Download The Philippine HIV AIDS Epidemic: A Call to Arms

The Philippine HIV/AIDS Epidemic: A Call to Arms SPECIAL
ARTICLE
CASE REPORT
‘Žȱ‘’•’™™’—Žȱ
Ȧȱ™’Ž–’ŒDZȱȱŠ••ȱ˜ȱ›–œȱ
ȱ
œŽ•ȱŠž›’ŒŽȱǯȱŠ•ŸŠ—Šȱ
ȱ
—œ’žŽȱ˜ȱ˜•ŽŒž•Š›ȱ’˜•˜¢ȱŠ—ȱ’˜ŽŒ‘—˜•˜¢ǰȱŠ’˜—Š•ȱ—œ’žŽœȱ˜ȱ
ŽŠ•‘ǰȱ—’ŸŽ›œ’¢ȱ˜ȱ‘Žȱ‘’•’™™’—ŽœȱŠ—’•Šȱ
ŽŒ’˜—ȱ˜ȱ—ŽŒ’˜žœȱ’œŽŠœŽœǰȱŽ™Š›–Ž—ȱ˜ȱŽ’Œ’—Žǰȱ˜••ŽŽȱ˜ȱŽ’Œ’—ŽȱŠ—ȱ‘’•’™™’—ŽȱŽ—Ž›Š•ȱ
˜œ™’Š•ǰȱ—’ŸŽ›œ’¢ȱ˜ȱ‘Žȱ‘’•’™™’—ŽœȱŠ—’•Šȱ
Š•’”ȱŒ’Ž—’œȱ›˜›Š–ǰȱŽ™Š›–Ž—ȱ˜ȱŒ’Ž—ŒŽȱŠ—ȱŽŒ‘—˜•˜¢ȱ
ȱ
ȱ
ABSTRACT
The incidence of HIV/AIDS in the Philippines has been rising
to unprecedented levels and we are in the midst of a full-blown
epidemic. In 2009, a record number of new cases were
diagnosed, with the highest number of new cases ever reported
in a month (126) occurring last December. While effective
treatment exists for persons living with HIV/AIDS, the number of
trained healthcare personnel who are competent to care for
these patients is in very short supply. HIV/AIDS treatment is
tremendously complex, and requires specialized training in
order to maximize the benefit derived from medications.
Moreover, antiretroviral drugs are prohibitively expensive, and
the potential loss of external funding from the Global Fund
which currently supports antiretroviral treatment will be
catastrophic. Prevention and awareness campaigns remain by
far potentially the most effective means of controlling HIV/AIDS
in the Philippines. Clinical capacity building through training of
