 1 year, and have no active opportunistic infections. Another Ugandan third year pharmacy student and I travelled to one of the community pharmacy, where this program has been implemented, to interact with patients and the staff to gather feedbacks. These feedbacks will be used to improve the program in the future. From our conversations, the majority of patients really enjoy being in this program, as they think it is more convenient and flexible for them to pick up the medications. The whole visit was done by the nurse, where she discussed with the patients about the medications (adverse events and how to use), answered any questions that the patients had, and provided patients the medications. During the conversation with the pharmacist at IDI, Joe, Melanie, and I were surprised when we learned that the pharmacist’s roles within this program is to serve as supervisor to make sure the pharmacy meets the criteria to stay in the program, as the counseling and recommendations are usually done by the nursing staff and pharmacy technicians. This is completely opposite from what we normally see in the United States! The pharmacist also explained to us that it is more cost-effective to conduct training the nurses and pharmacy technician on how to counsel, monitor side effects, and make any recommendations to the patients. Moving forwards, the program is hoping to broaden the program to PReP and PEP, integrate more technologies for data management, and scale up beyond 6 pharmacies.

On Saturday, Joe, Melanie, and I challenged ourselves and went to Jinja for rafting the whole day on the Niles river. We magically survived all the madness that the rapids brought to us. We also got to meet two other PA students from South Caroline and learned about their clinical experience in Uganda.
                                      
Even though the past 3 weeks went by too fast, we are so thankful for all the learning opportunities, as they let us step out of our comfort zone to acquire numbers of interesting clinical and cultural knowledge. This rotation has truly been eye-opening for all of us! With only less than 2 weeks left in Uganda, we are hoping to learn more about the roles of pharmacists in Uganda in various settings, so we can compare and contrast with the roles of pharmacists in the U.S.