HIV and Neurological Complications (Zimbabwe)

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HIV and Neurological Complications (Zimbabwe)

  1. 1. NEUROLOGICAL COMPLICATIONS OF HIV INFECTION : ZIMBABWE 2005
  2. 2. Jens Mielke Department of Medicine College of Health Sciences, Harare
  3. 3. Epidemiology of HIV in Zimbabwe <ul><li>2/3 of the people in the world living with HIV live in sub-Saharan Africa, </li></ul><ul><li>2 million people in Zimbabwe HIV+ </li></ul><ul><li>24.6% of adults 15-49 are HIV+ </li></ul><ul><li>life expectancy in Zimbabwe: </li></ul><ul><ul><li>52 years in 1990 / 34 years in 2005. </li></ul></ul><ul><li>In 2003, 170 000 people in Zimbabwe died of AIDS. </li></ul><ul><li>66.6% of HIV-1-infected women were infected with subtype C, 48.3% with subtype A, and 33.3% with subtype B </li></ul>
  4. 4. Healthcare resources <ul><li>the world’s slowest growing economy ( - 3.1% growth in 2004) </li></ul><ul><li>little public funding available for HIV care. </li></ul><ul><li>For political reasons excluded from many US – based funding programmes for roll-out </li></ul><ul><li>antiretroviral drug ‘rollout’ programmes are not yet treating significant numbers of patients </li></ul>
  5. 5. Healthcare resources <ul><li>However: urban and rural health care infrastructures in place </li></ul><ul><li>Active collaborative HIV research; prevention, treatment and complications </li></ul><ul><li>High awareness at government and medical school of priorities </li></ul><ul><li>90% of hospital admissions in internal medical and paediatric services are HIV infected </li></ul>
  6. 6. Status of Antiretrovirals <ul><li>In 2004 ARVs first offered in the public sector, in dedicated opportunistic disease clinics </li></ul><ul><li>but the majority of recipients of ARVs are purchasing them privately and are receiving treatment from private sector </li></ul><ul><li>In 2005, 6000 of the 290 000 people who need to be on treatment are receiving treatment </li></ul>
  7. 7. Status of Antiretrovirals <ul><li>combination generic antiretroviral medications at lower cost have accelerated the use of ARVs considerably </li></ul><ul><li>There are published national ARV use guidelines, </li></ul><ul><li>the mainstay of therapy is a combination drug (stavudine, lamivudine and nevirapine). </li></ul><ul><li>Protease inhibitors are included in second line therapy </li></ul>
  8. 8. Epidemiology of HIV opportunistic diseases <ul><li>Little systematic review </li></ul><ul><li>tuberculosis the commonest opportunistic disease by far </li></ul><ul><li>90% of tuberculosis cases are pulmonary, but extrapulmonary (pleural, lymph node, peritoneal, pericardial, ileal and meningeal) do occur more commonly than in non-HIV infected individuals </li></ul>
  9. 9. Epidemiology of HIV opportunistic diseases <ul><li>Other opportunistic diseases probably present with roughly the same frequency as elsewhere, </li></ul><ul><li>important exceptions : </li></ul><ul><ul><li>Kaposi’s sarcoma (which is possibly commoner), </li></ul></ul><ul><ul><li>cryptococcal meningitis (which is the commonest CNS opportunistic infection) and </li></ul></ul><ul><ul><li>toxoplasmosis encephalitis (which is relatively uncommon). </li></ul></ul>
  10. 10. Epidemiology of Neurological Opportunistic Infections <ul><li>Meningitis </li></ul><ul><li>increased dramatically since the onset of the HIV pandemic </li></ul><ul><li>outcome of meningitis is seriously altered by the presence of HIV infection, with in-hospital mortality exceeding 60% for patients with bacterial and tuberculous meningitis in Zimbabwe </li></ul>
  11. 11. Epidemiology of Neurological Opportunistic Infections <ul><li>Cryptococcal meningitis remains the commonest cause of adult meningitis </li></ul><ul><li>45% cryptococcus neoformans , 16% pyogenic ( mainly streptococcus pneumoniae ), 12% tuberculous, the remainder an unidentified mixed bag of ‘mononuclear’ meningitis – presumably viral and partially treated bacterial meningitis). </li></ul>
  12. 12. Epidemiology of Neurological Opportunistic Infections <ul><li>since 2003 fluconazole has been available in the public sector, </li></ul><ul><li>960 patients treated at one referral centre – but very poor follow-up and re-prescription rate (<10% more than three prescriptions) – most not on ARVs. </li></ul><ul><li>Immune reconstitution syndromes are a serious complication of antiretroviral therapy. </li></ul>
  13. 13. Epidemiology of Neurological Opportunistic Infections <ul><li>Cryptoccocoma presenting as an intracranial mass lesion, </li></ul><ul><li>cryptococcal myelitis presenting as an acute spinal cord syndrome </li></ul><ul><li>cryptococcal meningitis in children – all routinely seen </li></ul><ul><li>Complications of cryptococcal meningitis seen include optic neuritis and other cranial mononeuropathies, cerebrovascular accident and hydrocephalus </li></ul>
  14. 14. Intracranial mass lesions <ul><li>MRI scan since 1995 </li></ul><ul><li>stereotactic biopsy (and therefore frequently histological diagnosis) remains unavailable </li></ul><ul><li>Polymerase chain reaction diagnosis for viral agents is not available. </li></ul><ul><li>likely that toxoplasma encephalitis and tuberculoma are similar to published results from South Africa , (toxoplasmosis less common than tuberculoma as compared to opposite findings in the northern hemisphere). </li></ul><ul><li>Bacterial abscesses and as a distant fourth primary CNS lymphoma make up the remainder </li></ul>
  15. 15. Spinal cord disease <ul><li>acute presentation: </li></ul><ul><ul><li>vertebral tuberculosis </li></ul></ul><ul><ul><li>transverse myelitis (sometimes zoster) </li></ul></ul><ul><ul><li>Spinal meningitis (TB, cryptococcal) </li></ul></ul><ul><ul><li>Intraspinal (intramedullary or extradural) lymphoma </li></ul></ul><ul><li>Chronic / subacute </li></ul><ul><ul><li>progressive radiculopathy </li></ul></ul><ul><ul><li>vacuolar myelopathy </li></ul></ul><ul><ul><li>Syphilis not common (widespread penicillin use) </li></ul></ul>
  16. 16. Peripheral Neuropathy <ul><li>Distal symmetrical peripheral neuropathy </li></ul><ul><li>drug induced neuropathy has become an important differential diagnosis </li></ul><ul><li>Acute demyelinating (postinfectious) and chronic inflammatory demyelinating polyneuropathy </li></ul><ul><li>Cranial neuropathies, (facial nerve palsy, isolated third or sixth nerve palsy, mononeuritis multiplex syndrome, peripheral mononeuropathies.) </li></ul>
  17. 17. AIDS Dementia <ul><li>not systematically studied in Zimbabwe </li></ul><ul><li>Anecdotal cases of AIDS dementia definitely exist </li></ul><ul><li>Do patients survive long enough to become overtly demented ? </li></ul>
  18. 18. Conclusion <ul><li>adverse economic and political circumstances in Zimbabwe seriously hamper efforts to counter the effects of the HIV pandemic </li></ul><ul><li>opportunities for learning about the neurological manifestations of HIV and associated opportunistic diseases continue. </li></ul><ul><li>co-existence of AIDS victims naïve to ARVs and treated groups, </li></ul><ul><li>late presentations of opportunistic diseases, </li></ul><ul><li>high prevalences of fungal and bacterial diseases </li></ul>

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