physicians is already in effect, but may need to be ramped up
further in the face of accelerating case numbers. In addition,
international research collaboration for access to state of the art
therapies and approaches will play an important role if we hope
to reverse the epidemic. Finally, novel policies including opt-out
testing, aggressive case finding, and test and treat strategies
need to be explored in order to effectively combat this threat.
Key Words: HIV/AIDS, Philippines, Health Policy, Epidemic
ȱ
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Œšž’›Žȱ ––ž—Žȱ Ž’Œ’Ž—Œ¢ȱ ¢—›˜–Žȱ ˜›ȱ ȱ ’œȱ
ŒŠžœŽȱ ‹¢ȱ ‘Žȱ ž–Š—ȱ ––ž—˜Ž’Œ’Ž—Œ¢ȱ ’›žœȱ ǻ
Ǽǯȱ ȱ
’œȱ ŠŒšž’›Žȱ ‘›˜ž‘ȱ œŽ¡žŠ•ȱ Œ˜—ŠŒǰȱ Ž¡™˜œž›Žȱ ˜ȱ ’—ŽŒŽȱ
‹•˜˜ȱ ˜›ȱ ‹•˜˜ȱ ™›˜žŒœǰȱ ˜›ȱ ‘›˜ž‘ȱ –ŠŽ›—Š•ȱ ˜ȱ Œ‘’•ȱ
›Š—œ–’œœ’˜—ǯȱœȱŠ›ŽȱŒŽ••ǰȱ‘ŽȱŚȱ™˜œ’’ŸŽȱ˜›ȱȬ‘Ž•™Ž›ȱŒŽ••ǰȱ
’œȱ‘Žȱ•¢—Œ‘™’—ȱ˜ȱ‘ŽȱŠž•ȱ’––ž—Žȱœ¢œŽ–ǯȱŸŽ›ȱ‘ŽȱŒ˜ž›œŽȱ
˜ȱ Šȱ Œ•’—’ŒŠ••¢ȱ •ŠŽ—ȱ ™Ž›’˜ȱ ˜ȱ Ž’‘ȱ ˜ȱ Ž—ȱ ¢ŽŠ›œǰȱ ‘Žȱ Ÿ’›žœȱ
›ŠžŠ••¢ȱ Ž™•ŽŽœȱ ‘ŽœŽȱ ŒŽ••œǰȱ ’—Œ›ŽŠœ’—ȱ ‘Žȱ ›’œ”ȱ ˜ȱ ‘Žȱ
ȱ
ȏȏȏȏȏȏȏȏȏȏȏȏȏȏȏȏȱ
˜››Žœ™˜—’—ȱŠž‘˜›DZȱœŽ•ȱŠž›’ŒŽȱǯȱŠ•ŸŠ—Šǰȱȱ
ŽŒ’˜—ȱ˜ȱ—ŽŒ’˜žœȱ’œŽŠœŽœȱ
Ž™Š›–Ž—ȱ˜ȱŽ’Œ’—Žȱ
‘’•’™™’—ŽȱŽ—Ž›Š•ȱ
˜œ™’Š•ȱ
ŠȱŸŽ—žŽǰȱŠ—’•ŠǰȱŗŖŖŖȱ‘’•’™™’—Žœȱȱ
Ž•Ž™‘˜—ŽDZȱƸŜřŘȱśŘŗȬřŘśŖȱ
–Š’•DZȱŽœŽ•ǯœŠ•ŸŠ—Šȓ–Š’•ǯŒ˜–
ŽŸŽ•˜™–Ž—ȱ ˜ȱ œŽŸŽ›Žȱ Š—ȱ •’ŽȬ‘›ŽŠŽ—’—ȱ ˜™™˜›ž—’œ’Œȱ
’—ŽŒ’˜—œǯȱ ›’˜›ȱ ˜ȱ ‘Žȱ ’œŒ˜ŸŽ›¢ȱ ˜ȱ ŽŽŒ’ŸŽȱ ›ŽŠ–Ž—ǰȱ
Ȧȱ ’—ŽŒ’˜—ȱ Šœȱ Ž—Ž›Š••¢ȱ ›ŽŠ›Žȱ Šœȱ Šȱ ŽŠ‘ȱ
œŽ—Ž—ŒŽǯŗȱ
—ȱ Žœ’–ŠŽȱ řřǯŚȱ –’••’˜—ȱ ™Ž˜™•Žȱ ˜›• ’Žȱ Š›Žȱ
Œž››Ž—•¢ȱ ’—ŽŒŽȱ ’‘ȱ ǯȱ Řǯŝȱ –’••’˜—ȱ —Ž ȱ ŒŠœŽœȱ Ž›Žȱ
›ŽŒ˜›Žȱ ’—ȱ ŘŖŖŞǰȱ Š—ȱ Řȱ –’••’˜—ȱ ŽŠ‘œȱ Ž›Žȱ ›Ž™˜›Žǯȱ
ŸŽ›Š••ǰȱ‘Žȱ—ž–‹Ž›ȱ˜ȱ—Ž ȱŒŠœŽœȱ‘ŠœȱŽŒ•’—Žȱ‹¢ȱŗŝƖȱœ’—ŒŽȱ
ŘŖŖŗǰȱŠ—ȱ‘Žȱ—ž–‹Ž›ȱ˜ȱŽŠ‘œȱ‘ŠœȱŽŒ›ŽŠœŽȱ‹¢ȱŗŖƖǯȱœȱŠȱ
›Žœž•ȱ˜ȱ–˜›Žȱ™Ž˜™•Žȱ•’Ÿ’—ȱ•˜—Ž›ȱ˜—ȱŽŽŒ’ŸŽȱ‘Ž›Š™¢ǰȱ‘Žȱ
˜Š•ȱ —ž–‹Ž›ȱ ˜ȱ ŒŠœŽœȱ ‘Šœȱ Š™Ž›Žȱ ˜ȱ ‹žȱ ’œȱ œ’••ȱ œ•’‘•¢ȱ
’—Œ›ŽŠœ’—ȱŽœ™’Žȱ‘Žȱ˜ŸŽ›Š••ȱŽŒ›ŽŠœŽȱ’—ȱ—Ž ȱ’—ŽŒ’˜—œǯŘȱȱ
Ž–Š›”Š‹•Žȱ™›˜›Žœœȱ’—ȱ‘Žȱ›ŽŠ–Ž—ȱ˜ȱ
Ȧȱ‘Šœȱ
‹ŽŽ—ȱ–ŠŽȱ’—ȱ‘Žȱ™ŠœȱŘśȱ¢ŽŠ›œǯȱ‘Žȱ’›œȱŽŽŒ’ŸŽȱ
ȱ›žǰȱ
£’˜Ÿž’—Žǰȱ ŠœȱŠ™™›˜ŸŽȱ‹¢ȱ‘Žȱȱ’—ȱŗşŞŝǯȱ
˜ ŽŸŽ›ǰȱ’ȱ
Šœȱ‘ŽȱŠŸŠ’•Š‹’•’¢ȱ˜ȱ™›˜ŽŠœŽȱ’—‘’‹’˜›œȱ’—ȱŗşşśȱ‘Šȱ™ŠŸŽȱ
‘Žȱ Š¢ȱ ˜›ȱ ‘Žȱ žœŽȱ ˜ȱ Œ˜–‹’—Š’˜—œȱ ˜ȱ Š—’›Ž›˜Ÿ’›Š•ȱ ›žœȱ
ǻȂœǼȱ’—˜ȱ ‘Šȱ’œȱ—˜ ȱŽ›–Žȱ‘’‘•¢ȱŠŒ’ŸŽȱŠ—’›Ž›˜Ÿ’›Š•ȱ
‘Ž›Š™¢ȱ ǻ
Ǽȱ ‘Šȱ •Žȱ ˜ȱ Šȱ ›Š–Š’Œȱ ŽŒ›ŽŠœŽȱ ’—ȱ ‘Žȱ
—ž–‹Ž›ȱ ˜ȱŽŠ‘œȱžŽȱ˜ȱ‘ŽȱŸ’›žœǰȱŠ—ȱŠ—ȱ ˜ŸŽ›Š••ȱŽŒ›ŽŠœŽȱ
’—ȱ ›Š—œ–’œœ’˜—ǯŗȱ Žǰȱ ȱ ’œȱ ™›˜‘’‹’’ŸŽ•¢ȱ Ž¡™Ž—œ’ŸŽǰȱ
’‘ȱœ˜–Žȱ˜™’–’£Žȱ›Ž’–Ž—œȱŒ˜œ’—ȱ—ŽŠ›•¢ȱȱǞŘǰŖŖŖȱ™Ž›ȱ
–˜—‘ȱ™Ž›ȱ™Š’Ž—ǯȱ‘›˜ž‘ȱ‘ŽȱŽœŠ‹•’œ‘–Ž—ȱ˜ȱ‘Žȱ•˜‹Š•ȱ
ž—ȱ˜›ȱǰȱž‹Ž›Œž•˜œ’œȱŠ—ȱŠ•Š›’ŠǰȱŠŸŠ’•Š‹’•’¢ȱ˜ȱ›ŽŽȱ
–Ž’ŒŠ’˜—ȱ ˜›ȱ •˜ Ž›ȱ Š—ȱ –’•ŽȬ’—Œ˜–Žȱ Œ˜ž—›’Žœȱ ‘Šœȱ
’—Œ›ŽŠœŽǰȱ Š—ȱ ™Ž›œ˜—œȱ •’Ÿ’—ȱ ’‘ȱ ȱ Š›Žȱ œž›Ÿ’Ÿ’—ȱ ˜›ȱ
•˜—Ž›ȱ™Ž›’˜œȱ ’‘ȱŽ Ž›ȱŒ˜–™•’ŒŠ’˜—œǯřȱ
‘Žȱ ˜‹“ŽŒ’ŸŽœȱ ˜ȱ‘’œȱ ™Š™Ž›ȱ Š›Žȱ˜ȱ ŽŸŠ•žŠŽȱ ‘Žȱ Œž››Ž—ȱ
ȦȱŽ™’Ž–’Œȱ’—ȱ‘Žȱ‘’•’™™’—ŽœǰȱŠ—ȱ˜ȱŽ¡Š–’—Žȱ Š¢œȱ
˜ȱ –˜›Žȱ ŽŽŒ’ŸŽ•¢ȱ Œ˜—›˜•ȱ ‘Žȱ ’œŽŠœŽȱ Š—ȱ ™˜Ž—’Š••¢ȱ
›ŽŸŽ›œŽȱ‘ŽȱŽ™’Ž–’Œǯȱ
ȱ
Ȧȱ’—ȱ‘Žȱ‘’•’™™’—ŽȱŽ’—ȱ
‘Žȱ’›œȱ ˜ȱŒŠœŽœȱ˜ȱ
Ȧȱ’—ȱ‘Žȱ‘’•’™™’—Žœȱ Ž›Žȱ
›Ž™˜›Žȱ ’—ȱ ŗşŞŚǯȱ ’—ŒŽȱ ‘Ž—ǰȱ ŚǰŚŘŚȱ Œ˜—’›–Žȱ ŒŠœŽœȱ ˜ȱ ȱ
’—ŽŒ’˜—ȱ ‘ŠŸŽȱ ‹ŽŽ—ȱ ›Ž™˜›ŽŚȱ Š—ȱ ‘Žȱ —ž–‹Ž›œȱ Œ˜—’—žŽȱ ˜ȱ
Œ•’–‹ǯȱ —ȱ ŘŖŖřǰȱ ‘Žȱ •˜ ȱ —ž–‹Ž›œȱ ˜ȱ ȱ ŒŠœŽœȱ ’—ȱ ‘Žȱ
‘’•’™™’—Žœȱ›Ž•Š’ŸŽȱ˜ȱ˜‘Ž›ȱŒ˜ž—›’Žœȱ’—ȱ‘Žȱ˜ž‘ŽŠœȱœ’Š—ȱ
›Ž’˜—ȱŠ›ŠŒŽȱ’—Ž›—Š’˜—Š•ȱŠŽ—’˜—ǯȱȱ Šœȱ‘¢™˜‘Žœ’£Žȱ
‘Šȱœ˜–ŽȱŠŒ˜›ȱ–Š¢ȱ‹Žȱ™›˜ŽŒ’—ȱ’•’™’—˜œǰȱœ’—ŒŽȱœŽ¡žŠ••¢ȱ
›Š—œ–’Žȱ’œŽŠœŽȱǻǼȱ›ŠŽœȱ Ž›Žȱœ’–’•Š›ȱ˜ȱ‘Šȱ˜ȱ˜‘Ž›ȱ
Œ˜ž—›’Žœǯśȱ ‘Ž›ȱ ‘Š—ȱ Šȱ ™˜œœ’‹•Žȱ •ŽŸŽ•ȱ ˜ȱ ™›˜ŽŒ’˜—ȱ ›˜–ȱ
‘’‘ȱŒ’›Œž–Œ’œ’˜—ȱ›ŠŽœǰȱ—˜ȱ˜‘Ž›ȱŠŒ˜›ȱ‘Šœȱ‹ŽŽ—ȱ˜ž—ǯȱ
Email: [email protected]
60 ACTA MEDICA PHILIPPINA
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Heart Failure
and Short Epidemic:
Stature in a A
43 Call
year-old
male
The Philippine
HIV/AIDS
to Arms
Table
1. Initial Laboratory Results
..-D
-
!/E
Blood chem.
CBC
-0!E1($$>7
Reference
Result
Reference
.!/
.
Value
Value
7 -
4.5 #$*-
. 3.9-6.1
RBS
WBC
5-10
.7#>>&
($$&=
4.27-6.07
HGBA1C
RBC
4-6
2.6-6.4
BUN HGB
.
-
90 " 120-150 -
53-115
CREA
HCT
0.27
0.38-0.48
75.57
34-50
ALB
MCV
FL
- 780-100
75 !/
0.34-1.7
TAG
MCH
27-31 PG
-
0.91-1.56
HDL
MCHC
320-360 G/L
!/ 1.1-3.8
LDL
RDW
11.5-15.5%
4.2-5.2
TOTAL
CHOL
PLT
Inc
200-400
-
2 7
>$:
15-37
AST
RETIC
0.005-0.015 2
!2
30-65
ALT
SEG
48
50-70%
2
Alk po4
LYMPH
50
20-44%
08':1
!77
140-148
NA
MONO
2
2-9%
2
3.6-5.2
K . -
EO 7 0
0-4% 01 100-108
CL BASO
0 2
0-2%- 5
2.12-2.52
CA++
BLAST
0
0%
3
P
. 0.74-1
MG++ -
- 7 . . , 7
=
7.
Table 2. Thyroid Function Tests
($$) 7 (3$$ A
"- Reference Value
Result
0A"1 Free T4
(0.8-2.0)
0.02 ng/dL
&
.7
#($$$
TSH
(0.4-6.0)
24.75 Uiu/ml
#8: 7 .- ($$# .-'$$:
! "
.
- . -
7 .
5 5- . !/6"
. A
- " 0" 1
7
..
" ; 0=";1 " .
7
!/6" .
Figure 1. Electrocardiogram
upon admission
" " !/6" 7
.- transferred to the intensive care unit (ICU) for ventilatory
#'
support and closer monitoring. On bedside cardiac ultrasound,
there was a finding of eccentric left ventricular hypertrophy,
global hypokinesia with depressed overall systolic function
F with concomitant spontaneous echo contrast on left ventricular
!7 .=
(LV) cavity suggestive of rheologic stasis, the ejection fraction
!/6" . was 25%, with moderate mitral regurgitation, moderate
=
.
aortic regurgitation with aortic sclerosis, severe tricuspid
-
regurgitation
with mild pulmonary hypertension, pulmonary
and
.minimal
,
or
7
regurgitation,
pericardial
effusion
pericardial
43 NO.
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2010
4.-..
.- ABG
Urinalysis
. 7.408 pH Color. straw
Result
A-
7 -
49.1
pCO2
Clear
Transp
6.3
6.4
70 pO2 1.010 Sp Gravity
31.3
HCO3
8.0
pH
5.0
.-
2
93.6
O2 sat NEG
123 Sugar
7 -
7 21%
FiO2
NEG
Protein
32
7
.
36.9
Temp
0-1
RBC
0.82
5
0-2
WBC
0.67
Cast
. 4.21
PBS 75
Rare
Epith cell
5.25
7!/6"-
,
Slight poikilocytosis,
Occ’l 95
=
Bacteria
!/6"
A
acanthocytes,
ovalocytes,
Rare
Mucus th
91
slight toxic granulation,
57-
-
Rare
Crystals
184
slight
anisocytosis
-
-
Am urates
136.9
3.35
- 57
- 86 - - !/
!/
2.37
!/6" 2.27
0.83
57 - !
75? 7
7 !/6"
- fat
pad. Cardiac
were not
consistent
with an
acute
-
enzymes
.
coronary
event
(Table
3),
however,
intravenous
(IV)
heparin
- 5 5 (overlapping
with oral warfarin) was still given to cover for
,
the presence
of a possible LV
thrombusas
demonstrated
by
rheologic
stasis
on
cardiac
ultrasound.
Medications
3 7 - .
were
shifted
to IV diuretics
and inotropes;
oral digoxin
was
started.
IV
antibiotics
were
given
for
possible
pulmonary
<
infection.
The 7
patient later
showed .
improvement,
and was
on
eventually
weaned
off
from
ventilatory
support,
extubated,
.
-3
Table
3. Cardiac Enzymes
($$
"
2
Reference Range (mmoL)
Result
5 POSITIVE
Qualitative
F-
Troponin I
CK-MB
0-6.0 1.14
7
CK-TOTAL
21-232 543
4
-
.-
!/ .- .- -
-
.
- .
- 5
- 89
.-
. 7 !/ - 0<
-1 7 .
0. .<
-1
Figure
2. Chest radiograph on admission
ACTA MEDICA PHILIPPINA 61
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The Philippine HIV/AIDS Epidemic: A Call to Arms
" 0. 21 7
7
.
5
=- 7 .
7
7.,.
>
, 3 .
5
. " *- 7
, ($ 3$:
5
#$
3 ($$
.
;
7
3.
')$5-
7
-##
F-2
.7-7
*
0 . , .
1*
!/.2
F
- !/6" ..
.-
. . . 7 . .
7757
=- 5- " -
!/ . 2
.
7
.
!/6" " ,7
-
- - - !/6" - - !
- 57 7 7 57 7 . .5 = #>9$? 7
. 75
"
!/6" 7
7 7
7
'$$:F
57
. 7 - F .-
7 F 5
!
#
(
'
3
)
&
8
9
>
#$
##
57< G" "** ($ - D H # ($$#I
'330('1#8&3*8(
H A
D !/6" 0AD"1 F
! 4< 0F!41 " A
D. ($$>
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66
6.6;6($$>6H#8$$A
($$>
"
H-(8($#$
! !/*" ()** . D
H
($$&$')30('1(3#3*8
D - ! ;. !/6";-.($$>
E J !/ -- K ($$'
HI'0&1'($
A
"- 0A"1 !/6" . ($$9 ". 66777
6756.6
666
"
H-(8($#$
! D -
!/*#
"($$8=.#>I(#031)$#*8
/<<!EE
=($$9K
L ? L /! 2
E
L
($$9I9>0)1#&)*#&>
2 - " " -
")($( ".*K
*. !/*#-DH
#($$>I'&#0('1(('$*((3$
;G ! " 7- "F / * - - 7!/*#
F!4
-7
*-K#($$>I>0813$>*3#8
G H ". " D"*"4;
- - !/DH
($$>I'&$0#91#9#)*#9(&
Email: [email protected]
62 ACTA MEDICA PHILIPPINA
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